INTRODUCTION

Currently, the scope of dermatological healthcare extends beyond the outpatient clinic. Dermatologists are increasingly playing a pivotal and proactive role in the assessment of patients within hospital and emergency settings. However, there is limited knowledge regarding the primary reasons for such consultations. The nature and frequency of dermatological consultations may differ significantly depending on each country’s healthcare system. This variation is influenced by factors such as the level of healthcare services provided by each institution (primary, secondary, and tertiary care), the accessibility to emergency, intensive care, and/or inpatient services, and whether the facility includes dermatology residents and offers round-the-clock dermatological evaluation. To the best of our knowledge, this study is the first to document the reasons for dermatological consultations at emergency departments and in inpatient settings in Mexico.

MATERIALS AND METHODS

This study is a detailed, observational, and retrospective analysis conducted at the National Institute of Medical Sciences and Nutrition Salvador Zubirán in Mexico City. Over a span of two years (March 1, 2021, to March 1, 2023), we reviewed cases that necessitated dermatological consultations within the emergency and inpatient services. As a premier tertiary care institution under the aegis of the Mexican Ministry of Health, the institute offers comprehensive medical care to adults with complex medical and surgical pathologies. Its infrastructure includes a multitude of medical disciplines, with 11 primary specialties, 14 subspecialties, and 43 advanced specialty programs, particularly, serving patients with complicated rheumatologic, hematologic-oncologic, and infectious diseases. The emergency department is manned by residents and attending physicians in internal medicine, from which a substantial number of dermatological consultations are requested.

Patient evaluations were performed by dermatology residents, ranging from the first to the third year of their training, under the supervision of board-certified dermatologists with a minimum of a decade of clinical practice. Complex cases were reviewed collectively by an expert panel comprising 11 dermatology residents and 8 senior dermatologists.

The hospital’s operational workflow is structured into 14 inpatient sectors, each equipped with 12 designated beds and complemented by emergency, intermediate, and intensive care facilities. A daily proactive search is instituted across these units to identify new referrals for dermatological evaluation.

Consultation hours predominantly spanned from 6:30 AM to 3:00 PM, supplemented by 24-hour availability of a resident dermatologist for urgent assessments as directed by the attending physicians. The average response time was approx. 1.5 hours, ranging from 1 to 3 hours.

In our statistical methodology, the median and range were utilized to describe the central tendency of continuous variables, given their distribution. Nominal variables were presented as percentages. We employed the chi-squared and Fisher’s exact tests for categorical variables and the Mann–Whitney U test for continuous variables to compare the characteristics of patients with and without dermatological conditions. A p value of 0.05 or less was deemed statistically significant. All statistical analyses were performed with SPSS software, version 21.

RESULTS

Infectious Etiologies as Primary Consultation Causes

In this study, infectious etiologies emerged as the predominant reason for medical consultations, comprising 49.7% of the cases (564 consultations). Viral infections were the most prevalent, constituting 24.1% of these cases. Notably, herpes simplex virus (HSV) infections were the foremost cause of the consultations, accounting for 11.4%, followed closely by varicella-zoster virus (VZV) and herpes zoster infections, which comprised 5.8% of the cases. Fungal infections, with candidal intertrigo as the leading type, represented the second most common cause of the consultations, encompassing 18.3% of the cases. Bacterial infections were responsible for 15.7% of the cases, with non-purulent soft tissue infections being the predominant reason for consultation, accounting for 9.5% of the cases. Within this category, Escherichia coli was identified as the most frequently isolated pathogen, contributing to 2% of the cases (Table 1). Contrastingly, sexually transmitted infections and parasitic infestations were relatively infrequent, accounting for only 2.1% and 0.6% of the consultations, respectively

Table 1: Etiological agents isolated in skin cultures from bacterial infections of soft tissues.

Consultation Locations: Inpatient Service vs. Emergency Department

Out of a total of 1,134 consultations, a significant majority, 909 (80.1%), occurred within the inpatient service, while the remaining 225 (19.9%) took place at the emergency department. Sex distribution revealed a slight predominance of female patients in inpatient consultations (50.8%), whereas at the emergency department, sex distribution was relatively balanced. The median age for patients was comparable across both settings, being 52 years for inpatient services and 54 years for emergency department visits. Temporal trends indicated a higher frequency of emergency department consultations in May (12.9%), in contrast to a peak in inpatient consultations during March (10.6%) and August (10.1%). This pattern aligned with the commencement of the medical residency cycle in Mexico starting in March.

