Due to the difficulty of getting an appointment with a dermatologist in a timely manner, most of the doctors surveyed stand up for their patients themselves in urgent cases. “But it is also quite the case that I get on the phone and call the dermatologist’s office and say I want to see this patient today or tomorrow. [Interviewer: Does that work?] Yes, when I’m pushing. Then I notice the reluctance, but that’s fine […]. “ (HA 8)
“When it is acute and I don’t know anything, I always try to find a skin colleague with a lot of whining and whining. That is a relatively difficult task, but it is still possible […]. “ (HA 6)
Sometimes the uncomfortable task of getting a quick appointment is delegated to the patient. “I am sometimes so in need that I provide people with a referral and with the order to make discounts in the dermatologist’s practice until they are looked at.” (HA 11)
Many of the general practitioners surveyed commented critically that written feedback from the dermatologist is usually missing or incomplete. This makes it difficult for general practitioners to understand the diagnosis and / or therapy and to implement them effectively. “Nah. So many doctors do not write at all, many specialist colleagues do not write a report at all, others describe findings without entering a therapy. “ (HA 9)
“Really, the reports. This is by far the most important thing […] as I do with internists, that he does two or three examinations and says, because of this, he thinks it could most likely be this and that, and most likely to treat with it. But when I get something back, it will be a handwritten pamphlet where the diagnosis can be read and an ointment underneath. Ready, off, end […]. “
Many of the doctors questioned also expressed their disappointment that, in their opinion, no causal therapy decision was made for a large proportion of the referred patients, but purely symptomatic treatment, mostly with a topical steroid. “[…] that [cortisone] is apparently the dermatological panacea that is also coming back very widely from specialist medical colleagues. Then they are sometimes very artfully packaged in some form of preparation that still includes remedies that a family doctor does not understand or do not know, but if you take a closer look, there is 0.1% betamethasone in it again, you are a bit disaffected again. “ (HA 8)
Use of topical cortisone supplements
Not least because of this, treatment with a topical steroid is often initiated by family doctors. The interviewed general practitioners named severe allergic reactions, intertrigo, exacerbations of chronic skin diseases and eczema of various locations as clear indications. “The indication must of course be focused, I would not primarily add cortisone to a dermatomycosis .
“So, the most severe symptoms, an exacerbation of a chronic skin disease, psoriasis, but also an acute drug rash, we have relatively often. These are things where I am relatively generous personally says a specialist at skin clinic in south delhi.
When it comes to selecting the right preparation, general practitioners show very heterogeneous behavior. While some are based on the tiered scheme, others choose their preparations more intuitively, rely on past experience with the preparation or use their own formulas. “To be honest, I orient myself towards the Red List and the main groups there and use the preparations accordingly. Depending on whether strong, medium or weak.
“These are always decisions that are made a little on the instinct. So, I don’t have a concrete procedure.
The use of combination preparations is controversial and ranges from complete rejection to acceptance as a suitable means in difficult treatment situations such as unclear skin findings, acute worsening of the findings, high levels of suffering or expectations on the part of the patient. “[Laughs] Well, that’s something against hunger, anger and cold. I’m not really in favor of that. I actually prefer to take monopreparations because with such a combination preparation I don’t always know exactly, firstly what have I treated now, secondly, which part of this combination preparation has actually worked and thirdly, what are the side effects of it?
“[…] Of course I also take DecodermTri, although I then find a little dermatological indictment in front of me when I take that, because I know exactly that I will take a combination pack of everything that it could be somewhere to achieve that. But sometimes I just have no other chance in family medicine.
In summary, three different types of users of cortisone preparations can be distinguished among the surveyed general practitioners (see Fig. 1).
The staunch advocate: “Yes. Immediately afterwards. Locally and systemically. And in the very serious cases, we put them on the IV straight away. That’s how I got to know it in the hospital, where a cortisone infusion is made.
After excluding dangerous processes that could be avoided, the pragmatist uses cortisone: “If I clearly favor a diagnosis, then I treat it accordingly. If I have the impression that I don’t know exactly what it is, but if a week of cortisone comes up here, then it’s gone and the spook is over, then I’ll treat without a diagnosis.
And there is the alternative skeptic : “Based on my personal experience, I have become much more cautious and we continue to prescribe or re-prescribe if indicated in the previous history and already started by the dermatologist or indicated as standard therapy for the disease but a spontaneous application to try out, that I have become very, very careful.