|Year : 2019 | Volume
| Issue : 3 | Page : 212-218
Clinical spectrum of dermatological disorders in children referred from pediatrics department
Taru Garg1, Riaz Ahmed2, Srikanta Basu3, Ram Chander1
1 Department of Dermatology and STD, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India
2 Department of Dermatology, Venereology and Leprosy, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India
3 Department of Pediatrics, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India
|Date of Web Publication||28-Jun-2019|
Dr. Taru Garg
Department of Dermatology, Venereology and Leprosy, Lady Hardinge Medical College and Associated Hospitals, Shaheed Bhagat Singh Road, Connaught Place, New Delhi - 110 001
Source of Support: None, Conflict of Interest: None
Background: Worldwide, limited studies have been done to study the spectrum of dermatological referrals in children. Aims and Objectives: The aim of this study was to analyze the spectrum of dermatological disorders in children referred from pediatrics department. Materials and Methods: It was a hospital-based observational study. Five hundred twenty-five children of either sex or age ≤18 years, in whom, parents had given written informed consent, and referred to Dermatology from Pediatric medicine department were included in this study. The diagnosis was made based on clinical features supported by necessary investigations. Working hours were considered as routine and emergency. Nelson' severity scoring system was used to classify children as sick. Results: Most of the children were referred during routine hours (85.7%), maximally from inpatient department (46%) followed by outpatient department (37%). Most common diagnosis was viral infections (21.2%), closely followed by eczematous disorders (17.6%) and disorders due to arthropods (17.1%). Majority of patients were not sick (83.61%). Pediatricians did not suggest any diagnosis in 70.85% of referrals followed by doubtful diagnosis in 26.85% and definitive diagnosis in 2.28% of patients. Conclusion: Majority of referrals were done during routine hours in nonsick patients. As many common easily treatable dermatoses were observed in all the referrals reiterating the fact that these referrals should be sought as early as possible to prevent unnecessary delays in the diagnosis and patient management. Furthermore, a robust dermatological training should be provided to undergraduates and interns to better equip the nondermatologists to diagnose common dermatological disorders.
Keywords: Dermatological referrals, Nelson score, pediatrics department
|How to cite this article:|
Garg T, Ahmed R, Basu S, Chander R. Clinical spectrum of dermatological disorders in children referred from pediatrics department. Indian J Paediatr Dermatol 2019;20:212-8
|How to cite this URL:|
Garg T, Ahmed R, Basu S, Chander R. Clinical spectrum of dermatological disorders in children referred from pediatrics department. Indian J Paediatr Dermatol [serial online] 2019 [cited 2019 Dec 14];20:212-8. Available from: http://www.ijpd.in/text.asp?2019/20/3/212/261862
| Introduction|| |
Skin disorders are common in Pediatric age group. Children may have a primary skin disorder or a coexisting skin disorder or may have a primary systemic disorder with cutaneous manifestations. These children may present to a Dermatologist or more commonly to a Pediatrician. Dermatological conditions constitute 30% of all outpatient visits to a pediatrician, and 30% of all visits to dermatologists are by children., Almost all specialties require the services of a dermatologist during the management of their patients. In a previous study out of all dermatology consultations, 11.7% were from the pediatrics department. Referrals by pediatrician to a dermatologist can be from their outpatient department (OPD), inpatient department and from casualty. Skin disorders have been estimated to represent 4% of all pediatric emergency care unit visits, with only 30% of these being true emergencies. The diagnoses and impact of inpatient consultations have been detailed for adult Dermatology. However, there is meagre data on this in pediatric age group. Interesting findings observed in the available literature on the issue are: relative inability of most referral doctors to diagnose skin diseases accurately and marked changes in dermatologic diagnoses and treatment resulting from dermatologic consultation. There are very few reported studies on dermatology referrals from pediatrics department including different domains, as for pediatric emergency, inpatient care, outpatient care or overall. As there is paucity of studies in this regard, we conducted this study to delineate the pattern of referrals from pediatric medicine.
