The impact of dermatology consultation on diagnostic accuracy and antibiotic use among patients with suspected cellulitis seen at outpatient internal medicine offices: a randomized clinical trial.

IMPORTANCE: Cellulitis is a common and costly problem, often diagnosed in the outpatient setting. Many cutaneous conditions may clinically mimic cellulitis, but little research has been done to assess the magnitude of the problem. OBJECTIVE: To determine if obtaining dermatology consultations in the outpatient primary care setting could assist in the diagnosis of pseudocellulitic conditions and reduce the rate of unnecessary antibiotic use. DESIGN, SETTING, AND PARTICIPANTS: Nonblinded randomized clinical trial of competent adults who were diagnosed as having cellulitis by their primary care physicians (PCPs), conducted at outpatient internal medical primary care offices affiliated with a large academic medical center. INTERVENTIONS: Outpatient dermatology consultation. MAIN OUTCOMES AND MEASURES: Primary outcomes were final diagnosis, antibiotic use, and need for hospitalization. RESULTS: A total of 29 patients (12 male and 17 female) were enrolled for participation in this trial. Nine patients were randomized to continue with PCP management (control group), and 20 patients were randomized to receive a dermatology consultation (treatment group). Of the 20 patients in the dermatology consultation group, 2 (10%) were diagnosed as having cellulitis. In the control group, all 9 patients were diagnosed as having cellulitis by PCPs, but dermatologist evaluation determined that 6 (67%) of these patients had a psuedocellulitis rather than true infection. All 9 patients (100%) in the control group were treated for cellulitis with antibiotics vs 2 patients (10%) in the treatment group (P < .001). One patient in the control group was hospitalized. All patients in the treatment group reported improvement of their cutaneous condition at the 1-week follow-up examination. CONCLUSIONS AND RELEVANCE: Dermatology consultation in the primary care setting improves the diagnostic accuracy of suspected cellulitis and decreases unnecessary antibiotic use in patients with pseudocellulitic conditions. Obtaining an outpatient dermatology consultation may be a cost-effective strategy that improves quality of care. TRIAL REGISTRATION: clinicaltrials.gov Identifier:NCT01795092.

Cutaneous calciphylaxis: a retrospective histopathologic evaluation.

Calciphylaxis is a rare and life-threatening disease characterized by cutaneous necrosis and vascular calcification. Often, skin biopsy specimens are not diagnostic because of the limited depth of the specimen, biopsy site, and clinical stage. To better understand the utility of various histologic features in rendering the diagnosis of calciphylaxis and to compare von Kossa versus Alizarin red stains in the detection of calcium deposits, we retrospectively analyzed the histologic features and histochemical stain findings of 56 skin biopsies from 27 consecutive patients seen at Massachusetts General Hospital from October 2002 to April 2012, with confirmed diagnosis of calciphylaxis and compared with that of 19 skin biopsies from 17 patients with other disease processes. All forms of vascular calcification and vascular thrombosis were significantly associated with cutaneous calciphylaxis. Perieccrine calcium deposition, highly specific to calciphylaxis, was the only form of calcium deposition noted in 4 (7%) skin biopsies from patients with calciphylaxis. Although the staining appears to be comparable, the deposits seen on Alizarin red appeared larger and were birefringent. Although subtle, perieccrine calcification may aid in the diagnosis of calciphylaxis in settings where typical vascular and extravascular calcification are not identified. Performing both von Kossa and Alizarin red stains might increase the detection of calcium deposit.