Download Dermatology Referral Guidelines

Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
Buckinghamshire Dermatology Referral Guidance
1
Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
CONTENTS
PAGE
Notes
3
Sub Specialities
1. Atopic Eczema in Children & Adults
4
2. Viral Warts & Molluscum Contaginosum
10
3. Hand Eczema
12
4. Acne
14
5. Psoriasis
16
6. Skin Cancer
19
7. Scabies
20
8. Actinic/Solar Keratoses
21
9. Rosacea
26
10. Urticaria & Angioedema
28
11. Generalised pruritus
30
12. Onychodystrophy
31
Supplementary Information
13. Referral Criteria
Title of Guideline
Guideline Number
Version
Effective Date
Review Date
Original Version Produced
Approvals:
Buckinghamshire Healthcare
NHS Trust Formulary
Management Group
Buckinghamshire Area
Prescribing Committee
Clinical Guidelines Subgroup
Author/s
32
Dermatology Referral Guidelines
311
1
August 2013
January 2015
November 2012
January 2013
October 2013
February 2013
November 2013
April 2013
September 2013
Mrs Sarah Crotty, Interface Pharmacist, Aylesbury Vale and
Chiltern CCGs
Dr R Ratnavel, Consultant Dermatologist Bucks Healthcare
NHS Trust (BHNHST)
Mrs Maire Stapleton, Formulary Pharmacist, Bucks Healthcare
NHS Trust (BHNHST)
Dermatology (BHNHST) and Medicines Management of Aylesbury
Vale and Chiltern CCGs
SDU(s)/Department(s)
responsible for updating the
guideline
Buckinghamshire Healthcare NHS Trust/Aylesbury Vale and Chiltern Clinical Commissioning
Groups
Consulted:
Dr Ravi Ratnavel, Dr Raj Bajwa, Dr Stuart Logan, Dr Saj Zaib, Mrs Maire Stapleton,
Mrs Sarah Crotty, Dr Raj Thakkar, Dr Christine Campling, Dr Sophie Grabczynska
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Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
Dermatology
This is intended as a guide only. It is not exhaustive and appropriate clinical judgement
should be used for individual cases.
When referring to Dermatology (either community or Acute) please provide information in
accordance with the core required information fields of the referral letter with particular
attention to the following sections:
Past history:
Relevant family history, H/O any co-morbidity, presence of risk factors
Investigations:
State whether the patient has had any relevant investigations (and attach results if available):
e.g. Renal function tests, FBC, X-ray, USG reports and specific tests like PSA.
Please note, if you are concerned about your patient's condition and require urgent
assessment it is not necessary to undertake routine tests unless this will significantly alter
your referral decision.
Emergency admission likely to be appropriate
Suggested referral to Secondary Care or GPSI
Continue to manage in Primary Care if appropriate
Note: All follow up appointments following inpatient stays in hospitals, for the same condition,
should be arranged via secondary care and NOT booked by GPs.
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Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
1)
ATOPIC ECZEMA IN CHILDREN AND ADULTS
http://publications.nice.org.uk/atopic-eczema-in-children-cg57
What to consider in Primary Care before referring:
General
Atopic eczema is a common disease affecting up to 15% of children. It may also
affect adults.
Involvement of the face frequently occurs in infants with adoption of characteristic
flexural distribution by the age of 18 months.
Realistic treatment aims to be discussed with the patient and parent.
General treatment measures:
Soaps and detergents including bubble bath and shower gels should be avoided.
Cotton clothing should be used and avoid wool next to the skin.
Fingernails should be kept short to reduce skin damage from scratching.
Bathing is not harmful but an emollient must be used.
Emollients
Emulsifying Ointment, 500g,
Hydrous (oily cream) Ointment, 500g,
Diprobase Cream or Ointment, 500g, ointment or cream
E45, 500g,
Cetraben, 500g,
Doublebase, 500g,
Unguentum M Cream, 500g.
Greasier preparations are better at hydrating the skin e.g:
Liquid Paraffin / White Soft Paraffin Ointment 50:50, 500g,
White or Yellow Soft Paraffin, 500g,
Soap Substitutes
Emulsifying ointment
Aqueous Cream
Bath Emollients
Bath emollients are of particular value for children less than 5 years.
Adults do not routinely need prescribed bath emollients unless they have areas that they
cannot reach to apply creams.
Diprobath additive
Oilatum – non-fragrance preparation, 250ml and 500ml
Oilatum junior 500ml
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Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
Some combination preparations have niche uses:
Those containing antiseptics can be useful for infective episodes.
Dermol® 500 (contains antiseptic)
Emulsiderm (contains antiseptic)
Oilatum Plus (contains antiseptic)
Urea acts as a Keratin softener and so can be useful for areas of hard skin which also require
hydration:
Calmurid (contains Urea)
Barrier Creams
Drapolene, or Metanium
Treatment in Primary Care
Emollients should be prescribed in all cases & in adequate quantities.
Some patients react to one and may need an alternative, therefore you need several options.
Persist until the patient finds something they like and will therefore use. Use directly on the
skin during and after bathing.