A comparative analysis of consultation reasons between emergency and inpatient services revealed notable differences. Infectious causes were more prevalent in emergency consultations (66.7%) compared to inpatient settings (45.5%). Particularly, soft tissue infections (both purulent and non-purulent) were significantly more common at the emergency department (38.7% vs. 9.9%; p < 0.005). Conversely, eczema and dermatitis were more frequently observed in inpatient consultations (18.8% vs. 3%; p < 0.005) (Tables 2 and 3).

	Table 2: Infectious etiology consultations in dermatology services: motives and causes.
	Table 3: Non-infectious etiology consultations in dermatology services.

Adverse drug reactions with cutaneous manifestations, specifically drug eruptions, were similarly represented in both the inpatient and emergency services (9% vs. 9.5%).

DISCUSSION

Previously conducted studies on hospital dermatology have reported various reasons for consultations in large centers around the world. In California [1], at the emergency department, the main causes of hospital admission were Stevens–Johnson Syndrome/TEN in 22% of the cases, followed by blistering diseases (pemphigus vulgaris 14%), and finally other severe drug reactions (11%). In that study, 204 patients were analyzed, and only 18% (37 out of 204) of cases required hospital admission, meaning that 82% were not considered genuine dermatological emergencies (eczema, contact dermatitis, common psoriasis, and basal cell carcinoma). In Spain, there were three highly relevant studies related to this topic. The first of these was published in 2008 [2], aiming to evaluate the characteristics of dermatology consultations at the emergency department before the implementation of dedicated shifts for the specialty. This study was a turning point in the training and academic planning of the specialty in this country. It is highlighted that, in 2008, a total of 141,601 patients were evaluated at the emergency department, among which 3,662 had a skin condition. Among them, 96 pathologies were diagnosed, and the most common was urticaria (19.27%), followed by cellulitis (16.73%), and unspecified rash (8.06%). Following the implementation of specialized shifts for the specialty, a prospective study was conducted at the Ramón y Cajal University Hospital [3], where 861 dermatology consultations were performed over a two-month period (14.4 patients/day). A total of 131 diagnoses were made, and the most frequent causes were cellulitis (10.1%), acute urticaria (9.3%), and contact dermatitis (9.1%). Only half of the interconsultation visits were considered true emergencies, and it was highlighted that the on-call dermatologists demonstrated significant problem-solving capabilities. In 2016, another study was published [4], at a tertiary-level center in Spain, where the main reasons for emergency department visits in adults were acute urticaria (7.6%), contact dermatitis (6.1%), and drug eruptions (4.6%). When grouped by categories, the most common causes were infectious (23%), eczemas and dermatitis (15.1%), and procedural and surgical complications (9.5%). However, the primary causes of hospitalization were cellulitis (38.3%), drug eruptions (8.3%), and vasculitis (8.3%). Other centers around the world reporting their epidemiology include two Italian studies. The first [5] was a retrospective study conducted from 2006 to 2011, where the main reasons for emergency department consultations were infections (27.1%), followed by non-specific descriptive diagnoses (22.5%), physical or mechanical agent injuries (13.1%), eczema (10%), and insect bites (9.5%). The most frequent dermatological causes for hospital admission were physical or mechanical agent injuries (33.3%), infections (27.5%), drug eruptions (15.9%), and autoimmune diseases (7.4%). The second study [6] was a prospective, single-center study conducted over a three-year period focusing on patients who visited the emergency department, passed the triage, and were under observation, excluding non-urgent cases and those immediately discharged. The main cause of admission was infectious (41.67%), primarily bacterial, followed by atypical rashes (13.98%), and vasculitis (11.29%). In France [7], the primary reason for dermatology consultations in the emergency department was infectious causes. In Turkey [8], a retrospective study conducted from 2017 to 2018 reported that infectious causes (86.9%), mainly viral, were the leading reason for emergency department consultations, followed by inflammatory dermatoses (5.4%), urticaria, and angioedema (14%). On the other hand, in the Asian continent, two notable studies stand out on this topic. The first, from India in 2003 [9], highlighted infectious causes as the main reason for consultation, followed by drug eruptions. In contrast, in Korea [10], the primary reason for dermatological consultations in the emergency department was urticaria and angioedema (68.1%), followed by infectious causes and non-specific descriptive diagnoses. Only 6.2% of the cases required hospital admission.

