It seemed like a teachable moment. My student looked on as Laura took off her shoes and showed us livid, polycyclic plaques covering the dorsum of her left foot. The way her rash looked, bordering 10 obviously fungal toenails, left little doubt about the problem.
“I’m going to guess you’re using a steroid cream,” I said.
“Could I please tell you the whole story?” said Laura, with some impatience.
“Sure,” I said. I love whole stories.
So Laura told me hers, starting with her walk through the tall grass in the summer, followed by “poison ivy” that her primary care physician treated with “a cream.”
“Did the cream have hydrocortisone in it?”
“I think so,” she said. But that didn’t work, so her doctor prescribed another cream. That one seemed to help a bit, but then the rash got redder and itchier, so she got another cream. “I think it was called clobetasol,” Laura said.
“Several years ago,” Laura went on, “you said I had toenail fungus in my nails, but I didn’t want to take pills for it because it didn’t bother me enough.”
“Maybe now would be a good time,” I said.
After I had recommended oral and topical therapy (and stopped the clobetasol!), my student and I went into my office. Like most of my students, she is headed for a career in primary care, in her case, Family Medicine.
“What do you think?” I asked her. “How does this case reflect on the state of dermatology expertise in the primary care community?” We’ve been discussing this, because Laura’s was not the first such example, just the most egregious.
My student’s eyes widened. No need to belabor the point.
“The problem is not that Laura’s primary care physician made a mistake,” I said. “I make them too, like prescribing antifungal creams for eczema and steroid creams for fungi. The problem is not noticing that you’ve made the mistake – with the evidence literally staring you in the face – and then either fixing it, or else consulting someone else who can help you fix it.”
“I’m going to do a better job!” said my student, with feeling.
Perhaps she will. At least she will graduate medical school having learned that there is such a thing as nummular eczema and been told that not every round rash is a fungus. As with almost every 4th-year student who’s taken my elective for the last 35 years, she had little dermatology exposure until now beyond a couple of PowerPoint shows of exotic diseases. I had none either back in school, when dinosaurs roamed the earth.
After I graduated, my prestigious pediatric residency taught me a grand total of three dermatologic facts: 1. For tinea capitis, shine a Wood’s light on the scalp; 2. For pityriasis rosea, shine a Wood’s light on the body; and 3. If a groin wash involves the inguinal fold, it’s a yeast infection. I learned a lot, didn’t I?
Reflecting on Lesson #1, Trichophyton tonsurans, which doesn’t fluoresce, has predominated for half a century (and 90% of the time, the problem is seborrhea anyway). As for #2 and #3, never mind.
Decade after decade, the patients troop in: Eczemas treated as fungi, fungi treated with steroids, itchy rashes treated with permethrin, then treated again because the itch didn’t stop, because you can’t kill bugs that aren’t there.
Clinical dermatology is not rocket science. Eczema and fungus are so common that it is hardly possible not to encounter them in daily practice. Generations of providers come and go, yet the same clinical missteps persist.
Why are the common skin problems of ordinary patients not a priority in medical education? Why do so many practitioners keep doing the same things and not get better at doing them?
Perhaps such common problems just pass under the educational radar. Maybe these diseases aren’t sexy enough, their poor outcomes not consequential enough. Maybe the shoe just doesn’t pinch hard enough on these itchy, polycyclic plaques.
My students are very young and earnest. They mean to get out into the world and do a good job. Many challenges before them, which now include crushing, mind-numbing bureaucratic demands. Can we ask that, while they are busy clicking drop-down boxes on their EHR’s and mastering genomic medicine, they also treat eczema as eczema and fungus as fungus?
One hopes so.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.