Emulsifying Ointment, 500g,
Hydrous (oily cream) Ointment, 500g,
E45, 500g,
Diprobase Cream or Ointment, 500g ointment or cream
Cetraben, 500g
Doublebase, 500g
Unguentum M Cream, 500g
Greasier preparations are better at hydrating the skin e.g:
Liquid Paraffin / White Soft Paraffin Ointment 50:50, 500g
White or Yellow Soft Paraffin, 500g
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Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
Topical Corticosteroids
Although potent preparations can cause skin atrophy, mild corticosteroids such as 1%
hydrocortisone do not and are safe to use in the long term.
Hydrocortisone 1% is the strength of choice for the face and flexures. Topical Corticosteroids
are often underused because of concern about the side effects.
Ointment preparations are more effective than creams and contain fewer additives. Creams
can be used if the eczema is weeping or on the face.
There are four groups of potency. Within each potency group there is no evidence for
increased efficacy or safety of any one particular product.
Mild
Hydrocortisone 1% cream or ointment.
Moderate
Ciobetasone Butyrate (Eumovate).
OR
Betamethasone Valerate 0.025% cream or ointment (Betnovate RD).
Potent
Betamethasone Valerate 0.1% cream ointment and scalp appln. OR lotion
(Betnovate).
Mometasone (Elocon) reserved as 2
nd
line if Betnovate does not suit.
Beclomethasone Diproprionate cream and ointment (0.025%) (Propaderm).
Very Potent
Clobetasol Propionate (Dermovate) 0.05% cream, ointment and scalp application.
Try to avoid the use of very potent steroids due to the increased risk of skin atrophy and the
fact that these super potent steroids can affect the appearance of the rash so that diagnosis is
much more difficult.
Mild or moderately potent preparations should control most cases of eczema when prescribed
in appropriate amounts. It may be necessary to gain control with moderately potent
preparation and then reduce to a mild strength.
1 to 2 weeks of a potent strength product may be required, particularly for resistant, lichenfied
lesions in older children.
Avoid repeat prescriptions for potent strength corticosteroids.
In dry eczema try steroid / urea Alphaderm cream (moderate potency as urea increase the
penetration of the hydrocortisone).
Assessment of severity of disease and progress on treatment
The Nottingham patient eczema questionnaires are an excellent way of assessing severity.
They are available for adults and children.
http://www.nottingham.ac.uk/scs/divisions/evidencebaseddermatology/resources/nottinghame
czemaseverityscale(ness).aspx
It is very difficult to give guidance on amounts of topical steroids for the treatment of eczema.
If the right strengths for the site and severity of eczema are being used repeatedly without any
steroid free gaps, then patients should probably be considered for alternative treatments or
investigation.
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Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
Infection Control
Antihistamines
Suitable for short-term use to control itch especially at night.
Sedative antihistamines
Chlorphenamine
Hydroxyzine
Infective Eczema
Infection should be suspected whenever eczema worsens. Eczema that weeps or crusts is
probably infected with staphylococcus aureus- if in doubt take swabs for microbiology.
The commonest infecting organism is Staph. aureus which produces characteristic yellow
crusting.
Consider antiseptic moisturiser combination in the bath:
Oilatum Plus bath oil
OR
Directly onto the skin: Dermol® 500
If the infection is widespread or severe treat with systemic antibiotics (for 7 to 10 days): Flucloxacillin 500mg QDS OR Erythromycin 2 x 250mg QDS (if penicillin allergic)
Widespread infected eczema should be treated with a systemic antibiotic and plain topical
steroid ointment.
If recurrent infections occur take nasal swabs from the family members and if positive: Consider MSSA eradication according to the local BHT policy. Link to be added when
available
Bandaging
Recommended products
Cheapest Standard conforming bandage range is currently Easyfix K (K band is more
expensive)
Elasticated Viscose Stockinette Bandage.
E.g. Tubifast
3.5 cm, red line (small limb)
5 cm, green line (medium limb)
7.5 cm, blue line (large limb)
10.75 cm, yellow line (child trunk)
20 cm, purple line (adult trunk)
Vests, leggings, gloves and socks provide no advantages over old clothes and prescribing
these are low priority.
Zinc paste bandages alone or Zinc paste and ichthammol (e.g. Icthopaste), may be useful in
chronic lichenified eczema, Ichthammol is believed to reduce pruritus. Apply creams such as
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Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
st
steroids and emollients 1 before applying Icthopaste, a final bandage over the Icthopaste is
also required.
Initial training techniques may be required which can be given by a suitably trained
nurse or nurse specialist.
Zinc paste bandages used over emollients or over topical corticosteroids can result in
rapid improvement of resistant, particularly lichenified eczema.
Wet wrap using tap water to dampen a standard bandage over emollients or steroids
or both – may also be helpful, particularly at night in small children.
Wet wrap garments are both cost effective and acceptable to patients.
Allergies
The house dust mite can aggravate eczema in some patients.
Vacuum mattress and keep dust level down.
In severe cases try protective coverings to pillows and bedding (e.g. INTERVENT) –
not prescribable on FP10
No tests are available to confirm or refute food allergy as a cause of worsening of
eczema. RAST tests and skin prink tests are not helpful. Patch testing is used to
investigate specific contact allergic eczema if from an occupational cause.
Food allergies, especially to egg, wheat and dairy products rarely cause worsening of
eczema.
Consider exclusion diets only in difficult cases.
Seek advice of dietician for young children and abandon if no improvement is
apparent after 2 – 4 weeks.
Food intolerance is often a temporary phenomenon. An attempt should therefore be made
every few months to re-introduce the food in question. Dietetic advice is required if exclusion
diets are used for more than 2 – 4 weeks.
