Dermatological hospitalizations and consultations referrals

During the period of August 2018-January 2020, we identified 12,656 pediatric hospitalizations, with 865 dermatological ICDs registered, which represents 6.8% of the total hospitalizations. The main dermatological ICDs were “cellulitis and acute lymphangitis” (14.3%), “cutaneous abscess, furuncle, and carbuncle” (11.0%), and “purpura” (8.8%) (Table 1).

Dermatology referrals included 266 referrals from hospital teams, either from the pediatric ward (54.5%) or the pediatric emergency (37.6%) as the main requesting hospital sectors. Most of the referrals originated from general pediatrics (73.3%) and pediatric oncology (8.3%). The majority of pediatric patients were hospitalized under public health system coverage (66.1%) (Table 2).

In relation to referrals’ information, a significant portion of them did not present data about clinical conditions (48.5%). The location of skin lesions was the most referred clinical data (30.0%). Only 3.7% of referrals reported the four clinical parameters analyzed, whereas diagnostic hypotheses were indicated in only 28.5% of the dermatology referrals (Table 2).

Profile of dermatology consultations

After preliminary analysis and duplicate referrals exclusion, we identified 167 pediatric consultations performed by the dermatology team during the 18-month period, with a response time of < 24 hours for most of the evaluations (80%). Most inpatients were males (56.9%), “younger than 1 year” (19.2%), or “11-14 years” (19.2%). Most evaluations led to single diagnoses (77.8%), with “dermatitis and eczema” and “skin infections” standing out as the most prominent groups of dermatoses, with 38.7 and 31.2%, respectively (Table 3).

Regarding the profile of dermatoses by age groups, we observed a higher prevalence of “Skin infections” among neonates, infants, and preschoolers, whereas “dermatitis and eczema” were most frequent among schoolers and adolescents (Figure 1). About dermatological ICDs, “scabies” (B86) and “impetigo” (L01) stood out among the major skin diseases at younger ages, whereas “drug eruptions” (L27) were more relevant with advancing age, particularly in adolescence. “Atopic dermatitis” (L20) exhibited high prevalence in all age groups but with greater expression in preschoolers and schoolers (Table 4).

Figure 1 Groups of skin diseases in dermatological consultations, by age groups*. *Total of 167 consultations corresponds to 199 dermatological diagnoses; chi-square test 63,502, p = 0,029. **Age groups: neonates (under 1 month); infants (2-11 months); toddlers (1-2 years); preschoolers (3-5 years); schoolers (6-10 years); adolescents (11-17 years). ***Infectious dermatoses and ICDs: bacterial infections (L00, L01, L02, L03, L08, A30, A46, A53); viral infections (B00, B01, B02, B07, B08, B97); fungal infections (B35, B36, B37, B42); parasitic infections and infestations (B85, B86, B87). 

Laboratory tests (29.3%) and skin biopsies (10.8%) were the main requested complementary exams. Skin biopsies presented anatomopathological reports in concordance with the clinical diagnoses of dermatology teams in 66.6% of the evaluations (n = 12/18). “Bacterial cultures” were requested only in 6% (n = 10/167) of hospital consultations, with Staphylococcus aureus as the most prevalent etiologic agent (40%; n = 4/10).

With respect to dermatologists’ management, corticoids were the most recommended drugs in consultations (35.7%), with a predominance of topical presentations (59.3%), followed by moisturizers (26.3%) (Table 3). Antibiotics were indicated in 22.7% of the dermatology evaluations, highlighting the systemic presentation (n = 33/86.8%), mainly oxacillin (n = 14/38; 36.8%) and cephalexin (n = 9/38; 23.7%).

“Outpatient follow-up” and “inpatient and outpatient follow-up” were the leading orientations of dermatology follow-up, appearing in 35 and 32% of hospital consultations, respectively. Furthermore, 4.8% (n = 8/167) of dermatological consultations presented loss of follow-up during the dermatology hospital assistance, whereas 28.7% (n = 48/167) were managed and discharged by the dermatology team without the need for additional outpatient follow-up (Figure 2).

Figure 2 Follow-up recommendations of dermatology consultations*. *Outpatient follow-up’ consists of dermatological consultations whose duration of dermatology assistance was ≥ 7 days and with recommendation for outpatient follow-up after completion. “Inpatient + outpatient follow-up” included dermatological consultations whose dermatology assistance duration was longer than 7 days and with a recommendation for outpatient follow-up after completion. 

Dermatology consultations: epidemiology of hospital skin diseases

Throughout the 18-month period analyzed, dermatology teams performed 167 hospital consultations, with a higher prevalence of adolescent and schooler inpatients, converging with a study in a Brazilian university hospital¹⁶. Conversely, this trend differs from findings in a Turkish pediatric hospital, where infants and preschool were the most frequent age groups⁹.

These contrasts can be related to demographic and epidemiological differences between the populations of such countries or even reflect methodological divergences insofar as studies with pediatric populations tend to adopt different compositions of age groups, hampering comparative analysis. Thus, if we consider age, one-third of dermatology consultations addressed 2-year-old or younger patients, which may represent an immunological immaturity and a higher life-threatening risk in the early stages of life⁹.

