🩺 Dermatology for GPs: Complete Survival Guide | GP Training Resources

Updated Guidelines 2024:

NICE updated CKS for Eczema (March 2024) and Psoriasis (January 2024). New guidance on topical JAK inhibitors and biosimilar prescribing included.

🩺 Dermatology for GPs: Your Survival Guide

Spot-on skin wisdom - because every rash tells a story (and you need to read it correctly)

☕ Tea-Friendly Learning ⏰ For GP Trainees Short on Time 🚩 Red Flag Focused

Date Updated: November 2025

Executive Summary: What You'll Master Today

Because you have 47 other things to do before lunch, and that's just the morning list

What This Page Covers:

• Red-flag conditions that'll keep you awake at night
• Common skin problems you'll see daily
• Diagnostic frameworks that actually work
• Examination techniques for confident consultations
• When to refer (and when to keep calm)
• Psychosocial impact management
• MRCGP-relevant scenarios and resources

Quick Facts at a Glance:

25%

1 in 4 people have eczema at some point

80%

of childhood eczema is gone 8 years after diagnosis

95%

of childhood eczema is gone 20 years after diagnosis

66%

Overall 2/3rds of children outgrow eczema

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path: DERMATOLOGY

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Brainy Bites: Essential Dermatology Wisdom

Key Questions for Data Gathering

"When did you first notice it?" - Onset timing is crucial for diagnosis

"Does it itch, hurt, or feel normal?" - Symptom quality guides differential

"Any new products, travel, or medications?" - Trigger identification

"How is this affecting your daily life?" - Psychosocial impact assessment

Red Flags – What Not to Miss!

Rapidly spreading erythema with systemic upset (cellulitis/necrotizing fasciitis)

Changing pigmented lesion (ABCDE features for melanoma)

Widespread blistering or skin peeling (SJS/TEN)

Non-healing ulcer >6 weeks (malignancy risk)

1️⃣ Red-Flag & Serious Conditions Not to Miss

Critical Presentations Requiring Urgent Recognition

Rare but life-threatening conditions that need immediate action

Emergency: Widespread skin peeling, mucosal involvement, systemic upset. Mortality 10-30% for TEN.

Clinical Features:

• Painful skin with positive Nikolsky sign
• Mucosal erosions (mouth, eyes, genitals)
• Target lesions progressing to confluent erythema
• Fever, malaise, dehydration

Immediate Actions:

• Stop all non-essential medications
• Emergency dermatology referral
• Consider burns unit if >10% BSA
• Supportive care: fluids, analgesia

ABCDE Criteria:

Asymmetry - One half unlike the other

Border - Irregular, scalloped, or poorly defined

Color - Varied from one area to another

Diameter - Larger than 6mm (pencil eraser)

Evolving - Changing in size, shape, or color

High-Risk Features:

• New pigmented lesion >40 years
• Changing existing mole
• Bleeding or ulceration
• Satellite lesions

Referral Pathway:

• 2-week wait referral if suspicious
• Dermoscopy if available
• Photograph for monitoring
• Patient education on self-examination

Basal Cell Carcinoma

• Pearly, rolled edge
• Central ulceration
• Slow-growing
• Sun-exposed areas
• Locally invasive but rarely metastasizes

Squamous Cell Carcinoma

• Ulcerated, tender lesion
• Fast-growing
• Keratotic surface
• Can metastasize
• 2-week referral if suspected

2️⃣ Common Conditions in Primary Care

Inflammatory & Eczematous Dermatoses

The bread and butter of dermatology consultations

Clinical Features

• Flexural distribution
• Intense itching
• Dry, scaly skin
• Family history atopy

Management

• Emollients (mainstay)
• Topical steroids (step-up)
• Calcineurin inhibitors
• Antihistamines for itch

Referral Criteria

• Severe/widespread disease
• Treatment failure
• Suspected infection
• Psychosocial impact

Seborrhoeic Dermatitis

• Scalp, face, chest distribution
• Greasy, yellowish scales
• Associated with Malassezia
• Worse with stress, illness

Treatment

• Antifungal shampoos (ketoconazole)
• Mild topical steroids
• Calcineurin inhibitors for face
• Regular maintenance therapy

Key Point: Contact dermatitis often has sharp demarcation and corresponds to area of contact with allergen/irritant.

