More than 1000 skin or skin-related conditions are listed by the International Classification of Disease 10 (ICD 10), and skin disease affects 30% – 70% of the global population.¹ It has been estimated that between 6% and 24% of all primary care consultations are skin related, making dermatological conditions one of the commonest reasons for consultation.^2,3 Yet, it has been suggested that insufficient attention is paid to skin conditions in the national and global health discourse.⁴ Pyoderma, scabies and superficial mycoses have a high prevalence in the general population, particularly in children,^5,6 and expenditure on these conditions is relatively high,^4,7 yet medical and nursing professionals may be poorly equipped to manage these dermatoses.⁸ The high costs associated with these disorders may in part be because of a lack of proficiency amongst primary care practitioners, who may lack the knowledge to diagnose and treat these conditions appropriately.^9,10 The high incidence of human immunodeficiency virus (HIV) infection in KwaZulu-Natal (KZN), where seroprevalence increased from 15.5% in 2014 to 27% in 2018,^11,12 has resulted in an increase in the number of patients with HIV-related skin conditions presenting to primary healthcare centres (PHCs).¹³ Dermatological conditions have both a physical and psychological impact on patients.¹⁴ Patients with disfiguring skin conditions are susceptible to psychological distress,^15,16 and those with acne, psoriasis and atopic dermatitis are prone to reactive depression and suicide.^15,16,17,18 Recognition of this has led to the development of the field of psychodermatology.¹⁹ Adequate care of patients therefore requires a holistic biopsychosocial approach.²⁰ If this is to be successful, it is critical that clinicians are knowledgeable about common dermatological conditions and proficient in the recognition and management thereof.

As of October 2019, there were 265 dermatologists registered by the Health Professions Council of South Africa (personal communication, Health Professions Council of South Africa). A total of 42 are based in KZN, with only 12 working in the public sector, serving a population of over 11 million (Prof. Anisa Mosam, personal communication). The uninsured population is therefore grossly underserved by dermatologists, and the vast majority of patients presenting with skin conditions are cared for by non-specialist medical and nursing professionals working at a primary care level.

In this study we set out to assess the level of knowledge of recognition, diagnosis and management of common skin conditions amongst medical and nursing professionals working in the primary care setting in three urban centres in KZN and to assess the short-term effect of a structured training session designed to improve such knowledge.

We studied 295 participants: 195 nurses and 100 doctors. The mean (standard deviation [SD]) age for all participants was 41.1 (10.5) years. The mean (SD) age for nurses was 42.3 (10.5) years and for doctors 38.7 (10.1) years. The difference is significant (p = 0.005). There were no significant difference in the ages of staff at the different centres (p = 0.38), or by type of facility (p = 0.58) (data not shown). Test performance is summarised in Table 1 and performance by topic shown in Figure 1.

Performance in the pre-intervention test was poor, with a mean (SD) score of 40.6% (20.5%). Medical professionals scored significantly higher than nursing professionals (p < 0.0001). There were significant differences in performance by district (p < 0.001) and type of facility (p < 0.001), with the highest scores noted in district hospitals and in the eThekwini Health District.

Given the differential performance between medical and nursing professionals, we considered the possibility that the differences between districts and type of facility might have been confounded by differences in the ratios of doctors to nurses within these. Two-way factorial ANOVA excluded a significant interaction between profession and both district (p = 0.33) and type of facility (p = 0.15), suggesting that the observed differences indicate real differences in performance. There appeared, however, to be some interaction between district and type of facility (p = 0.04). There was a significant negative correlation between age and pre-intervention score (r = -0.28, confidence interval [CI] -0.38–0.17, p = 0.001; Figure 2). This was shown for both medical professionals (r = -0.32, CI -0.49–0.13, p = 0.001) and nursing professionals (r = -0.19, CI -0.32–0.05, p = 0.009).

The mean (SD) post-intervention score was 68.7% (22.5%), indicating a significant improvement over pre-intervention scores (p < 0.0001). Post-intervention scores were 1.7 times higher than the pre-intervention scores. This improvement was noted for both medical and nursing professionals and for all districts and type of facility. Participants who scored poorly on the pre-intervention test improved proportionately more in the post-intervention test than those with higher initial scores (Spearman’s rho -0.81, CI -0.85–0.77, p < 0.0001, Figure 3), suggesting a significant catch-up in performance. There was no significant difference in the post-intervention scores of medical and nursing professionals (p = 0.25), although significant differences persisted between the three districts (p < 0.001) and between the three types of facilities (p = 0.03).

Most public-sector patients seeking assistance with a dermatological problem experience their first interaction with the health service in a primary care setting. The low scores obtained on the pre-intervention test in our study suggest that most clinicians working in primary care in the three districts we tested are not adequately prepared to manage common skin conditions. This might potentially result in incorrect diagnosis and treatment and a higher incidence of complications of simple skin conditions. Knowledge appeared to be weak across a range of common skin conditions. Even topics that at face value appear simple and frequently encountered, for example scabies, were answered no better than those which might be regarded as more complex, such as psoriasis.

Skin disorders are common in the community and therefore frequently encountered by primary care practitioners. Our results however suggested that this experience has not led to adequate proficiency in diagnosis and management. The significant negative correlation between proficiency and age we identified may suggest that knowledge decay with time is more relevant than increasing experience in determining proficiency. Alternatively, it may reflect better undergraduate teaching amongst more recent graduates. In both cases, however, the overall poor proficiency indicates either a deficiency in undergraduate training or a continuous inadequate in-service professional development in the field of dermatology during clinical practice or both. Our own enquiries suggest that formal exposure to dermatology training across South African medical schools may range from as little as 15 to 240 h, spread across a 5-or 6-year curriculum.

Given the poor knowledge of common skin disorders that we have shown in this study, we suggest that the general level of dermatological expertise amongst nurses and doctors working in primary care should be improved. This is likely to require a multifaceted approach, including improved dermatology training in nursing colleges and medical schools, repeated exposure to continuing professional development programmes and in-service training and improved communication and collaboration between primary care practitioners and specialist dermatologists. There are also very limited opportunities for diploma studies in dermatology practice for primary care practitioners.²¹

Our study has shown that even a brief intervention, not requiring more than 3 h on a single day, is sufficient to bring about a substantial increase in immediate knowledge, as shown previously in both KZN²² and Mali.²³ Our study looked only at a short-term improvement in test performance, but not at retention of improvement or improvement in practice. We recognise that without reinforcement, the degree of improvement shown may well not be maintained indefinitely, thus requiring regular and recurring exposure to dermatology training opportunities.