A career in dermatology

Dermatology offers an interesting clinical or surgical career in combination with a balanced and flexible working life, write Imran Yusuf and colleagues

Some medical specialties, such as dermatology, are allocated a very modest amount of teaching during undergraduate training[1]—not only in the United Kingdom, but around the world.[2] Dermatology also suffers from the common assumption that because its primary diseases have low mortality rates, the specialty isn’t important and, therefore, is not as fulfilling as a career choice. This can lead junior doctors to neglect dermatology as a career possibility without genuinely considering its numerous advantages.

Is skin interesting or important? The skin is the largest organ in the human body, with an average surface area of 1.8 m2, and its three layers constitute 16% of a person’s total body weight[3]—far heavier than the healthy human brain or liver. It is, therefore, unsurprising that skin is the organ system that hosts the greatest number of diseases, with more than 2000 estimated primary or systemic cutaneous diseases.[4] If an interesting specialty should boast clinical variety, logic would rank dermatology among the most fascinating.

In the Western world and in Australasia, skin cancers are the most common malignancies, and the three major forms are increasing in incidence.[5] [6] [7] Malignant melanoma is considered among the most lethal of skin cancers, and it kills more than 1500 people a year in the UK; squamous cell carcinoma kills 500 more a year,[3] but can be cured with early detection and surgical excision.[8] Patients need not be acutely unwell for clinical interventions to be lifesaving, and although the satisfaction may be more subtle, it is no less significant.

The overt nature of dermatological disease such as eczema and psoriasis results in an often profound impact on quality of life.[9] Consider, for example, the distress that alopecia (hair loss) causes—it is grossly out of proportion with the physiological function that hair serves.[10] [11] A dermatologist is thus presented with plenty of opportunities to improve a patient’s physical and psychological wellbeing—and, naturally, along with this comes a high level of job satisfaction.

The scope of dermatology Disorders of the skin, hair, and nails fall within the remit of a dermatologist. The specialty is divided broadly into medical and surgical fields, with clinicians in secondary care often practising both. It should be noted that in some countries, training and practice in dermatology are combined with venereology, whereas in the United Kingdom, genitourinary medicine is a separate specialty.

Dermatology is chiefly an outpatient specialty, and most patient referrals request an initial diagnosis and treatment of an unknown skin disease or review of more complex and chronic cases beyond the skill of the general practitioner. Occasionally, patients are very unwell or incapable of applying therapies at home and require inpatient admission under the care of a dermatologist until they can be managed in the community. Patients are also admitted to day case units for the infusion of novel biologic therapies to manage psoriasis and other skin diseases.[12]

A dermatologist will assess emergency referrals from general practice and skin disease in hospital inpatients, and will provide advice to other clinicians, such as general practitioners, over the phone. Weekend on-call duties are less demanding than in other medical specialties; typically a registrar can be expected to cover one in four weekends.

Dermatologists manage acute and chronic disorders of the skin. There are many subspecialties in dermatology, and a consultant in a tertiary referral centre will often have an interest in one or two of these in addition to practising general dermatology or holding a surgical interest.

Diagnoses are clinical in the overwhelming majority of cases, and dermatology requires relatively few investigations. Clinically diagnosing skin disorders takes skill and experience, plus a good grounding in clinical medicine. Dermatologists use a comprehensive formulary with topical therapies, systemic drugs including novel immunomodulatory drugs, phototherapies (with or without oral sensitisers), laser treatments, cryotherapy, and other treatment modalities alone or in combination—a huge variety of treatments to manage a tremendous number of diseases. 

Medical dermatology Medical dermatology, an emerging subspecialty, is the study and care of patients with:

Skin diseases that can have systemic manifestations, including connective tissue diseases, vasculitis, sarcoidosis, graft versus host disease, and severe drug reactions.

Potentially disabling or fatal skin diseases usually treated with systemic therapy, such as severe psoriasis, severe atopic eczema, cutaneous T cell lymphoma, and autoimmune blistering diseases.

Cutaneous manifestations of systemic disease.

The British Society for Medical Dermatology has been formed to advance this subspecialty in the UK.

Surgical dermatology For those of you keen to indulge your surgical passions, there is good news. Dermatology manages a substantial turnover of skin tumours (both benign and malignant), of which surgical excision is the primary form of management. A surgical dermatologist uses clinical judgment and a dermatoscope (a hand held, illuminated magnifying instrument) to identify lesions that require excision for histological confirmation and further treatment. Occasionally, incisional or punch biopsies are taken to solve diagnostically challenging medical dermatoses.

Dermatological surgeons, like plastic surgeons, operate from scalp to sole. In specialist centres there is an overlap of these disciplines because dermatologists are able to perform technically demanding excisions from the face and close wounds with flaps of adjacent skin or skin grafts from more distant sites with proficiency equal to that of plastic surgeons.