Allergic Contact

• Delayed hypersensitivity (Type IV)
• Common: nickel, fragrances, rubber
• Patch testing for diagnosis
• Avoidance is key

Irritant Contact

• Direct chemical damage
• Immediate or cumulative
• Common: soaps, detergents
• Barrier protection important

Discoid Eczema

Features:

• Coin-shaped lesions
• Well-demarcated
• Often on limbs
• Can be very itchy

Management:

• Potent topical steroids
• Emollients
• Treat secondary infection
• Consider systemic therapy if severe

Lichen Simplex Chronicus

Pathophysiology:

• Chronic itch-scratch cycle
• Lichenification develops
• Often single plaque
• Psychological component

Treatment:

• Break itch-scratch cycle
• Potent topical steroids
• Occlusive dressings
• Behavioral modification

Psoriasis Spectrum

Understanding the various presentations and systemic associations

Remember: Psoriasis is a systemic inflammatory condition. Screen for cardiovascular risk, diabetes, and depression.

Chronic Plaque

• Well-demarcated plaques
• Silvery scale
• Extensor surfaces
• Auspitz sign positive

Guttate

• Small drop-like lesions
• Often post-streptococcal
• Trunk and limbs
• May resolve spontaneously

Flexural

• Smooth, red plaques
• Minimal scaling
• Groin, axillae
• Can be misdiagnosed

Assessment Tools & Referral Criteria

PASI Score: Psoriasis Area and Severity Index

DLQI: Dermatology Life Quality Index

Refer if: PASI >10, DLQI >10, or failure of topical therapy

Systemic Associations:

• Psoriatic arthritis (30%)
• Cardiovascular disease
• Metabolic syndrome
• Depression and anxiety

3️⃣ Diagnostic Approach & Investigations

A Practical GP Framework

Systematic approach to working out rashes, lumps, and skin changes

Essential Questions

• Onset: When first noticed? Sudden or gradual?
• Spread: Started where? How has it changed?
• Symptoms: Itch, pain, burning, numbness?
• Triggers: New products, stress, illness?

Contextual Factors

• Medications: New drugs, recent changes?
• Occupation: Chemical exposure, irritants?
• Travel: Recent trips, new environments?
• Contacts: Family members affected?

Distribution Patterns

• Flexural: Eczema, psoriasis (inverse)
• Extensor: Psoriasis, lichen planus
• Dermatomal: Herpes zoster, contact
• Photodistributed: Drug reactions, lupus

Special Areas

• Palms/soles: Syphilis, eczema, psoriasis
• Scalp: Seborrhoeic, psoriasis, alopecia
• Nails: Psoriasis, fungal, lichen planus
• Mucosa: Lichen planus, pemphigus

Primary Lesions

Macule: Flat, <6mm

Patch: Flat, >6mm

Papule: Raised, <6mm

Plaque: Raised, >6mm

Vesicle: Fluid-filled, <6mm

Bulla: Fluid-filled, >6mm

Pustule: Pus-filled

Nodule: Deep, >6mm

Wheal: Transient, raised

Secondary Changes

Scale: Flaky skin

Crust: Dried exudate

Erosion: Partial thickness loss

Ulcer: Full thickness loss

Lichenification: Thickened skin

Atrophy: Thinned skin

Primary Care Tests

• Skin scraping: KOH prep for fungi
• Nail clippings: Mycology culture
• Swabs: Bacterial culture, viral PCR
• Photography: Monitoring changes

Blood Tests (When Indicated)

• Autoimmune screen: ANA, ENA
• Thyroid function: Alopecia, vitiligo
• Glucose: Recurrent infections
• Iron, B12: Hair loss

ABCD Rule for Pigmented Lesions: Asymmetry, Border irregularity, Color variation, Diameter >6mm

Benign Features

• Symmetrical pattern
• Regular network
• Uniform color
• Sharp border

Concerning Features

• Asymmetrical pattern
• Atypical network
• Multiple colors
• Blue-white veil

Urgent Referral (2WW)

• Suspected melanoma
• Suspected SCC
• Rapidly growing lesion
• Ulcerated lesion >6 weeks

Routine Referral

• Uncertain diagnosis
• Treatment failure
• Severe psychosocial impact
• Biologic therapy consideration

4️⃣ Differential Diagnosis Frameworks

Symptom-Based Clusters

Compare key presentations that commonly confuse trainees

Critical History Taking: Always ask about over-the-counter treatments and any new medications, including new soaps, detergents, washing powders, face creams and lotions, aftershaves and perfumes. These are extremely important triggers that patients often forget to mention.