Evening Primrose Oil
There is no consistent evidence that it helps, therefore NOT RECOMMENDED
Chinese herbs
There are no product licenses and currently standardisation is poor.
Serious adverse effects have been recorded and they cannot be recommended.
Some contain potent topical steroids.
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Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
Referral Threshold - Community
Dermatology Service
Community Dermatology service
Only cases of severe or difficult eczema need
to see a Dermatologist:
Diagnostic difficulty
For second line treatment such as
photochemotherapy and cytotoxic
drugs. Eczema herpeticum.
If allergic contact dermatitis is suspected –
consider patch testing in secondary care
Referral Threshold 999 for emergency
Urgent referral to Dermatology
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Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
2)
VIRAL WARTS AND MOLLUSCUM CONTAGIOSUM
All treatment is low priority
What to consider in Primary Care before referring:
General Comments
Viral Warts and Verrucae all treatments are LOW PRIORITY
These two viral induced lesions are common, especially in children and are selflimiting
There are no easy or guaranteed treatments or magic cures and lesions are best left
to resolve spontaneously. Greater than 60% of hand and facial warts clear within two
years.
Plantar warts tends to be most persistent.
Molluscum Contagiosum
90% of mollusca clear spontaneously within one year. All treatments are LOW PRIORITY
Treatment in primary care
Viral Warts and Verrucae all treatments are LOW PRIORITY
Use a high concentration salicyclic acid preparation such as:
-
Occlusal = Salicyclic acid 26%
Many products also available over the counter.
Instruct the patient that this should be applied daily after bathing and
rubbing down the softened skin with pumice stone or sandpaper. This
may need to be continued for many months.
Cryotherapy is available in many but not all GP practices:
Best performed at one to three weekly intervals with two freeze thaw cycles, (hands 70% cure
rate after four treatments, plantar warts less than 40%). If there is no sign of improvement
after six treatments then it is unlikely to be effective and should be discontinued. Higher cure
rates with combined cryotherapy and topical agents.
Molluscum Contagiosum all treatments of the condition are LOW PRIORITY
except eczema and infections
Observation only is the usual option.
Treatment associated eczema or impetigisation with:

Emollients

Mild topical steroids +/- antibiotic therapy
Affected children should have their own towels to reduce the risk of transmission to
siblings
Individual lesions will resolve if the central core is damaged by any modality including
cryotherapy but this is not recommended in young children, as it is too painful.
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Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
Referral Threshold – Community
dermatology
Community Dermatology Service
In general patients with viral warts/verrucae
and molluscum should not be referred.
Patients may be referred if:
Severe disabling warts despite six months
of topical salicylic acid treatment +/cryotherapy.
Significant warts or mollusca in
immunocompromised patients
Referral – 999 for emergency admission
Urgent referral to Dermatology
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Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
3) HAND ECZEMA
What to consider in Primary Care before referring:
Clinical Features
A Endogenous Eczema (e.g. atopic)
B Exogenous Eczema
(i) Irritant Contact Eczema (ICD)
Due to substances coming into contact with the skin, usually repeatedly causing damage and
irritation. Substances such as:
Water
Detergents
Shampoos
Household cleaning products
(ii) Allergic Contact Dermatitis (ACD)
Due to type IV allergic reaction to a substance the skin is in contact with.
All types of endogenous and exogenous eczema can present with either ‘wet’ (blistering and
weeping) or ‘dry’ (hyperkeratotic and fissured) eczema
General Comments
Other skin conditions can mimic eczema and should be kept in mind.
It is usually worth examining the patient’s skin all over as this can provide clues to
other diagnoses e.g. plaques in extensor distribution in psoriasis, scabetic nodules in
scabies.
If an eczematous looking rash is present on only one hand, a fungal infection needs
to be excluded by taking skin scrapings for mycology.
If contact dermatitis is suspected a careful occupational and social history should be
taken and the patient may benefit from Patch Testing
Patch Testing is only of value in patients with eczema - It is of no use with type 1
reactions (e.g. food allergies causing anaphylaxis or urticaria).
In practice the cause of eczema is often multi-factorial with external factors
precipitating eczema in a constitutionally predisposed individual, in which case patch
tests are usually unhelpful. Resistant hand eczema does however, merit
consideration of these to exclude type 4 reactions.
Treatment in Primary Care
Avoidance of irritants
Soap substitutes such as Emulsifying Ointment should be used.
Gloves e.g. Household rubber or PVC gloves should be used for wet work such as
dishwashing. Gloves may also be required for dry work e.g. gardening.
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Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
Recommended emollients
Emulsifying Ointment, 500g,
Hydrous (oily cream) ointment, 500g,
Diprobase cream or ointment, 500g, ointment or cream
E45 cream, 500g,
Cetraben cream, 500g,
Doublebase gel, 500g,
Unguentum M cream, 500g.
Greasier preparations are better at hydrating the skin e.g. –
Liquid paraffin / White soft paraffin Ointment 50:50, 500g,
White or Yellow Soft Paraffin, 500g,
Topical Steroids
The strength of topical steroids required varies from case to case
It may be necessary to use a potent steroid in the short term
Use cream formulation if wet – use ointment if dry
Potassium permanganate – Permitab 400mg. Can be purchased OTC
Dilute 1 tab in 4L of water to pale pink (rose wine colour) and soak for fifteen minutes
2 to 3 times daily for acute wet eczema until blistering weeping has dried.