| Materials and Methods|| |
It was a hospital-based observational study conducted at the Department of Dermatology of tertiary care center, between November 2015 and March 2017 and study was approved by the Ethics Committee and Institutional Review Board. Five hundred and twenty-five children of either sex and age ≤18 years, in whom, parents had given written informed consent to use their data, referred to dermatology from pediatric medicine emergency, inpatient and OPD were included in this study. Pediatric patients who had directly come to Dermatology Department without any pediatric referral and neonates were excluded from this study. Detailed demographic data, history and examination, and other information were recorded, as per clinical pro forma. The diagnosis was made based on clinical features supported by necessary investigations wherever required. Skin biopsy was performed in a total of 26 patients (10 vasculitis, 3 papulosquamous disorders, 2 panniculitides, 2 lichen scrofulosorum, 1 each in bacterial infection, urticaria, drug reaction, viral infection, angiokeratoma, neonatal lupus erythematosus, langerhans cell histiocytosis, ectodermal dysplasia, and seborrheic dematitis). Potassium hydroxide mount was done in case of dermatophytic (14 patients) or candidal infections (28 patients). Gram-stained smears were made in cases of bacterial infections (10 patients). Tzanck smear was done in cases of viral infections (10 patients). Samples for blood (15 patients) and pus (45 patients) culture and sensitivity were taken wherever required. Other routine investigations carried out for the diagnosis and management of the patients included complete blood counts (326 patients), liver and kidney function tests (253 patients), serological tests as: Chikungunya serology (22 patients), antinuclear antibody (6 patients), others (antistreptolysin O antibody titres in 78 patients, C-reactive protein in 82 patients, coagulation profile in 6 patients), and radiological tests (81 patients). Final diagnosis was made on the basis of history, clinical examination, and investigations. The dermatologic diagnoses were grouped in following categories for analysis bacterial infection, viral infection, fungal infection, disorders caused by arthropods, eczematous disorders, disorders of skin adnexa, papulosquamous disorders, panniculitides, urticaria, drug reaction, vasculitis, pigmented disorder, and others [Figure 1].
Working hours were considered as routine and emergency as follows – Routine working hours: Monday to Friday between 9 am and 4 pm and Saturday between 9 am and 1 pm. Emergency working hours: Monday to Friday between 4 pm and 9 am and on the weekend, Saturday 1 pm to Monday 9 am. Nelson's severity index scoring system (NSIS) was used to classify children as sick on the basis of 5 parameters (respiratory effort, color, activity, temperature and play), a score of 10 points is designated as “not sick,” 8 or 9 points as “moderately sick,” and 7 or less points as “very sick.” Clinical photographs of representative dermatological lesions were taken in all the patients. Treatment was individualized as per the dermatological disorder.
Statistical Package for the Social Science software 17.0 was used for the analysis. Categorical variables were expressed as frequencies and percentages and were analyzed using Chi-square test considering P < 0.05 as statistically significant. Quantitative variables were presented as mean ± standard deviation.
| Results|| |
In total, 331 (63.04%) males and 194 (36.95%) females were included in the study. Maximum number of patients (n = 387, 73.33%) were in the age group of 1 month to 5 years. Majority of patients were ≤10 years of age (n = 472, 89.90%). Maximum number of patients were referred from inpatient department (n = 246, 46%) followed by OPD (n = 194, 37%) [Figure 2].
|Figure 2: Various categories of disorders: (a) viral warts, (b) scabies, (c) miliaria rubra, (d) vasculitis, (e) impetigo contagiosa, (f) seborrhoeic dermatitis, (g) Urticaria, (h) candidal intertrigo, (i) trachyonychia|
Click here to view
Out of 525 patients, maximum number of patients had dermatological diagnosis of viral infections (n = 114, 21.2%), closely followed by eczematous disorders (n = 95, 17.6%), and disorders due to arthropods (n = 92, 17.1%) [Table 1]. Fourteen patients (2.66%) had more than one dermatological diagnosis. Maximum number of patients of viral infection was from the inpatient department (42.98%), followed by OPD and pediatric emergency. This difference was found to be statistically significant (P = 0.012). However, bacterial infection referrals were most common from the OPD (53.70%) followed by inpatient department and pediatric emergency with statistically significant difference (P = 0.024). In urticaria, the majority of patients were from pediatric emergency (48.88%) followed by inpatient and OPD, and this was found to be statistically significant (P < 0.001). In vasculitis, majority of patients were from inpatient department (91.66%) followed by OPD and pediatric emergency, and this was also found to be significant (P = 0.007). Disorders due to arthropods were almost equally present in both referrals from inpatient (46.73%) and outpatient (43.47%) departments. Referrals for eczematous disorders, fungal infections, drug reactions, pigmented disorders, and others were found to be more from inpatient as compared to OPD, whereas referrals for disorders of adnexa, papulosquamous disorders, and panniculitides were more from OPD [Table 2].
