Dermatology: When to Refer

Dermatology Referrals Can Help Your Practice Grow

by Terri Bonenberger, DVM, DACVD

One of my favorite shows is “Say Yes to the Dress,” a reality show following the progress of sales associates, managers, and brides on the way to finding that perfect wedding dress. Common themes include overwhelming advice of friends and family, helping the bride (and occasional bridezilla) overcome personal challenges, and staying on budget. Believe it or not, this can be a lot like a day in the life of a veterinarian.

As a dermatologist, I know that veterinary dermatology can be a frustrating specialty—many of the diseases we treat are common and chronic (hello, canine atopic dermatitis!). Allergic skin disease, recurrent pyoderma, and otitis externa are among the most common conditions seen by primary care veterinarians (PC DVMs). But interestingly, veterinary dermatology has one of the lowest referral rates in specialty medicine. Why is that?

It’s Only Skin, Right?

Unfortunately, chronic skin disease is often significantly debilitating for both owners and pets alike. A 2019 study from Veterinary Dermatology evaluating caregiver burden identified that a significantly greater caregiver burden was felt by veterinary dermatology clients. This is consistent with our expectations. However, the study also found that in the presence of good skin disease control, caregiver burden can be just as low (or normal) as general veterinary clients with a healthy dog, and this is good news! Another study focusing on caregiver burden found that dermatology treatment that is effective and understood by the pet owner also leads to reduced owner distress, translating into less stress for PC DVMs. These factors are ways that specialty care from a board-certified veterinary dermatologist can help satisfy your clients and patients.

Challenging Common Assumptions—What the Research Shows

It’s common in daily life to make assumptions, especially when we don’t have enough information to fill in the gaps. In many cases, we assume that a client will not be interested in referral, that referral could be harmful to our relationship with the client, or that referral will negatively impact the practice’s financial bottom line.

1. Improved Client Trust and Satisfaction

The American College of Veterinary Dermatology conducted a survey of 300 clients who had seen their PC DVMs for a dermatology problem followed by care from a board-certified veterinary dermatologist. The survey found that 73% of clients became frustrated if the PC DVM could not solve the initial complaint by the third visit. How many complex cases of canine atopic dermatitis, recurrent pyoderma, or pseudomonas otitis can be “solved” in three 15-minute visits? Unfortunately, client frustrations are often displaced onto the veterinarian regardless of how well the veterinarian practices medicine.

The study revealed that the three-visit tipping point often resulted in the client seeking a second opinion from another PC DVM and not returning to the original clinic (even for nondermatologic complaints). Interestingly, most clients within the study were not referred until the fifth visit. It was estimated that if these clients had been referred prior to the third visit, they would have saved an average of 25% in medical costs. The majority of the clients surveyed reported they would have been more satisfied with their veterinarian if they had offered referral earlier.

TIP: You may risk increasing costs and ultimately losing clients by delaying a dermatology referral.

2. Improved Patient Outcome

If your patient’s skin disease is not improving or improves but returns, consider dermatology referral. Two of the most common chronic conditions dermatologists treat are atopic dermatitis and chronic otitis externa. Early referral resulting in improved clinical outcomes helps to prevent the chronic, scarring changes that often lead to more complex infection management (multidrug-resistant methicillin-resistant staphylococcus infections) or invasive procedures (such as TECA-BO for end-stage ear disease).

In patients you have diagnosed with atopic dermatitis, consider referral for allergy testing. A recent study from Veterinary Dermatology revealed that a larger proportion of allergy patients started on hyposensitization therapy under the care of a dermatologist had better compliance and more successful patient outcomes.

A 2019 study from Veterinary Dermatology compared treatment outcomes for chronic canine otitis externa in primary care and dermatology specialty practices. The study found that dogs with chronic otitis externa had better long-term outcomes when treated by board-certified veterinary dermatologists (in addition to treatment already received by PC DVMs) than when those dogs were managed by their PC DVM alone. Importantly, the more chronic the inflammation, the more prolonged the discomfort for the dog, with increased chances that irreversible pathologic changes occur, resulting in recommendations for palliative therapies such as ear canal ablation surgery.

TIP: It is never inappropriate or too early to offer referral to a dermatologist. In addition, many dermatology cases require comanagement by a dermatologist and PC DVM.

My Tips on Maximizing Referral Success (Hint: Plant the Seed Early!)

Guidelines for referral are often lacking in veterinary school education, and when to refer will vary based on a PC DVM’s personal comfort level in managing various skin diseases. Start the discussion early in cases of allergic dermatitis or recurrent otitis. Address the symptoms (pruritus, infection), but discuss the underlying causes and long-term therapy options.

Clinical signs it may be time for a veterinary dermatologist: • Three or more visits with the same problem with partial to poor response. This can indicate chronic disease or possibly disease mimicry (treating a dog for presumed allergic dermatitis that actually has cutaneous lymphoma). In cases of chronic disease, our goals are early intervention to prevent the chronic, scarring changes that can occur within the skin and ears. • Allergy testing shows that further action is required. Intradermal testing remains the gold standard because the test assesses for allergen-specific IgE within the skin (the affected organ). Reputable serologic allergy tests do exist, but simply running the test does not equate with successful long-term management of allergic dermatitis. • Atypical lesions or a sudden change to a pet’s skin condition.

These cases often require skin biopsy or other nonroutine diagnostics (e.g., tissue cultures for opportunistic bacterial or fungal infections) that are expensive to most clients. In these cases, sample selection and knowing a complete list of differential diagnoses are especially important. Offering referral prior to performing these expensive tests can save you and the client from the frustration of inconclusive results and the need for repeat testing.

• Ulcerative diseases affecting the skin, nasal planum, foot pads, and/or mucocutaneous junctions. When present, these lesions could be an early sign of a bad disease (e.g., autoimmune, vasculitis, fungal infection) that might be treated best if diagnosed early. If you are struggling with poor client compliance:
• Much of what we treat in dermatology is chronic and not curable, so your best remedy for this is setting a client’s expectations through excellent communication. Since the onset of COVID-19, many veterinary practices are experiencing a surge in demand for services and client communications via phone call, text, and email. If you’re finding it challenging to address complex dermatology cases in the allotted appointment slots or keep up with the extensive communication these cases require, referral may be beneficial.
• Most initial dermatology exam visits are one hour, with recheck exams routinely 30 minutes, giving us more time for these cases. In addition, our dermatology technicians are one of our secret weapons! These specially trained technicians educate clients every day (via phone calls, texts, and emails) and help us proactively manage disease flare-ups. In most cases, long-term medications and therapies (Cytopoint, Apoquel, topical and dietary therapies) continue to be refilled by the PC DVM (representing a continued revenue source) with the benefits of guidance from a veterinary dermatologist.

Final Thoughts

Like a bride-to-be looking for the perfect wedding dress, don’t be afraid to ask for help! It is important that PC DVMs and veterinary dermatologists develop strong working relationships that are mutually beneficial for both parties.

Most dermatologists are happy to provide complementary consultations, work-in emergency dermatology referrals, and provide local continuing education for PC DVMs who are our partners and consistently refer their clients and patients. This benefits all parties involved! To find a dermatologist in your area, visit acvd.org under the “Find a Dermatologist” tab.

Terri Bonenberger, DVM, DACVD, consults, writes, and lectures nationally and internationally. She is a co-owner of Canine Skin Solutions, a skincare line for dogs with allergies, and practices at Southeast Veterinary Dermatology in Charleston, South Carolina..

Photo credits: Watcharin panyawutso/iStock via Getty Images