Feature	Eczema	Psoriasis	Scabies	Drug Eruption
Distribution	Flexural	Extensor	Web spaces, wrists	Widespread
Morphology	Ill-defined, weeping	Well-defined plaques	Burrows, papules	Variable
Itch	Intense	Mild-moderate	Severe, worse at night	Variable
Key Clue	Atopic history	Silvery scale	Contact history	Recent medication

Acne Vulgaris

• Comedones (blackheads/whiteheads)
• T-zone distribution
• Adolescent/young adult
• Hormonal triggers

Rosacea

• Central facial erythema
• No comedones
• Middle-aged adults
• Triggers: alcohol, spicy food

Seborrhoeic Dermatitis

• Greasy, yellowish scales
• Nasolabial folds, eyebrows
• Often involves scalp
• Malassezia-related

Lupus (Malar Rash)

• Butterfly distribution
• Spares nasolabial folds
• Photosensitive
• Systemic symptoms

When in doubt, refer: Any changing pigmented lesion in an adult should be assessed by dermatology.

Benign Naevus

• Symmetrical
• Regular border
• Uniform color
• <6mm diameter
• Stable over time

Melanoma

• Asymmetrical
• Irregular border
• Color variation
• >6mm diameter
• Evolving/changing

Seborrhoeic Keratosis

• "Stuck-on" appearance
• Warty surface
• Brown/black color
• Multiple lesions
• Older patients

5️⃣ Data-Gathering & Examination Tips

SCA-Ready Skin Consultation

How to structure a confident dermatology consultation

Opening Questions (Start Broad)

"Tell me about this skin problem..."

• "When did you first notice it?"
• "How has it changed since then?"
• "What does it feel like?"

Follow-up probes:

• "What do you think might have caused it?"
• "Have you tried anything for it?"
• "How is it affecting you?"

Trigger Identification

• Products: New cosmetics, detergents, jewelry
• Medications: Recent prescriptions, OTC drugs
• Environment: Work exposure, travel, pets
• Stress: Life events, illness, hormonal changes

Psychosocial Impact

• Work: Time off, performance impact
• Social: Embarrassment, avoidance
• Sleep: Itch disrupting rest
• Relationships: Intimacy, self-esteem

Examination Checklist

Systematic Approach:

✓ Good lighting (natural if possible)
✓ Expose adequate area
✓ Describe lesions accurately
✓ Check distribution pattern
✓ Examine nails, scalp, mucosa

Documentation:

✓ Size (measure largest lesion)
✓ Shape and border
✓ Color and surface
✓ Secondary changes
✓ Regional lymph nodes

Across Skin Tones: Erythema may appear purple/brown in darker skin. Scaling and texture changes are often more reliable signs than color.

6️⃣ Psychosocial & Holistic Care

Chronic Skin Disease as Long-Term Condition

Recognizing the broader impact beyond the visible symptoms

Quality of Life Assessment

DLQI (Dermatology Life Quality Index):

• 10 questions about impact
• Score 0-30 (higher = worse)
• >10 = severe impact
• Guides treatment decisions

Common Psychological Impacts

• Anxiety and depression
• Social withdrawal
• Body image issues
• Sleep disturbance
• Reduced self-esteem
• Relationship difficulties

Addressing Stigma and Misconceptions

Common Patient Concerns:

• "Is it contagious?"
• "Is it because I'm dirty?"
• "Will it ever get better?"
• "Am I using too much steroid?"