|Table 2: Proportion of various dermatological disorders according to sites of referral|
Click here to view
Maximum number of patients (n = 450, 85.7%) were referred during routine hours. Twelve patients (2.28%) from emergency were referred during routine hours. Disorders of all categories were referred more commonly during routine hours. However, statistically significant difference of referrals between routine and emergency hours was observed for viral infections, fungal infections and urticaria, (P = 0.043, 0.011, <0.001, respectively). Most common disorders referred during emergency hours were viral infections (29.8%) followed by urticaria (25.9%) [Table 3].
|Table 3: Proportion of various dermatological disorders according to referral time|
Click here to view
NSIS scores for patients ranged from 3 to 10 (mean score 9.68 ± 0.931). Majority of patients were not sick from all the three sites of referral: (pediatric emergency: 85.90%, inpatient: 74.00%, and outpatient: 94.80%). Number of sick children referred from inpatient department (7.70%) was more as compared to pediatric emergency (3.50%). On the comparison between all the three sites of referral, the difference was statistically significant for viral infection, vasculitis, and drug reaction (P = 0.012, 0.014, 0.005, respectively) referrals. Maximum percentage of patients, who were moderately sick belonged to drug reaction category (36.36%) followed by panniculitides (33.33%). Maximum percentage of patients in very sick category had drug reaction (18.18%) followed by vasculitis (16.66%) [Table 4].
|Table 4: Proportion of various dermatological disorders according to Nelson's Severity Index Scores|
Click here to view
In majority of patients no diagnosis had been made by pediatrician (n = 372, 70.85%) from all the three sites of referral: (pediatric emergency; n = 51, 60.0%, inpatients; n = 196, 79.61%, and outpatients n = 125, 64.43%), followed by doubtful diagnosis; (n = 141, 26.85%). Definitive diagnosis was made in 12 (2.28%) patients.
| Discussion|| |
This study was conducted in a tertiary care setup where we have a separate wing for pediatrics in which we run an OPD dedicated to pediatric dermatology. Here, we see patients reporting directly to our OPD along with referrals from all pediatric specialties including pediatric medicine, pediatric surgery, pediatric orthopedics, pediatric otorhinolaryngology, and pediatric ophthalmology. We also get referrals from pediatric medicine inpatient department and pediatric emergency. We had conducted this study to know the clinical spectrum of dermatological disorder from all three referrals sites of pediatric medicine department as there was no previous study with a similar design. The studies which are available either show spectrum of dermatological disorders in children as a whole or focus on dermatological disorders from pediatric emergency and inpatient department.
In this study, maximum number of patients were referred from pediatric medicine inpatient department (46%) followed by OPD (37%). The remaining patients (16.2%) came from pediatric emergency department. In a retrospective review of all pediatric dermatology inpatient consultation data over a period of 42 months in children 18 years and below, a total of 486 consultations were given to inpatient children with an average of 123 consultations per year. Maximum number of dermatology consult references was from general pediatrics (240,49.4%) followed by pediatric intensive care unit (PICU) (184, 37.9%). In another retrospective study among the pediatric dermatology hospital consult group there were 75 patients who had 83 dermatology consults during hospitalization, the main consult requesting services included general pediatrics (n = 39, 47.0%), followed by pediatric hemato-oncology (n = 11, 13.3%) and PICU (n = 8, 9.6%). In both the studies, the number is less as compared to our study as we have an exclusive large pediatric setup with a large patient load. In a study conducted by Sarkar et al. on Pediatric emergency referrals, over a period of 1 year, a total of 103 referrals were requested inclusive of neonates.
On analysis of the referral time, maximum number of patients (85.7%) was referred to us during the routine hours, as compared to 14.3% in the emergency hours. This can be explained by the fact that the hospital is busiest during the routine hours as all OPDs are running, and majority of referrals from inpatient departments are being sent during this time. According to a study conducted by Wakosa et al. in which the authors studied the patient profile of dermatological emergencies, it was found that Mondays were the busiest days of the week. However, we did not analyze according to the days of the week. Interestingly, we noticed that 12 patients (2.28%) from emergency were referred to us during the routine hours and most of these patients were not sick.