Make up a pale pink/rose colour using warm water
Antibiotics (topical/systemic) Exclude secondary infection and treat if appropriate
Referral – Community Dermatology
Severe chronic hand dermatitis,
which is unresponsive to treatment
described above.
Occupational difficulty after standard
therapy in primary care falls.
If allergic contact dermatitis is
suspected, Patch Testing may be
considered.
Referral - 999 for emergency admission
Urgent referral to Dermatology
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Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
4) ACNE
What to consider in Primary care before referring:
General Comments
Mild & moderate acne should be managed in primary care.
Several different agents may need to be tried alone or in combination.
DO NOT use combinations of agents with similar properties or actions e.g. topical
plus systemic antibiotics.
Inform patient that response is usually slow and allow at least 12 weeks before
review.
Try treatments individually so you can assess what works, rather than using
combinations.
Treatment Aims
To reduce the severity and length of illness.
To reduce the psychological impact on the individual.
To prevent long-term sequelae such as scarring.
Treatment in primary care
Mild Acne
(Uninflamed lesions – open and closed comedones (blackheads), sometimes with
papules/pustules)
Topical benzoyl peroxide preparations +/- topical antibiotic e.g. benzoyl peroxide 2.5%, 4%,
5% or 10% when available. Quinoderm - if supply problems with benzoyl peroxide persist.
(Use topical retinoids at all stages of acne to help minimise formation of comedone)
Topical antibiotic combination preparations e.g. Clindamycin 1%, 30ml
It is cheaper to use constituent parts than the combination products.
Moderate Acne Defined as: A greater number of more extensive inflamed lesions, with
scarring risk.
Systemic antibiotics
In cost order: (Treatment should continue for 6 months minimum and repeat if necessary)
Oxytetracycline, 500mg, twice daily,
Erythromycin 2 x 250mg, twice daily, – 1st line A/B in pregnancy
Lymecycline 408mg daily,
Topical benzoyl peroxide or retinoids may be used in combination. Use topical retinoids
at all stages of acne to help minimise formation of comedone.
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Buckinghamshire Joint Dermatology Referral Guidance 2013
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Moderate or Severe Acne
Defined as – Papules/pustules with deeper inflammation and some scarring.
Systemic treatment with antibiotics plus topical therapy.
Consider additional hormone therapy in women. Ethinylostradiol/Cyproterone acelate – (cocyprindiol 2000/35) – only if there is a clear hormonal association / Polycystic Ovary Disease.
Note CSM warning suggests single courses in primary care but long term use over 4 – 6
months should be under specialist supervision.
Stopping co-cyprindol can cause rebound acne.
Severe Acne
i.e. Confluent or nodular lesions usually with significant
scarring.
Referral to community dermatology,
or secondary care service.
Isotretinoin is not currently
available from GPSI service
Commence systemic therapy and refer for
systemic isotretinoin treatment.
The main reason for referring a patient with acne is for
isotretinoin treatment.
Females of child bearing age should be
established on an effective contraceptive prior to
treatment with isotretinoin.
The indications for isotretinoin treatment are as follows:
Risk of scarring
Severe nodulocystic acne / acne fulminans
(immediate referral)
Moderate acne that has failed to respond to
prolonged courses of two oral antibiotics (e.g. 6
months of each oral antibiotic) in addition to
topical treatment.
Mild to moderate acne in patients who have an
extreme psychological reaction to their acne and
have failed to respond to prolonged courses of
systemic antibiotic treatment and topical
treatment.
Referral Threshold - 999 for emergency
admission Urgent referral to Dermatology
Isotetinoin systemic treatment is a reason for
secondary care referral
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Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
5) Psoriasis
What to consider in Primary Care before referring:
General Comments
Psoriasis is a chronic relapsing condition: mild & moderate involvement can usually be
managed in primary care. Prior to referral, basic treatment should be tried as outlined.
Nursing input by an appropriately skilled nurse at this stage will decrease need for referral to
dermatology service. Ensure patients understand how and when to use their treatments.
Treatment in primary care
Chronic Plaque Psoriasis First line therapy: calcipotriol
Calcipotriol (Dovonex) – Apply twice daily (up to 100g weekly) ointment
Calcitriol (Silkis) – Apply twice daily (max 200g weekly)
Calcitriol can be used in flexures, but is possibly less potent than calcipotriol
Expect improvement to be gradual, achieving maximum effect over 12 weeks treatment.
If useful can be continued long term or intermittently. If used correctly many patients will
achieve at least flattening and partial clearance of plaques
Calcipotriol & potent topical steroid with e.g. Betnovate RD (Note: Dovobet ointment is more
expensive than constituent part– so avoid) – Apply each accurately to plaques once daily for
4 week.
This combination provides rapid improvement over a 4 week course; use calcipotriol alone for
maintenance therapy – steroid can cause irritation
Exorex lotion – coal tar extract 1% lotion +/- a mild or moderate steroid ointment
Apply away from flexures twice daily
Refined tar products are less smelly or messy than old unrefined preparations. May stain
clothes or irritate. Expect slow response over 6 – 12 weeks
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Buckinghamshire Joint Dermatology Referral Guidance 2013
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Dithranol preparations
Dithrocream (dithranol) 0.1%, 0.25%, 0.5%, 1%, 2%
Micanol (dithranol 1% or 3% in a lipid stabilised basis)
Start with the lowest strength, applied daily to plaques for 15 to 30 minutes, then wash off.
