Misdiagnosis of Common Dermatological Infections - Causes and Consequences

Introduction:

Skin specialists routinely manage several infectious conditions of the skin. However, the diverse presentation of these conditions often leads to misdiagnosing dermatological infections. Misdiagnosis can lead to subsequent inefficient and inappropriate treatment, worsening the situation and following skin and soft-tissue infections.

What Are the Most Common Dermatological Infections That Are Misdiagnosed?

The most commonly misdiagnosed dermatological infections include fungal infections, followed by bacterial and viral infections. Fungal skin infections, also known as dermatophyte infections, affect skin, hair, and nails. It is estimated to affect 25 % of the world's population. Because of their routine presentation, dermatologists often efficiently manage fungal infections. However, they are easily misdiagnosed too, which can lead to further complications.

• Tinea capitis (ringworm of the scalp) is the most commonly misdiagnosed dermatophyte.

• The bacterial skin infection that is commonly misdiagnosed is skin tuberculosis.

• Molluscum contagiosum (a viral infection causing painless bumps on the skin) and verruca plana (flat warts caused by the human papillomavirus) are the commonly misdiagnosed viral skin infections.

• Scabies caused by mites is also easily misdiagnosed.

• Some non-infectious conditions are misdiagnosed as cellulitis, which leads to unnecessary hospitalizations and antibiotic administration.

What Are the Causes of the Misdiagnosis of Dermatological Skin Infections?

Studies examining the causes of misdiagnosis are very few. The errors are often attributed to

• Representative heuristics (mentally matching the symptoms with a disease narrowing the differential diagnosis).

• Availability heuristics (for the purpose of easy recall, the physician may accept a wrong diagnosis).

• Premature closure (accepting a wrong diagnosis at an early stage without considering any other differential diagnosis).

What Are the Most Commonly Misdiagnosed Fungal Skin Infections?

1. Secondary syphilis, pityriasis rosea, and annular psoriasis are cutaneous inflammatory conditions that mimic fungal infections. Therefore, continued education on cutaneous fungal infections, accompanied by proper knowledge and education on bedside diagnostic methods like the use of potassium hydroxide, should be encouraged.

2. A survey was conducted in 2016, including several board-certified dermatologists in Orlando. According to the survey, of the 13 cases of skin conditions presented, 8 out of 13 patients, the majority of cases, were correctly identified by more than 50 % of the dermatologists. However, as categorization accuracy has increased, the percentage of dermatologists who can correctly categorize has decreased. Out of the 13 cases, only four were categorized with an accuracy of 75 percent, and only one case was categorized with accuracy by more than 90 % of the dermatologists present.

3. Tinea Capitis: It is a commonly misdiagnosed cutaneous fungal infection. It affects the skin and scalp and is known as "scalp ringworm." The patients are children between three and seven years old and present with hair loss, redness, itching, and dry, scaly areas. Tinea capitis is often misdiagnosed as a condition that causes patchy hair loss, scaling, and scalp inflammation. Some of the common conditions mistaken for tinea capitis and vice versa are

• Seborrheic dermatitis, scalp psoriasis, and atopic dermatitis. However, the scales are more diffuse in these cases.

• Trichotillomania and alopecia areata causes patchy non-scaling hair loss.

• Lichen planopilaris and discoid lupus erythematosus are responsible for scarring alopecia.

• Impetigo, pyogenic abscess, pyoderma, and bacterial scalp folliculitis often present symptoms that resemble tinea capitis.

What Are the Consequences of Cellulitis Misdiagnosis?

Often, non-infectious conditions affecting the skin are misdiagnosed as cellulitis. Since cellulitis is a severe condition, the misdiagnosis leads to unnecessary hospital admissions and antibiotic use.

• Cellulitis is one of the most common skin and subcutaneous infections. It is a severe condition that can result in enormous morbidity and unnecessarily waste considerable healthcare efforts and costs. According to a survey in the US, approximately 240,000 patients were admitted to the hospital diagnosed with cellulitis, and 3.7 million dollars was the healthcare cost. Unfortunately, despite the availability of massive data about cellulitis, misdiagnoses of cellulitis with similar clinical conditions are frequently made. Currently, a sliver of appropriate evidence bases clinical guidelines needs to be included for the diagnosis of cellulitis, which often leads to misdiagnosis.

• Overdiagnosis of cellulitis is associated with redundant hospitalization, and one of the most undesirable outcomes is the use of potentially dangerous antibiotics, leading to the emergence of antibiotic resistance bacteria. Some cases of underdiagnosis have also been reported, though they are not so common. It results in the worsening of the situation leading to severe complications.

• Improved accuracy in the diagnosis of cellulitis is a necessity. A structured and systematic approach to the diagnostic criteria may decrease the chances of misdiagnosis, enhancing the quality of healthcare.

How Can Cellulitis Misdiagnosis Be Reduced?

• Proper education and diagnostic techniques are necessary to improve accuracy and avoid errors. In addition to educational awareness, promising tools like clinical diagnostic decision support systems (CDDSS) can be employed. A visually based computerized diagnostic decision support system is one tool that provides a robust differential diagnosis for more accurate identification of diseases.

• Several studies suggest that a visually-based computerized diagnostic decision support system (VCDDSS or VisualDx) can be used to generate a better and improved differential diagnosis for preventing misdiagnosis.

• Some studies in patients hospitalized for misdiagnosis reveal that out of the 145 patients admitted, 41 were misdiagnosed. Of the misdiagnosed cases, stasis dermatitis was most commonly mistaken for cellulitis (37 %). However, the use of VisualDx often showed the correct diagnosis along with the list of differential diagnoses. Therefore, it was suggested that VisualDx was capable of assisting physicians and dermatologists by generating more accurate differential diagnoses for patients presenting with infectious skin conditions.

• The misdiagnosis is frequently associated with loss of money and the patient's health. Therefore an appropriate decision support tool must be used in the early stages of diagnosis to reduce the probability of misdiagnosis and for better healthcare management.

Conclusion:

One of the main reasons for the misdiagnosis of cutaneous infections is attributed to the lack of appropriate knowledge. Proper education and implementation of knowledge should be employed in dermatological practice for accurate diagnosis and appropriate medical interventions. Misdiagnosis and the necessity to improve the accuracy of diagnostic criteria are not limited to cellulitis and fungal skin infections alone. When it comes to healthcare information technology, more attention should be given to documenting diseases more accurately and evaluating the treatment strategies for