In our study, overall NSIS ranged from 3 to 10 (mean score 9.68 ± 0.931). However, majority of patients were not sick from all three sites of referral. This was an expected outcome from outpatient setting as these patients are mainly walk-in patients who present to the OPD. The number of non-sick patients was lower in the other two groups, namely, emergency and inpatients as compared to the outpatient group. The total number of sick patients was 22 (4.19%) in which 19 patients were from inpatient department (7.70%), and 3 patients were from pediatric emergency (3.50%). This finding could be explained by the fact that our inpatient group also comprised of the critically ill patients admitted to the Intensive Care Units. In a previous study conducted by Mathias et al. in patients with Pediatric dermatological emergencies with NSIS scores ≤7 an equal number of patients had presented to the routine OPD of dermatology/pediatrics (50%) and the emergency department (50%). However, we did not get very sick patients in our OPD referrals.
We had categorized our patients according to dermatological disorders into different categories. In our study, viral infections (21.2%) were most common, followed by eczematous disorders (17.6%) and disorders due to arthropods (17.1%). In a study conducted by Negi et al. at Dermatology OPD, among pediatric dermatoses, infectious dermatoses contributed 50.9% of all cases under study, these results showed similar results as our study that infection is most common among pediatric age group. Similarly, in another study by Casanova et al.conducted on childhood dermatoses in a dermatology clinic of a general university hospital, which analyzed diagnoses by categories, the most frequent categories were tumors and infections (27.7% of patients for each category and 55.4% overall). The next most frequent category was eczema (n = 159, 14.6%), followed by skin adnexal diseases (n = 108, 9.9%), erythematosquamous dermatoses (n = 39, 3.6%), dyschromias (n = 26, 2.4%), dermatoses caused by insects and mites (n = 21, 1.9%), and reactive dermatoses (n = 15, 1.4%).
In our study, on analyzing inpatient referrals, eczematous disorders were most common (n = 52, 20.6%) followed by viral infections (n = 49, 19.4%). In a study conducted by Storan et al. on inpatients referrals, the authors found drug reactions and cutaneous infections (n = 12, 12.1% in each) as most common referrals. In another inpatient study conducted by Srinivas et al. the authors found that most common diagnostic categories were: cutaneous infection (n = 115, 23.7%), emergency skin conditions (n = 62, 12.8%), genodermatosis (58, 11.9%), and skin disorder secondary to systemic illness (n = 55, 11.3%). In yet another study conducted on dermatological referrals from inpatients, the most frequent diagnoses were contact dermatitis in 8.9%, drug reactions in 7.4%, candidiasis in 7.1%, and seborrheic dermatitis in 5.3%.
In pediatric emergency referrals, viral infections were found to be most common (33.0%) followed by urticarial (25.0%) in our study. In a study by Auvin et al. conducted in France, the six most common pediatric dermatological diseases observed in the ER were viral exanthema (17%), urticaria (15%), atopic dermatitis (8%), varicella (9%), diaper dermatitis and herpetic gingivostomatitis (4% each). These results go very well with our study where we observed maximum number of viral infections and urticaria. In a study by Kramkimel et al. on pediatric casualty patients, infectious diseases were observed in 46.5% of cases. These were mainly viral (27.6%) and bacterial infections (14.4%). Similarly, in another study from pediatric emergency, among the diagnostic groups, the most commonly observed were skin infections (25.2%), followed by dermatitis (23.5%), mucosal disorders (10.3%), and urticaria and angioedema (10.2%). Among infections, viral infections were the most commonly encountered (13.6%), followed by bacterial (10.6%) and fungal infections (0.6%). In another study by Landolt et al. on pediatric emergency patients on 1572 patients, viral and parainfectious exanthema were the most common diagnosis (17.6%), followed by anogenital dermatitis (7.7%), gingivostomatitis (7.1%), petechiae (6.4%), burns (6.0%), urticaria (5.0%), and insect bite reactions (5.0%). In our study also viral infection was the most common category, however, higher percentage of urticaria patients was seen compared to above two studies (25% vs. 10.2% and 5%)., In another study on pediatric emergency patients by Larsen et al. the most prevalent diagnoses were: Unspecified eczema (10.7%), drug eruptions (6.3%), psoriasis (6.3%), atopic dermatitis (5.6%), bacterial skin infections (4.0%), inflammatory skin disorders (3.7%), seborrheic dermatitis (3.5%), urticaria (3.0%), seborrhoeic keratosis (3.0%), toxic contact dermatitis (2.8%), ulcuscruri (2.8%), autoimmune diseases (2.8%), malignant skin tumors (2.5%), candidiasis (2.5%), pruritus/prurigo (2.5%), and viral skin infections (2.5%). This is in contrast to our study where viral infections were the most common group.