Increase through strengths weekly unless irritancy occurs.
Can be used as ‘short contact therapy’ at home, away from face, flexures and
genitals.
Often very effective if performed correctly with good remission time but time
consuming to do therefore only useful if patient is well motivated and psoriasis
localised.
Stains everything including skin, linen, bathroom furniture and may cause irritation of
the skin.
Give adequate quantities of topical preparations appropriate for extent of disease.
Guttate Psoriasis
Numerous small lesions, mostly on trunk, generally affecting children / young adults
acutely. Often follows sore throat and is self-limiting over 3 – 6 months.
Treat with emollients plus trials of tar preparations.
Calcipotriol or moderate potency steroids e.g. clobetasone butyrate 0.05%.
If severe consider referral for phototherapy.
Facial Psoriasis
Can be treated with mild potency steroid with antifungal initially
e.g. Dakacort (=1% hydrocortisone & miconazole 2%)
If very itchy a moderate potency topical steroid could be substituted
e.g. Betnovate RD or Eumovate
Scalp Psoriasis
For mild psoriasis consider T-gel which may be purchased over the counter.
For moderate scalp psoriasis consider Betnovate scalp application.
Use daily, apply to dry hair, leave on for 15 minutes and then add water, lather and shampoo
out. Review after 4 weeks.
Some require combination of agents such as steroid and a tar based scalp application.
E.g. Calcipotriol scalp solution, Sebco, Polytar, Alphosyl 2 in 1 or Capasal.
In more severe cases:
st
1 use keratolytic e.g. Sebco Scalp ointment massaged into scalp &left overnight, wash out in
the morning then apply a topical potent steroid e.g. Betamethasone 0.1% scalp application or
Synalar gel.
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If very severe:
Sebco Scalp ointment (Coaltar solution 12%, Salicyclic acid 2, precipitated sulphur 4% in
coconut oil) can be applied for 3 – 4 hours in the evening and washed out with tar shampoo
before bed. Calcipotriol scalp application or a topical steroid could then be applied overnight
in addition.
Flexural Psoriasis
Smooth well demarcated areas in axillae, groins, intra-mammary folds and natal cleft. May
occur alone or with chronic plaques elsewhere.
Use a mild to moderate potency steroids combined with antibiotic / antifungals e.g:
Daktacort cream
Trimovate creams
Apply once to twice daily.
OR can be treated with:
Calcitriol
Often partial response only is achieved.
Avoid potent steroids to the face.
Referral Criteria – Community Dermatology
Service
Community Dermatology Service
Extensive / severe or disabling psoriasis –
covering 20% body surface are or more.
Failure to respond to adequate treatment or
rapid relapse post treatment.
Extensive acute guttate psoriasis.
Unstable and generalised pustular psoriasis
– URGENT REFERRAL.
Diagnostic uncertainty.
Use of dithranol
Referral Threshold – 999 for emergency
admission Urgent referral to Dermatology
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Buckinghamshire Joint Dermatology Referral Guidance 2013
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Skin Cancer
What to consider in Primary Care before referring:
General Comments
Basal Cell Carcinoma (BCC)
These are common slow growing and locally invasive tumours.
Most are easily recognised with a pearly rolled edge and later central ulceration. Pigmented
and morphoeic (scar like, poorly defined) BCCs are less common variants.
The following malignancies are much less common:
Squamous Cell Carcinoma (SCC)
They may be slow growing, well differentiated, keratinising or rapidly enlarging, poorly
differentiated tumours.
5% may metastasise to regional lymph nodes.
Malignant Melanoma (MM)
This is the most dangerous skin malignancy. Early detection and excision is vital for good
prognosis. Melanoma subtypes
Superficial spreading
Nodular
Amelanotic
Lentigo Mailgna
Acral lentignous and subungual
Criteria for diagnosis
The six following point checklist may be useful in deciding whether to refer a changing
pigmented lesion:
Major features:
Change in size
Change in colour (variation of pigmentation)
Change in shape (irregular of edge)
Minor features:
Size ≥ 7mm diameter
Inflammation
Bleeding / crusting
Itch is not a good indicator of malignancy or otherwise, but may draw attention to a mole.
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Buckinghamshire Joint Dermatology Referral Guidance 2013
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Treatment in primary care is by referral:
Basal Cell Carcinoma (BCC)
They are best managed by complete excision by the dermatology surgeons within the
department and should be referred in the usual manner.
In some cases radiotherapy mat be a preferred option but tissue diagnosis (e.g.
biopsy) is still required prior to referral for radiotherapy and will be carried out in the
Dermatology clinic.
BCC’s (low risk, not on face) can only be removed in primary care by GPSI in the
intermediate service.
Squamous Cell Carcinoma (SCC)
Lesions with a high index of suspicion, especially if rapidly growing, should be referred by fax
within 24 hours.
USE 2 week wait SKIN CANCER REFERRAL PROFORMA
Malignant Melanoma (MM)
All referrals for suspicious moles should be faxed to the dermatology service to be seen within
2 weeks.
Any lesion felt to be highly suspicious of melanoma will be excised on the day of clinic or as
soon as possible afterwards.
Use 2 week wait skin cancer referral proforma available on CCG website
Referral – Community Dermatology
Service
Community Dermatology Service
All skin cancer should be referred to
dermatologists for confirmation of diagnosis
and treatment plan.
