PARTNERSHIP HEALTHPLAN OF CALIFORNIA
GUIDELINE / PROCEDURE
Guideline/Procedure Number: MPUG3061 (previously UG100361)
Guideline/Procedure Title: Scope of Primary Care Dermatology and
Indications for Referral Guidelines
Original Date: 12/17/2003- Medi-Cal
10/18/2006 – Healthy Kids
Lead Department: Health Services
☒External Policy
☐ Internal Policy
Next Review Date: 08/20/2015
Last Review Date: 08/20/2014
Applies to:
☒ Medi-Cal
☒ Healthy Kids
☐ Employees
Reviewing
Entities:
☒ IQI
☐P&T
☒ QUAC
☐ OPERATIONS
☐ EXECUTIVE
☐ COMPLIANCE
☐ DEPARTMENT
☐ BOARD
☐ COMPLIANCE
☐ FINANCE
☒ PAC
Approving
Entities:
☐ CEO
☐ COO
☐ CREDENTIALING
Approval Signature: Robert Moore, MD, MPH
☐ DEPT. DIRECTOR/OFFICER
Approval Date: 08/20/2014
I.
RELATED POLICIES:
A. N/A
II.
IMPACTED DEPTS:
A. --
III.
DEFINITIONS:
A. N/A
IV.
ATTACHMENTS:
A. N/A
V.
PURPOSE:
The purpose of this guideline is to define the scope of dermatology practice that is considered to be within
primary care and the appropriate situations for referral to specialty care and to facilitate communication and
appropriate referrals between primary care practitioners and dermatology. This document describes the more
common conditions where PCP management is appropriate and when referral is indicated, but it is not meant
to be all inclusive or act as a substitute for sound medical judgment. In all cases, a PCP should function
within the limits of his or her skill level and obtain consultation whenever additional expertise is needed or
the PCP is unclear about the diagnosis.
VI.
GUIDELINE/ PROCEDURE:
This guideline generally defines the services and responsibilities of PCPs. The guidelines state that a PCP is
responsible for all services required by the patient except when precipitous circumstances preclude the PCP
role. The PCP’s services are personal, and his/her responsibility is continuous. The scope of the
responsibility is comprehensive, (i.e. all required services including preventive services). The PCP should
provide those services which can be provided within his/her skills and obtain consultation when additional
knowledge or skills are required. Specifically, the PCP should always function within the limits of his/her
surgical expertise and refer the patient to the appropriate specialist for a surgical procedure beyond the
capability of the PCP. Consultation includes advice received from a telephone discussion with a specialist
and the referral of a patient to a specialist for services. When care by specialists is required, the
responsibility of the PCP is to coordinate all services.
A. The primary care physician should be responsible for the basic evaluation and management of the
following dermatologic conditions:
1. Stasis dermatitis and venous ulceration
2. Eczema, hand dermatitis, and contact dermatitis
Page 1 of 4
Guideline/Procedure Number: MPUG3061 (previously
Lead Department: Health Services
UG100361)
Guideline/Procedure Title: Scope of Primary Care Dermatology ☒ External Policy
and Indications for Referral Guidelines
☐ Internal Policy
Original Date: 12/17/2003- Medi-Cal Next Review Date: 08/20/2015
10/18/2006 – Healthy Kids
Last Review Date: 08/20/2014
Applies to: ☒ Medi-Cal
☒ Healthy Kids
☐ Employees
3.
4.
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10.
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14.
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21.
Atopic dermatitis
Acute and chronic urticaria
Acne, rosacea and related disorders.
Psoriasis, seborrheic dermatitis and lichen planus
Bacterial infections of the skin
Sexually transmitted bacterial infections including gonorrhea, nongonococcal urethritis, and syphilis
Sexually transmitted viral infections including genital warts, Molluscum contagiosum and genital
herpes simplex
Warts, herpes simplex and other viral infections of the skin
Superficial fungal infections including dermatophyte fungal infections and candidiasis
Exanthem and drug eruptions
Infestations and bites including scabies, pediculosis and insect bites
Diagnosis of bullous disorders
Dermatologic manifestations of connective tissue disease
Diagnosis of hypersensitivity reactions
Diagnosis of benign skin tumors and surgical treatment localized to non-critical areas
Diagnosis and treatment of premalignant and malignant nonmelanoma skin tumors and surgical
treatment localized to non-critical areas
Early recognition, biopsy, or referral of pigmented lesions suspicious for malignant melanoma
Common hair and nail diseases
Pediatric Dermatology – identification and referral as appropriate for common pediatric conditions
including congenital skin and vascular lesions and refractory atopic dermatitis.
B. A referral for dermatology conditions is considered appropriate in the following situations:
1. Acne
a. No response in mild to moderate acne with the topical therapy.
b. For mild to moderate acne without scarring the PCP should use at least three modalities over a
three to six month period before considering referral.
c. Active scarring
d. Consideration of intralesional corticosteroids or procedures for scars
e. Primary care physician is unfamiliar or uncomfortable with isotretinoin use.