In our study, out of 525 patients, maximum number of patients had dermatological diagnosis of viral infection (n = 91, 19.6%), followed by disorder due to arthropods (n = 84, 18.1%) in routine hours. Similarly, in emergency hours, majority of patients had dermatological diagnosis of viral infection (n = 23, 29.8%). However, it was followed by urticaria (n = 20, 25.9%). To the best of our knowledge, no other study had compared dermatological referrals during routine and emergency hours from Pediatric medicine.
In our study, majority of patients were not sick in all categories of dermatological disorders. Very sick patients were maximum in viral infection (n = 6, 27.27%), closely followed by eczematous disorder (n = 4, 18.18%). In a study by Mathias et al. most common disorders in sick category were found to be bacterial infections followed by drug reactions. Viral exanthem with thrombocytopenia was observed in 3.33% of patients. No patient with eczematous disorder was observed. These results differ from our study. This may be explained by different study design and could be due to the presence of concomitant systemic involvement in our study patients which can affect the NSIS score.
In our study, in category of disorders due to arthropods, most common disease was scabies in pediatric emergency (n = 5, 55.55%), and inpatient department (n = 33, 76.74%). However, in OPD, insect bite hypersensitivity was most common (n = 18, 45%). In a study on inpatients, referrals showed that scabies (n = 24, 55.81) was the most common disease among parasitic infections as observed in our study. In a study of pediatric dermatosis in OPD, among dermatoses due to insects and mites, insect bite (n = 11, 52.38%) was most common followed by scabies (n = 8, 38.09%). In bacterial infection, the most common disease was impetigo from all three sites of referral. A study on inpatient referrals showed staphylococcal scalded skin syndrome (SSSS) in 10 (1.4%) patients, similar to our study results (0.81%). In a study of pediatric emergency, among bacterial infections, the main emergency was SSSS, which accounted for 50% of all infections, whereas in our study SSSS accounted for 16.66% of all bacterial infections from emergency. In eczematous disorders, the most common disease was seborrheic dermatitis from all the three sites of referral. A study on inpatient referral showed seborrheic dermatitis in 16 (2.27%) patients as against higher percentage (10.9%) in our study. However, in a study of pediatric emergency, authors found that atopic dermatitis (n = 33, 8%) was the most common, amongst eczematous disorders. In fungal infection, most common disease was candidal infection in pediatric emergency (n = 3, 100%), and inpatient (n = 19, 70.37%), and dermatophytic infection in outpatient (n = 10, 55.55%) department. In a study of OPD, amongst fungal infection, dermatophytic infections (n = 34, 72.23%) were more common followed by candidal infection (n = 6, 12.76%) similar to our study. A Study by Ahmad and Ramsay on inpatient referral showed a lower percentage of dermatophytic infections as compared to our study (3.25% vs. 1.4%). In viral infection, herpes infection was most common in pediatric emergency (n = 12, 41.37%). In inpatient and OPD, most common was viral exanthem; (n = 16, 30.18%, n = 14, 41.17% respectively). In a study on inpatients referral herpes infection (n = 172, 72.26%) was most common, which was observed in our pediatric emergency referrals. In a study of pediatric dermatological emergencies, authors found viral exanthem (n = 68, 17%) to be most common, among viral infection.
In our study, in 29.14% of total referrals, a dermatological diagnosis was suggested by the pediatrician at the time of the referral. In studies conducted by Falanga et al. and Davila et al. on inpatient dermatology consultations, pediatricians had made the correct diagnosis in 44% and 28% of the consultations respectively.