Suspicious lesions, SCC and MM refer under
2/52 rule via faxed proforma
Referral Threshold – 999 for emergency
admission Urgent referral to Dermatology
20
Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
7) Scabies
What to consider in Primary care before referring:
General Comments
Human scabies is an infestation of the skin caused by the mite Sarcoptes scabiei.
The mites are most readily transmitted from one person to another by close physical
contact in a warm atmosphere e.g. sharing a bed, holding hands, adults tending to
children, children playing with each other.
An individual who has never had scabies before may not develop itching or a rash until
one month to three months after becoming infested.
There is usually:
Widespread inflammatory papular eruption.
Burrows on non-hair bearing skin of the extremities.
Pruritic papules around the axilla, nipples, umbilical region and buttocks.
Inflammatory nodules on the penis and scrotum.
The reactive rash to scabies can be eczematous or urticarial – Impetigo may also occur.
Usually more than one family member is affected.
It is mandatory that all members of the household and any other close social contacts of
an infested person should receive treatment at the same time as the patient.
Treatment in primary care
Treat patients when there is a strong clinical suspicion that they may be infested. If
unsure whether eczema or scabies, treat eczema first and review.
If diagnosis of scabies – the essential step is to kill all the mites in the skin using a
scabicide.
Scabicide
Apply either:
Malathion 0.5%, Aqueous solution (Derbac M) Rub it in to all parts of the body,
200ml
Permethrin 5% (Lyclear Dermal Cream), 60g
Treat all the skin other than the face.
Remove rings and use a nail brush to apply under the nails.
Remind patients to re-apply the scabicide after washing their hands.
Malathion should be left on the skin for 24 hours and Permethrin for between 8
and 12 hours.
At the end of this period the patients can bath, they must also change their
underclothes, nightclothes, sheets and pillowcases.
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Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
Disinfestation of clothing and bedding other than by ordinary laundering is not
necessary.
One treatment is probably curative but a second application after 1 week is
recommended.
If these directions have been followed, all mite in the skin will have been killed but the
pruritis may take 3 to 6 weeks to settle.
Do not keep using scabicides as repeated applications may irritate the skin.
Treat residual itchy areas with:
Topical anti-pruritic e.g. Crotamiton cream (Eurax)
Crotamiton / hydrocortisone (Eurax HC or constituent parts)
A higher potency of steroid may be needed to treat areas of secondary eczema.
Referral Threshold – Community
Dermatology Service
Community Dermatology Service
Diagnostic Uncertainty
Failure of response to treatment
Referral Threshold – 999 for emergency
admission Urgent referral to Dermatology
22
Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
8) Actinic Keratoses
Treatment of actinic keratosis
Actinic keratoses (AKs) present in a variety of ways:
Rough and dry textured skin lesions (single or multiple)
Flesh-coloured, grey, pink, or red macules, papules or plaques
Limited to a discrete area (localised) or diffuse
Flat and scaly on the surface, becoming slightly raised, hard and wart-like, or
rough and ‘sandpapery’
Horn-like texture from overgrowth of the keratin layer (hyperkeratosis)
Generally asymptomatic but some cause pruritus or burning sensation
There are no distinct clinical boundaries between AK and invasive squamous cell
carcinoma (SCC). AKs are risk markers for SCC and an early phase of a process which
may turn into an invasive SCC. It is therefore recommended that all AKs are treated.
Treatment selection is based upon:
Disease related factors: the type of lesion (e.g. thickness) the site, the number
and localisation.
Patient characteristics: e.g. age, frailty, ability to follow instructions, comorbidities, other risk factors e.g. immunosuppression, pre-existing skin cancers.
Patient preference: Most treatments are associated with some level of
discomfort, restrictions and alteration of appearance.
Treatment may be lesion directed or field directed. Depending upon the lesion
characteristics, a field-directed approach to treatment is preferable. It involves the
application of topical treatment to the area of photo damaged skin, containing both visible
and sub-clinical lesions. The aim of field directed therapy are:
Eradicate clinically evident AKs, sub-clinical AKs and smaller foci of transformed
clones.
Prevent development of invasive SCC.
Provide longer remission (e.g. prolong the time to new AK development in the
treated field).
Many (10 or more AK lesions) may indicate a preference for a field-directed treatment
approach.
Because lesions on different sites may have different tolerability levels, and because
different types of actinic keratosis may be present in the same patient, it is normal
practice to use different treatments simultaneously.
For more detailed advice see Eur J Dermatol 2008; 18(6) 651-9
23
Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
Medicines
All patients should be advised to use UV protection and emollients
Also known as solar keratosis are usually multiple, flat reddish brown lesions with
a dry adherent scale.
The vast majority of AKs DO NOT progress to squamous cell carcinoma.
Evidence suggests that the annual incidence of transformation of individual solar
keratosis to SCC is less than 0.1%. This risk is higher in immunocompromised
patients.
It is not necessary to refer all patients with solar keratosis.
24
Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
Treatment in primary care
1.
2.
3.
Diclofenac Sodium 3% in sodium hylauronate (Solaraze) – twice daily for 3
months.
Actikerall (5-FU / salicyclic acid) – for isolated lesions
Topical 5-fluorouracil (Efudix) – apply once to twice daily for 3 to 4 weeks.