Reassurance Strategies:

• Explain the condition clearly
• Address steroid phobia
• Provide written information
• Set realistic expectations

Lifestyle Factors

• Smoking: Worsens psoriasis, delays healing
• Alcohol: Triggers rosacea, psoriasis flares
• Diet: Limited evidence, avoid restrictive diets
• Stress: Major trigger for many conditions
• Sleep: Itch-scratch cycle disruption

Support Resources

• Dermatology specialist nurses
• Patient support groups
• Psychological services
• Occupational health referral
• Benefits and disability advice

Shared Management Plans: Involve patients in treatment decisions. Explain the chronic nature but emphasize that good control is achievable with the right approach.

7️⃣ Learning & Assessment Relevance

MRCGP Components

How dermatology maps to your assessment journey

Common AKT Topics

• Photo recognition of rashes/lesions
• Psoriasis management and biologics
• Eczema treatment ladders
• Acne therapy and isotretinoin safety
• Skin cancer recognition (ABCDE)
• Drug side effects and interactions

Key Learning Points

• NICE guidance on topical treatments
• Referral criteria and pathways
• Safety netting for red flags
• Steroid potency and side effects
• Contraindications to treatments

SCA Success Tip: Practice describing skin lesions accurately and systematically. Examiners love candidates who can paint a clear picture.

Likely SCA Scenarios

• Infant with eczema flare
• Teenager seeking acne treatment
• Adult with changing mole
• Elderly patient with leg ulcer
• Worker with occupational dermatitis

Assessment Domains

• Data gathering: Systematic history
• Clinical management: Appropriate treatment
• Interpersonal skills: Empathy, explanation
• Maintaining an ethical approach

COT Opportunities

• Chronic eczema management
• Psoriasis shared care
• Skin cancer surveillance
• Dermatology referral decisions
• Patient education sessions

Reflection Topics

• Prescribing safety (topical steroids)
• Isotretinoin monitoring
• Missed melanoma (SEA)
• Cultural sensitivity in skin examination
• Breaking bad news (skin cancer)

8️⃣ Skin Cancer Survival

Prognosis & Survival Rates

What you can tell patients about their outlook

Melanoma Survival

Overall UK Survival:

• 95% survive 5+ years

• 93% survive 10+ years

Prognosis depends on stage, age, health, and treatment response.

By Stage (5-year survival):

• Stage 1: Almost 100%

• Stage 2: ~85%

• Stage 3: ~75%

• Stage 4: Improving with immunotherapy

Basal Cell Carcinoma (BCC)

Excellent Prognosis:

• Cure rate: Nearly 100%

• Metastasis: Extremely rare

What to tell patients:

"This is highly curable with standard treatment. Spread to other parts of the body is extremely unlikely."

Squamous Cell Carcinoma (SCC)

Generally Good Prognosis:

• 3-year survival: ~94%

• Most are low-risk and curable

Important Caveats:

• Small risk of spread/metastasis

• High-risk features need closer monitoring

High-risk SCC factors: Large size, deep invasion, head/neck location, immunosuppression. These require closer follow-up and have less favorable prognosis.

Key Counseling Points:

• Early detection dramatically improves outcomes for all skin cancers
• Most skin cancers are highly treatable when caught early
• Regular self-examination and sun protection are crucial
• Follow-up appointments are important for monitoring

9️⃣ Useful GP Resources

Quick Reference & Continued Learning

Your dermatology toolkit for daily practice

Essential Guidelines

Professional Organizations

British Association of Dermatologists
Patient leaflets and clinical guidelines
Primary Care Dermatology Society
GP-focused dermatology resources

Learning Resources

DermNet NZ
Comprehensive image library (note UK differences)
RCGP eLearning Modules
Structured dermatology courses
GP Notebook: Skin Section
Quick reference summaries

Assessment Tools

BAD DLQI Tool
Quality of life scoring
PASI Calculator
Psoriasis severity assessment

You've Got This! 🎉

Remember: You don't need to be a dermatologist to provide excellent skin care. You just need to know when to worry, when to treat, and when to refer.

Most skin conditions are benign and manageable in primary care. Trust your clinical judgment, use your safety-netting skills, and don't hesitate to seek advice when needed. Your patients will appreciate your thorough, caring approach.

Now go reward yourself with that well-deserved coffee ☕

Always refer to current NICE guidelines and local protocols for the most up-to-date guidance.