2. Atopic Dermatitis
a. Severe or persistent dermatitis or eczema
b. Before starting any immunosuppressive therapy
c. Erythroderma or extensive exfoliation
d. Greater than a single use of systemic corticosteroids
e. Identification of triggers and allergens
f. Impaired quality of life
g. Severe complications, e.g., infectious, ocular, or psychosocial
3. Actinic Keratoses
a. When size or location of lesion requiring excision is beyond the capability of the PCP
b. When widespread and or poorly controlled disease is present
c. For extensive treatment of persistent actinic keratosis
d. Immunocompromised patients: such as any transplant patients and pts with CLL
e. When metastasis is suspected
f. When standard treatments or surgery has failed
4. Basal Cell Carcinoma and Squamous Cell Carcinoma
a. Lesions located on ANY ONE of the following - Nasolabial fold , All nasal lesions, Perioral
region, Periauricular region, and Periocular region.
Page 2 of 4
Guideline/Procedure Number: MPUG3061 (previously
Lead Department: Health Services
UG100361)
Guideline/Procedure Title: Scope of Primary Care Dermatology ☒ External Policy
and Indications for Referral Guidelines
☐ Internal Policy
Original Date: 12/17/2003- Medi-Cal Next Review Date: 08/20/2015
10/18/2006 – Healthy Kids
Last Review Date: 08/20/2014
Applies to: ☒ Medi-Cal
☒ Healthy Kids
☐ Employees
5.
6.
7.
8.
9.
b. Difficult to excise scalp, forehead, hand, foot and genital lesions
c. Lesions >2 cm
d. More aggressive variants of basal cell such as morphea-like, sclerosing types,
infiltrative,
poorly differentiated, perineural invasion or baso-squamous types
e. Lesions arising from scars or radiated skin
f. Tumors with indistinct clinical margins
g. Immunosuppressed patient
h. Recurrences
Dermatophytosis
a. Diagnosis is unclear
b. Unsatisfactory response to systemic treatment
Malignant Melanoma and Pigmented Skin Lesions – to a dermatologist as appropriate
a. Routine surveillance of high-risk patient if any one of the following applies
1) PCP not skilled or comfortable screening high-risk patient
2) Photographic mapping or microscopy is needed.
3) Patient has a personal history of melanoma and has multiple pigmented lesions
b. Evaluation of suspicious lesions
c. Biopsy or removal of lesions located in body areas felt to be beyond the PCP’s skill level to
remove with good surgical and cosmetic results
d. Wider excision needed
e. Regional lymph node dissection
f. Metastatic disease amenable to excision
g. Consideration of chemotherapy or immunotherapy
h. Radiation treatment of metastatic disease
Psoriasis
a. Chronic plaque psoriasis when all of the following are present:
1) Unsatisfactory response to topical treatment
2) Consideration of systemic treatments or phototherapy, e.g., UVB or PUVA
b. Generalized pustular or erythrodermic psoriasis
c. Psoriatic arthritis
Skin ulcers, diabetic, ischemic, pressure or venous – Referral to dermatologist or vascular surgeon,
or podiatrist as appropriate
a. Debridement of calluses or ingrown toenails
b. Periodic evaluation according to risk profile if the PCP is unable to monitor
1) No neuropathy: annual evaluation
2) Neuropathy present: semiannual evaluation
3) Neuropathy, either peripheral vascular disease or deformity present: quarterly evaluation
4) Previous ulcer or amputation: monthly to quarterly evaluation
5) Periodic monitoring of the feet, if the PCP is not skilled
c. Evaluation and performance of pressure-relieving foot surgeries or transmetatarsal amputation
d. Persistent ulcer
e. Recurrent ulcer
f. Complicated ulcer
g. Evaluation and performance of pressure-relieving foot surgeries or amputation.
h. Refer to vascular surgeon for abnormal noninvasive studies or nonhealing ulcer
i. Refer to plastic surgeon for nonhealing pressure ulcers.
Unusual cutaneous conditions and tumors
a. Mycosis Fungoides
b. Merkel Cell Carcinoma
Page 3 of 4
Guideline/Procedure Number: MPUG3061 (previously
Lead Department: Health Services
UG100361)
Guideline/Procedure Title: Scope of Primary Care Dermatology ☒ External Policy
and Indications for Referral Guidelines
☐ Internal Policy
Original Date: 12/17/2003- Medi-Cal Next Review Date: 08/20/2015
10/18/2006 – Healthy Kids
Last Review Date: 08/20/2014
Applies to: ☒ Medi-Cal
☒ Healthy Kids
☐ Employees
c.
d.
e.
f.
Leiomyosarcoma
Dermatofibrosarcoma Protuberans
Sebaceous Carcinoma
Keratoacanthoma
VII.
REFERENCES:
A. Clinical Dermatology: A Color Guide to Diagnosis and Therapy
VIII.
DISTRIBUTION:
A. PHC Provider Manual
B. PHC Department Directors
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE:
X.
REVISION DATES:
Medi-Cal
10/20/04; 10/19/05; 10/18/06; 10/17/07; 10/15/08; 11/18/09; 10/01/10; 08/20/14
Healthy Kids
10/18/06; 10/17/07; 10/15/08; 11/18/09; 10/01/10; 08/20/14
PREVIOUSLY APPLIED TO:
PartnershipAdvantage:
MPUG3061 – 10/18/2006 to 01/01/2015
Healthy Families:
MPUG3061 – 10/01/2010 to 03/01/2013
*********************************
In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with
involvement from actively practicing health care providers and meets these provisions:



Consistent with sound clinical principles and processes
Evaluated and updated at least annually
If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be
disclosed to the provider and/or enrollee upon request
The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar
illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits
covered under PHC.
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