Usually used on smaller volume areas. 5FU is safe, efficacious, with little systemic
absorption. Marked inflammation occurs prior to resolution and the patient must be
warned to expect this.
Other treatments (for isolated, well-defined lesions): - Cryotherapy – light freezing for 5 –
10secs.
Topical imiquimod. Specialist/Hospital only in Bucks
Photodynamic therapy. Specialist/Hospital only in Bucks
Surgery
Referral Threshold – Community
Dermatology Service
Community Dermatology Service
If there is suspicion of malignancy.
If the lesions have not responded
to treatment.
If the individual is on
immunosuppressant (e.g. postrenal transplants).
For specialist only treatments e.g.
imiquimod, photodynamic therapy,
surgery
Referral Threshold – 999 for emergency
admission
25
Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
9) Rosacea
What to consider in Primary Care before referring:
Clinical features
Flushing often made worse by alcohol, spicy foods, hot drinks, temperature changes or
emotion Telangiectasia
Papules on an erythematous background
Pustules
Rhinophyma
Absence of comedones
Treatment in Primary Care
Early treatment of rosacea is considered to be important as each exacerbation leads to
further skin damage and increases the risk of more advanced disease.
Intermittent therapy can be considered for those with very occasional flare-ups, but frequency
of recurrences can be reduced by maintenance therapy.
Systemic treatment may be needed to provide initial clearance with topical therapy to keep
the condition at bay. Clinical response to either systemic or topical treatment expected within
4 weeks.
Topical Treatment
(For mild to moderate cases or where systemic treatment is contraindicated)
st
1 line – Metronidazole 0.75% (e.g. Rozex) Gel or Cream (e.g. Rosex, Rosiced) twice daily.
nd
2 line – Azelaic acid 15% gel (e.g. Finacea) twice daily.
May be introduced at the end of a course of oral antibiotics to allow their tapering and
withdrawal.
Preparations with a cellulose base (e.g. Metrogel) tend to be less cosmetically acceptable to
patients & this product is not recommended.
Avoid topical steroids.
Systemic Treatment
st
1 line – Oxytetracycline, 500mg twice daily.
nd
2 line – Lymecycline, 408mg once daily.
rd
3 line – Doxycycline.
st
If pregnant erythromycin 2 x 250mg twice daily – 1 line
Continue therapy until benefit is obtained and reduce to antibiotics / topicals as required NB.
Tetracyclines are contraindicated in pregnancy, lactation and renal disease.
Both drugs classes can cause photosensitivity.
Patients should be advised to avoid direct sunlight and to wear a suitable sun block when
going outside.
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Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
Surgical Treatments all LOW PRIORITY in Bucks
Vascular Laser / Hyfrecator (used in the treatment of telangiectasia but requires an
exceptional case application)
Dermabrasion
Surgical shaving
Laser therapy (For the treatment of rhinophyma)
Patient Counselling
Patient Counselling can be advised on a number of issues:
Heat and cold
Alcohol and spicy foods all of which can provoke
Flushing, stress management
Camouflage / cosmetic advice
Ocular Rosacea
Ocular rosacea must be treated to prevent keratosis and blindness – Advise patient on lid
hygiene to manage blepharitis
Treatment use systemic tetracyclines (as above)
Referral
Threshold
–
Community
Community Dermatology Service
Dermatology Service
Doubt over diagnosis.
Severe disease associated with
development of pyoderma faciale.
the
Severe Ocular Rosacea with keratitis or
uveitis
Referral Threshold – 999 for emergency
admission Urgent referral to Dermatology
27
Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
10) Urticaria and Angioedema
What to consider in Primary Care before referring:
General Comments
Urticaria / Angioedema is believed to be an autoimmune process.
In the vast majority of patients with urticaria no underlying trigger factor associated
disease is found and the condition is self-limiting. Prick test and RAST tests are not
useful as a screening test of potential allergens in chronic ordinary urticaria.
Food allergy is usually obvious and trigger factors such a crustaceans, fish and nuts
can be easily identified.
Contact urticaria is generally suggested by the history and can be confirmed by
contact urticaria tests that are different to patch tests, which have no place in the
investigation of urticaria.
Physical urticaria including:
Dermagraphism
Cholinergic urticaria
Cold urticaria
Solar urticaria
Pressure urticaria
Can usually be identified on history.
Urticaria may follow non-specific infections, hepatitis, streptococcal infections, campylobacter
and parasitic infestation. Rarely, it may be a symptom of an underlying systemic disease such
as thyroid disease or connective tissue disease.
Management in Primary Care / Advice for self-care
Explain the condition to the patient and reassure that it is benign and usually self-limiting.
Minimise:
Overheating
Alcohol
Caffeine
Stress
Review Drug history – Both prescribed and non-prescribed, many drugs have been reported
to cause urticaria such as penicillins, ACE inhibitors, statins, NSAID’s, in particular aspirin.
Additionally opiates and NSAID’s may exacerbate existing urticaria.
Exclude: C1 Esterase Deficiency (If angioedema is the only sign)
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Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
Insect bites
Treatment in Primary Care: Antihistamines
There is little to choose between different antihistamines but individuals may vary in
their response to different agents.
Sedative or non-sedative antihistamine choice depends on the need for sedation.
Many antihistamines block histamine wheals and itching but do not suppress the rash
completely.
Use continuous medication if attacks occur regularly.
Use fast acting antihistamines as required for sporadic attacks.