Mohs micrographic surgery has added a further dimension to surgical dermatology by allowing microscopic confirmation of full excision of a primary tumour before surgical closure of a wound. In Mohs surgery, the patient waits with a dressing placed over the open wound while tissue is being analysed, ensuring a high rate of curative surgery while sparing healthy tissue, thereby reducing cosmetic comorbidity.[13] It is offered in 11 centres in the UK, and many others around the world. It has been shown to be effective in the management of malignant melanoma[8] and basal and squamous cell carcinomas.[14]

Compared with many surgical disciplines, surgical dermatology boasts very favourable outcomes. Operative morbidity is low, mortality is essentially nonexistent, and most individuals are cured when a tumour has been excised, adding to the rewards of the surgery.

Training in dermatology UK postgraduate training After obtaining a medical qualification (MB BS, MB ChB, or MB BChir equivalent), doctors wishing to become dermatologists must complete two years of foundation training and become fully registered with the General Medical Council. Thereafter, it is necessary to enter into core medical training or acute care common stem (ACCS), both of which last two years. During this time membership of the Royal College of Physicians (MRCP) examinations must be taken before applying for a training post in dermatology (applicants for specialty training year 3 need MRCP part 1). A full person specification for a specialty trainee year 3 in dermatology can be downloaded from the Modernising Medical Careers website (www.mmc.nhs.uk), as well as data on the number of specialty trainee year 3 jobs in the UK and the nature of the competition.

Dermatology training posts are awarded in competition, which is very strong. For example, often candidates have obtained a doctorate in medicine (MD) or philosophy (PhD) to enter the specialty, although this is common in other specialties such as cardiology or oncology. Specialist training is four years (specialist registrar), after which a certificate of completion of specialist training is awarded and the doctor becomes eligible to apply for a job as a consultant dermatologist. Postgraduate training outside the UK follows a similar course, although the nature of the examinations and competition may vary.[15]

Get involved in research Dermatology offers a wealth of research opportunities because skin is a visible and accessible organ. The specialty receives generous research funding, and dermatologists often have an academic background—an infrastructure that facilitates clinical research.

Useful websites British Association of Dermatologists—www.bad.org.uk

British Association of Dermatological Surgeons—www.bsds.org.uk

St John’s Dermatological Society—www.st-johns-society.co.uk

British Society for Medical Dermatology—http://medderm.co.uk

The British Skin Foundation—www.britishskinfoundation.org.uk

Competing interests: None declared.

References Davies E, Burge S. Audit of dermatological content of UK undergraduate curricula. Brit J Dermatol  2009;160:999-1005. McCleskey PE, Gilson RT, DeVillez RL. Medical student core curriculum in dermatology survey.J Am Acad Dermatol  2009;61:30-5 e4. Gawkrodger DJ. Dermatology. An illustrated colour text  . 3rd ed. Churchill Livingstone, 2002. Khatami A, San Sebastian M. Skin disease: a neglected public health problem. Dermatol Clin  2009;27:99-101. Roewert-Huber J, Lange-Asschenfeldt B, Stockfleth E, Kerl H. Epidemiology and aetiology of basal cell carcinoma. Br J Dermatol  2007;157(suppl 2):47-51. Brewster DH, Bhatti LA, Inglis JH, Nairn ER, Doherty VR. Recent trends in incidence of nonmelanoma skin cancers in the East of Scotland, 1992-2003. Br J Dermato  l 2007;156:1295-300. Linos E, Swetter SM, Cockburn MG, Colditz GA, Clarke CA. Increasing burden of melanoma in the United States. J Invest Dermatol  2009;129:1666-74. Dawn ME, Dawn AG, Miller SJ. Mohs surgery for the treatment of melanoma in situ: a review.Dermatol Surg  2007;33:395-402. Hong J, Koo B, Koo J. The psychosocial and occupational impact of chronic skin disease.Dermatol Ther  2008;21:54-9. Tucker P. Bald is beautiful?: the psychosocial impact of alopecia areata. J Health Psychol  2009;14:142-51. Bedocs LA, Bruckner AL. Adolescent hair loss. Curr Opin Pediatr  2008;20:431-5. Alexis AF, Strober BE. Off-label dermatologic uses of anti-TNF-a therapies. J Cutan Med Surg  2005;9:296-302. Robins P. 44 years in dermatologic surgery: a retrospective. J Drugs Dermatol  2009;8:519-25. Lawrence CM. Mohs surgery of basal cell carcinoma—a critical review. Br J Plast Sur  g 1993;46:599-606. Walton S, Finlay A. Dermatology training and career options in the UK for Indian graduates.Indian J Dermatol Venereol Leprol  2004;70:256-9. Imran Yusuf academic foundation doctor  Oxford Department of Dermatology, Churchill Hospital, Headington, Oxford Richard Turner consultant dermatologist  Oxford Department of Dermatology, Churchill Hospital, Headington, Oxford Susan Burge consultant dermatologist and honorary senior lecturer; former president of the British Association of Dermatologists  Oxford Department of Dermatology, Churchill Hospital, Headington, Oxford