Dermatology is one of the more relaxed and enjoyable rotations that a doctor can do in GP training, whilst still providing useful learning opportunities. It is normal to be nervous when starting a new rotation, but it will be more beneficial for you, if you try to get as involved as much as possible. In this article, Dr Bibiana Aiyegbeni shares 10 tips from her experience of a dermatology rotation.
1. Be familiar with key resources for diagnosis and management of skin conditions.
Here are some key resources to use before and during the rotation:
– Primary Care Dermatology Society website – https://www.pcds.org.uk/clinical-a-z-list
– DermNet website – https://dermnetnz.org/topics
– British Association of Dermatology (BAD) website – https://www.bad.org.uk/
-Dermatology handbook for medical students and junior doctors – https://cdn.bad.org.uk/uploads/2021/12/29200247/Derm_Handbook_3rd-Edition-_Nov_2020-FINAL.pdf) . This is a concise summary of key dermatological topics which you would be expected to learn and know by the end of the rotation. It is made freely available by the support of the BAD.
2. Things I wish I knew prior to starting the rotation:
A. Try to do some background reading
This includes skin anatomy, common dermatology terms to describe skin lesions e.g. macule, papule, vesicles, Acne, Actinic keratoses, Eczema and Psoriasis , common types of skin cancers: Basal cell cancer, Squamous cell cancer + Melanoma, common benign moles(junctional, intradermal, compound, seborrheic keratoses), common scalp conditions such as seborrheic dermatitis ,traction alopecia and alopecia areata and common fungal skin infections from tinea capitis to Onychomycosis.
B. Awareness of Red/Amber/Green drug rating (Classification)
This inform guidance on the prescribing of drugs initiated in primary and secondary care, for example Isotretretinoin( also known as Roaccutane) is a Red rated drug, this means that it can only be started by a hospital specialist. This will explain why the dermatologist may initiate certain drugs in their clinic and with other drugs they may ask the GP to prescribe such as Efudix for Actinic keratosis.
C. Access to local NHS primary care guidelines for the management of common dermatology conditions.
There may be local guidelines on medications that can be prescribed under the NHS. For example, South East London prescribing guidelines online ( see link- https://selondonccg.nhs.uk/wp-content/uploads/dlm_uploads/2023/05/Emollient-Guideline-SEL-FINAL-May-2023-v2.pdf ) provides guidelines on what GPs and community dermatology clinics may be able to prescribe such as emollients that are on the prescribing formulary for the local area.
D. Don’t be scaed to ask questions, questions, questions!!
It may seem nerve wracking to keep asking lots of questions, but this is why you are doing a training post in this rotation, so you can learn more about this exciting speciality
3. Be a good team player!!!
Try to be helpful to other clinical staff members as they are more likely to help you with obtaining useful learning opportunities. Try to learn the role of other clinical staff by observing them during the shadowing period from the health care assistants to the nurses. This will help you to know who to ask for help and what clinical services are provided in the dermatology department. They may also be able to show you how to use the camera in the department to take photos of skin lesions especially as there may not always be a medical photographer. This also includes always marking lesions with a skin marker pen, measuring and documenting the size of lesions.
4. Make the most of learning opportunities!!!
There are various clinics taking place including paediatric, suspected skin cancer clinics and procedures including phototherapy and iontophoresis and scalp steroid injections. Also, there are day surgery sessions where you can learn different techniques to remove skin lesions from shave excision to elliptical excision.
Also there may be regular skin cancer multidisciplinary meetings, which is useful to understand the management of complex skin cancers. Even though you feel you may not be doing this in your regular practice as a General Practitioner, by attending such clinics, it helps to improve your understanding of the treatment pathways for patients with skin issues.
Try to attend a community dermatology clinic run by a GP with special interest (GPSI)- there may be different learning opportunities as often patients may be seen by GPSI before being referred to secondary care such as rashes with uncertain diagnosis or resistant common inflammatory conditions such as psoriasis.
5. Try to see and examine as many patients as you can in the clinics
The more variety of patients you see in the clinic, the more you are likely to learn. You will be able to develop your clinical skills in dermatology from taking a dermatology history to examining skin lesions including paediatric patients. This rotation will give you the opportunity to learn to use dermatological terms to describe skin lesions such as macule, papule or vesicles. Some lesions are easier to identify after seeing many patients, whereby you will start to develop pattern recognition. This may also involve managing expectations of patients +/- parents of paediatric patients with their skin issues including skin scarring.
Also, this rotation will provide you with the opportunity to learn the basics of how to use a dermatoscope to identify benign vs malignant moles: you will not be expert in dermatoscopy after the rotation, but during the rotation you will be introduced to basic structural features that are characteristic of a benign vs malignant lesion.
During clinic, you may get the opportunity to do cryotherapy, skin scrapings and scalp brushings which are useful skills to learn, which can be transferred to General Practice. During the clinics, you are likely to assess and manage skin lesions including consenting patients for day procedures and starting medications such as Roaccutane under close consultant supervision. Other duties may include:
-Breaking bad news that a patient may or has a confirmed form of skin cancer and the next steps in management
-Writing clinic letters to the GP +/- referring to hospital specialists such as the paediatric allergy clinic
-Requesting and reviewing blood test results usually prior to starting patients on systemic medications such as methotrexate.
-Assisting in day procedures such as suspected skin cancer removal, biopsies and performing cryotherapy for patients.
-Opportunity to see patients on the wards who require a dermatology review.
6. Be punctual, organised and plan.
Obtain advice from your predecessors regarding tips for the rotation including things they wish they knew earlier in the rotation. Put in your leave requests early including annual and study leave, however you are likely to be supernumerary, so your leave is likely to granted.
Get to work at least 15 minutes early to give you time to prepare especially if in a different clinic room each session. Try to generate personal development plans at the beginning of the rotation as this will guide your learning during the rotation.
7. Try to familiarise yourself with common medications used in dermatology which may be prescribed or obtained over the counter at the chemist.
Commonly used over the counter medications include emollients (such as Epimax, Zerobase and Hydromol), ketoconazole shampoo, Antifungal nail Lacquer, wart preparations and antihistamines.
Commonly prescribed medications include:
-Topical steroid (cream, ointment, tapes) and steroid sparing treatment for eczema and other common inflammatory skin conditions including steroid maintenance and reducing regimen.
-Systemic treatments used for inflammatory conditions such as Methotrexate and biological therapies such as Infliximab.
-Roaccutane (Isotretinoin) for acne vugalris: this includes commencing /continuing Roaccutane for acne including. Screening questionnaires for depression to baseline blood tests, pregnancy tests and contraception advice.
8. Familiarise yourself with treatment guidelines
You may come across Treatment Access Policy which informs the department and GPs who do minor surgery on what they can treat under the NHS and what they cannot treat such as cosmetic skin tags. Also there may be local guidelines of which emollients (1st, 2nd and 3rd line) to prescribe for patients.
9. Learn the art of concise documentation
You will learn how to quickly document in patient’s records and how to write concise clinic letters to the GP and/or hospital specialists. Read this article on writing good clinic letters to get your started.
10. Generate Personal Development plans within the first couple weeks of the rotation.
Suggested Personal Development Plans (PDP) for this rotation:
To become confident in the assessment and management of eczema and psoriasis
To become confident in the assessment and management of acne vulgaris
To become confident in describing skin lesions in dermatological terms
I hope you found this article helpful! We are always looking to add more helpful content for GP training – if you want to write an article with tips from a different rotation, please get in touch!