In Latin America, there have been two studies conducted to date. The first study was carried out in Brazil [11], a prospective study conducted in 2010, which reported that the main reason for consultations in hospitalized patients was infectious causes (25%). This study emphasized the significance of the dermatology service as a consultant for hospitalization, as dermatological assessment led to disease management that influenced admission in 31% of the cases. Furthermore, it aided in diagnosing and/or treating dermatological conditions unrelated to the reason for admission. In Colombia [12], a retrospective study was conducted, where the primary causes of the consultations at the emergency department and hospitalization were infectious causes (28.83%), with fungal causes being the leading factor (12.71%), followed by papulosquamous and eczematous dermatoses (16.62%).

Table 4 presents a summary of previously published studies from 1994 to 2023 on the main reasons for dermatological consultations in hospitals of different countries.

Table 4: Studies on the causes of consultations in dermatology services.

In this study conducted at a tertiary care hospital, a total of 1,134 dermatological consultations in patients during their stay in the emergency department and hospitalization were reviewed. On average, the institute’s emergency department received 80,000 consultations during the study period. Consequently, dermatology consultations accounted for only 1.4% of all interconsultations. There was a predominance of the number of consultations in the hospitalization area (80% of the consultations). Other studies only included consultations at the emergency department [1–4,6–10,15–18,20–22]. Only in three studies, both populations were included [5,12,13], and in two studies, the difference between the studied population was not specified [11,19]. This may be explained by the magnitude of skin problems associated with hospitalizations for non-dermatological reasons, prolonged hospital stays, and polypharmacy, leading to multiple adverse skin reactions and cutaneous manifestations of systemic diseases, considering that our hospital is a reference center. Additionally, it is important to remember that, at the emergency department, patients come (in most cases) with serious and uncontrolled pathologies; therefore, similarly to what has been reported in other studies [2,14,21,23,24], we observed that skin infections predominated in dermatological consultations. Among these, soft tissue infections accounted for 38.7% of the cases, compared to the 9.9% reported in the hospitalization service.

In contrast to hospitalization, where consultations for eczema and reactive dermatitis predominated (18.8% vs. 3%) (p < 0.005), it is worth mentioning that all these consultations were requested for patients who were already hospitalized for a non-dermatological cause.

This is the first study reporting the findings of consultations for oral pathology, accounting for 20.1% of the reasons for consultation. Although the majority of them were not the main reason for consultation yet rather findings from a comprehensive dermatological review, it is important to mention them. Oral candidiasis predominated, followed by oral herpes, GUNA, mucositis, and deficiency dermatoses.

Consultations for adverse drug reactions with cutaneous manifestations (pharmacodermias) were similar in both services (9% vs. 9.5%). Most of them were non-severe cutaneous adverse reactions to drugs, among which morbilliform rash predominated. The drug most frequently associated was antibiotics. Regarding severe cutaneous adverse reactions, eight cases of DRESS syndrome and two cases of Stevens–Johnson syndrome (SJS/TEN) were observed.

Finally, we illustrate some of the reasons for consultation that we had in this study (Fig. 1).

Figure 1: (a) Oral ulcers caused by the herpes simplex virus. (b) Pseudomembranous candidiasis alongside seborrhea. (c) Case of eczema. (d) Intertrigo caused by Candida spp. (e) Soft tissue infection by Vibrio vulnificus. (f) Mpox infection. (g) Seborrheic dermatitis of the scalp.

CONCLUSION

This comprehensive study significantly advances the understanding of dermatological consultations in Mexican hospital environments. It underscores the prevalence of infectious dermatoses, notably soft tissue infections, in emergency settings, resonating with trends observed in Brazil and Colombia. A distinctive aspect of this research is its focus on the frequency of oral pathologies, particularly, oral candidiasis, in these consultations. Moreover, it highlights the similar incidence of drug-induced skin reactions in both inpatient and emergency scenarios. This investigation emphasizes the vital role of dermatology in a multidisciplinary hospital setting, highlighting its importance in early diagnosis and management of skin conditions. Such interventions are critical for reducing complications and hospital stay durations, and for diagnosing systemic diseases. The findings point toward the need for specialized dermatological training and resource allocation in Mexico and hint at the development of future management protocols to enhance patient care. This study not only contributes to the global dermatological literature yet also emphasizes the integral role of dermatology in comprehensive, multidisciplinary healthcare.

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