Based on the results of our study, we recommend that a robust dermatological training should be provided to undergraduates and interns to better equip the nondermatologists to diagnose common dermatological disorders. NSIS score or other similar scores should be utilized in emergency setting for better triage and prognostication of patients. Our study also emphasizes the need for better segregation and allotment of patients to various OPDs at the OPD registration counters. Finally, many common easily treatable dermatoses were observed in all the referrals reiterating the fact that these referrals should be sought as early as possible to prevent unnecessary delays in the diagnosis and patient management.
| Conclusion|| |
Majority of referrals were done during routine hours in non-sick patients. As many common easily treatable dermatoses were observed in all the referrals reiterating the fact that these referrals should be sought as early as possible to prevent unnecessary delays in the diagnosis and patient management. Also a robust dermatological training should be provided to undergraduates and interns in order to better equip the non dermatologists to diagnose common dermatological disorders.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Thappa DM. Common skin problems in children. Int J Pediatr 2002;69:701-6.
Federman DG, Reid M, Feldman SR, Greenhoe J, Kirsner RS. The primary care provider and the care of skin disease: The patient's perspective. Arch Dermatol 2001;137:25-9.
Kiellberg Larsen H, Sand C. Referral pattern of skin diseases in an acute outpatient dermatological clinic in Copenhagen. Acta Derm Venereol 2005;85:509-11.
Mathias RC, Jayaseelan E, Augustine M. Spectrum of pediatric dermatological emergencies at a tertiary care hospital in India: A descriptive study. Int J Dermatol 2013;52:27-31.
Falanga V, Schachner LA, Rae V, Ceballos PI, Gonzalez A, Liang G, et al.
Dermatologic consultations in the hospital setting. Arch Dermatol 1994;130:1022-5.
Nelson KG. An index of severity for acute pediatric illness. Am J Public Health 1980;70:804-7.
Srinivas SM, Hiremagalore R, Venkataramaiah LD, Premalatha R. Pediatric dermatology inpatient consultations: A retrospective study. Indian J Pediatr 2015;82:541-4.
Storan ER, McEvoy MT, Wetter DA, el-Azhary RA, Hand JL, Davis DM, et al.
Pediatric hospital dermatology: Experience with inpatient and consult services at the mayo clinic. Pediatr Dermatol 2013;30:433-7.
Sarkar R, Basu S, Patwari AK, Sharma RC, Dutta AK, Sardana K, et al.
An appraisal of pediatric dermatological emergencies. Indian Pediatr 2000;37:425-9.
Wakosa A, Roussel A, Delaplace M, Le Bidre E, Binois R, Valéry A, et al
. Interest of emergency dermatological consultation in a regional hospital. Presse Med 2013;42:409-15.
Negi KS, Kandpal SD, Parsad D. Pattern of skin diseases in children in Garhwal region of Uttar Pradesh. Indian Pediatr 2001;38:77-80.
Casanova JM, Sanmartín V, Soria X, Baradad M, Martí RM, Font A, et al.
Childhood dermatosis in a dermatology clinic of a general university hospital in Spain. Actas Dermosifiliogr 2008;99:111-8.
Penate Y, Borrego L, Hernandez N, Islas D. Dermatologists in hospital wards: An 8-year study of dermatology consultations. Dermatology 2009;219:225-31.
Auvin S, Imiela A, Catteau B, Hue V, Martinot A. Paediatric skin disorders encountered in an emergency hospital facility: A prospective study. Acta Derm Venereol 2004;84:451-4.
Kramkimel N, Soussan V, Beauchet A, Duhamel A, Saiag P, Chevallier B, et al.
High frequency, diversity and severity of skin diseases in a paediatric emergency department. J Eur Acad Dermatol Venereol 2010;24:1468-75.
Landolt B, Staubli G, Lips U, Weibel L. Skin disorders encountered in a Swiss paediatric emergency department. Swiss Med Wkly2 013;143:13731.
AlKhater SA, Dibo R, Al-Awam B. Prevalence and pattern of dermatological disorders in the pediatric emergency service. J Dermatol Dermatol Surg 2017;21:7-13.
Ahmad K, Ramsay B. Analysis of inpatient dermatologic referrals: Insight into the educational needs of trainee doctors. Ir J Med Sci 2009;178:69-71.
Davila M, Christenson LJ, Sontheimer RD. Epidemiology and outcomes of dermatology in-patient consultations in a Midwestern U.S. University hospital. Dermatol Online J 2010;16:12.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]