Regarding the profile of dermatoses, the main groups of diagnoses were “dermatitis and eczema” and “skin infections”, agreeing with previous investigations²,⁴,¹⁰,¹⁷ (Table 5). Hence, “drug eruptions” (L27) and “atopic dermatitis” (L20) figured as the most prevalent cutaneous disorders assisted by dermatology consultations, followed by “impetigo” (L01) and “herpes virus infections” (B00), which were the most frequent skin infections.

Atopic dermatitis is one of the most frequent dermatological causes of pediatric hospitalizations, particularly in preschool and school ages¹,²,⁹,¹⁸,¹⁹. This condition may evolve with recurrent exacerbations, presenting eczema, erythroderma, and secondary infections, then requiring hospital care¹,²⁰. With this in mind, the high prevalence of atopic dermatitis and skin infections can suggest their concomitance, as asserted by Narla S and Silverberg JI²⁰, who pointed out the greater susceptibility to bacterial and viral infections among patients with atopic dermatitis. According to Storan ER et al.¹⁸, timely pediatric hospitalizations can contribute both to managing atopic dermatitis, as well as to support parents and caregivers in the adherence to medical and non-medication measures for controlling the disease. Nonetheless, on the other hand, hospital environments may also represent health risks, mainly due to recurrent administration of medications and exposure to nosocomial bacteria.

During the hospital stay, medications are often necessary and widely prescribed by assistant teams, especially in systemic forms. However, the administration of multiple drugs, along with debilitated patients’ conditions, increases the risk of drug reactions². Drug reactions can induce a broad range of clinical manifestations, which often involve the skin, namely morbilliform exanthema, Stevens-Johnson syndrome, toxic epidermal necrolysis, among others¹⁰. Corroborating this perspective, we observed a high prevalence of drug eruptions among pediatric inpatients, particularly in the adolescent group.

Furthermore, the skin fragility of early pediatric age groups also increases the risk of iatrogenic lesions, usually associated with healthcare, including dressings, vascular punctures, and prolonged decubitus²¹. Thus, iatrogenic injuries can often suffer complications such as contact dermatitis, ulcers, secondary skin infections, and vascular cutaneous disorders²², which could be a possible reason for the preponderance of “cellulitis and acute lymphangitis,” (L03) “cutaneous abscess, furuncle, and carbuncle,” (L02) and “purpura” (D69), as the main dermatological diagnoses registered by pediatric assistant teams.

Dermatology consultations: diagnosis and recommendations

In view of the variety of skin disorders, dermatology can perform a supporting role to pediatric hospitalists, contributing to avoiding inconsistent diagnosis and incorrect treatments, which would lead to iatrogenic complications and/or drug reactions, mainly in the pediatric population². Thus, the exchange of knowledge and practices among dermatologists and pediatricians can confer a qualification for the assistance of complex skin conditions²³.

Moreover, dermatologists can also contribute by performing complementary exams, such as skin biopsy and direct mycological examination¹,⁹. Considering this assumption, we noted the main complementary exams in hospital consultations: laboratory tests (29.3%) and skin biopsies (10.8%), the latter performed by the dermatology team. Skin biopsies were reduced in relation to previous studies—in India¹⁰ (17.5%) and the United States²³ (35%)—which may be related to different epidemiological profiles of these settings, then necessitating further investigation.

Concerning dermatology recommendations, topical presentations were the main form of medication, in concordance with the literature²,⁹. Diverging from research in Turkish hospital², which pointed out moisturizers and antihistamines as major prescribing medications, our findings demonstrated topical corticoids and systemic antibiotics.

Although this study did not conduct a comparative analysis between non-dermatologists and dermatologists’ managements, Daye M et al.² highlighted a tendency for assistant teams to prescribe treatments before dermatology evaluation in about a third of consultations, then to establish inadequate treatments in half of those hospitalizations.

About two-thirds of dermatology consultations recommended an outpatient follow-up, a higher propensity than reported by Moon AT et al.²⁴ (48.1%) and Srinivas SM et al.¹⁰ (35.8%). Notwithstanding, disease severity and patients’ vulnerability greatly contribute to follow-up recommendations; thus, further studies are demanded to identify relations between epidemiological profiles and follow-up among different scenarios.

Pediatric dermatology and pediatrics: dialogue and contributions

Considering pediatric hospital dermatoses, both in dermatology consultations and in general pediatric wards, we noted that pediatricians demonstrated a tendency to diagnose more common and less complex cutaneous conditions, whereas dermatologists usually established more specific and defiant diagnoses, including atopic dermatitis, acne, psoriasis, and drug eruptions.

Nonetheless, our findings revealed severe cutaneous infectious—relatively common in pediatric populations—also emerged in dermatology consultations, such as scabies, impetigo, herpes virus infections, and molluscum contagiosum. This trend suggests a prominent need for training pediatricians on the diagnosis and management of dermatological disorders⁹. Furthermore, Dermatology consultations also represent a valuable teaching-learning opportunity, favoring the exchange of experiences and improvement of clinical practices¹⁷.

From this perspective, Daye M et al.² and Garg T et al.⁴ recommended integration strategies among pediatrics and dermatology in the shape of seminars, courses, and clinical case discussions. Thus, by proposing and developing these educational activities, a field of shared knowledge can be fashioned: hospital pediatric dermatology¹⁷.