If there is no response to one agent after four weeks, try an alternative second and
even then a third agent.
In some cases of severe acute urticaria, such as a penicillin reaction, a short reducing
course of prednisolone starting at 30mgs – 40mgs daily may be useful.
Systemic steroids should not be used in chronic urticaria.
Summary of low-sedating antihistamines.
Name
st
1 Choice
Equal 1
choice
rd
st
3 choice
Drug Interactions
Comments
Loratadine
None
Avoid in pregnancy
Cetirizine
None
Minimally sedating. Half the
dose in renal impairment. Avoid
in pregnancy.
Fexofenadine 180
None
Avoid in pregnancy
If ineffective consider
also more sedating
antihistamines
e.g. chlorphenamine,
hydroxyzine.
Hydroxyzine not usually 1
choice in pregnancy.
st
Note: In pregnancy it is suggested that the long established antihistamines be used e.g.
chlorphenamine
Double doses of antihistamines are used off license locally – the local experts believe they
are more effective in urticaria at higher doses.
Referral Threshold – Community
Dermatology Service
Referral Threshold – 999 for emergency
admission Urgent referral to Dermatology
29
Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
11) Generalised Pruritus
What to consider in Primary Care before referring:
General Comments
Dry skin, eczema and scabies are the commonest cause of generalised pruritus.
If someone is itching all over, take a full history and examine the skin very carefully.
Check lymph nodes and blood tests as below.
Management in Primary Care
If NO RASH can be seen other than excoriations consider the following:
Anaemia – Especially iron deficiency.
Uraemia.
Obstructive jaundice.
Thyroid disease both hypo and hyperthyroidism.
Lymphoma, especially in young adults.
Carcinoma, especially in middle aged and elderly.
Psychological
A full general examination may be helpful.
Organise the following investigations:
FBC and differential
ESR
Urea and electrolytes
LFT’s
Thyroid function tests
Iron Studies
Abdominal USS (Consider if clinically indicated)
Chest X-ray (Consider if clinically indicated)
NB: Be aware that pruritus may occasionally predate a malignancy by several years.
Treatment: Emollients, sedative anti-histamines, anti-pruritic bath oils.
Referral Threshold – Community
Community Dermatology Service
Dermatology Service
Refer to Dermatology if treatment fails.
-
Referral Threshold – 999 for emergency
admission Urgent referral to Dermatology
30
Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
12) Onychodystrophy
(thickened and dystrophic nails)
What to consider in Primary Care before referring: for onchodystrophy
General Comments
In Bucks we have a LOW PRIORITY statement around fungal nail infections.
The priorities committee considers the treatment of onychomycosis (fungal nail infection) with
terbinafine to be a low priority and not normally prescribed, with the exception of infection in
the frail elderly, diabetic or other immunocompromised patients. In these patients, take nail
clippings: start therapy only if infection is confirmed by laboratory. Terbinafine is more
effective than azoles. Liver reactions are rare with oral antifungals.
In the unusual situation where treatment is indicated on the NHS:
st
1 line – terbinafine, 250mg, daily 6 – 12 weeks (fingers) 3 – 6 months (toes)
(intermittent regimens are not as effective as daily treatment with terbinafine)
nd
2 line – Itraconazole, 200 mg, orally twice a day for 7 days a month
-2 courses (for fingers)
-3 courses (for toes)
General cutaneous examination and examination of all the nails is necessary.
Send samples (nail clippings including scrapings of thickened crumbly material on the
underside of the nail if present) for microbiology. If repeatedly negative, advise regular filing of
nails to keep nails short and thin.
Asymptomatic patients should be advised to ‘leave well alone’.
Treatment in Primary Care
If mycology is positive and dystrophy does not extend to nail matrix (distal onychromycosis)
consider no treatment. If treatment is required consider:
Oral antifungals: Always obtain +ve mycology before starting oral antifungal agents.
Terbinafine (Lamisil), 250mg od 3 – 6 months for toenails, 6 – 12 weeks for fingernails
Itraconazole (Sporanox) Pulse treatment, each pulse of itraconazole 200mg twice a day for 7
days repeated monthly (3 cycles for toenails, 2 for fingernails).
Referral Threshold – Community
Community Dermatology Service
Dermatology Service
Do not refer patients with this condition
Referral Threshold – 999 for emergency
admission Urgent referral to Dermatology
31
Buckinghamshire Joint Dermatology Referral Guidance 2013
Adapted from a document from NHS Hounslow with thanks
13) Referral Criteria for Secondary Care Dermatology
Primary Care Treatment
All mild and some moderate disease should be treated initially in primary care before
considering referral to a dermatologist.
Criteria for referral to Community Dermatology
Mild to moderate acute or chronic rash where unsure of diagnosis
Moderate inflammatory conditions where treatments in primary care have been
unsuccessful e.g.
- Moderate acne (where treatments in primary care have been unsuccessful)
- Moderate Eczema (where suggested primary care treatments have failed)
Urticaria (where suggested primary care treatments have failed)
Tinea/Bacterial Infections
Pruritus (where suggested primary care treatments have failed)
Criteria for referral to Acute Service
Severe acne
Severe psoriasis
Severe eczema
Blistering disorders e.g. bullous pemphigoid
Severe rash where unsure of diagnosis
Any condition requiring hospital treatment (e.g. phototherapy, patch testing,
day treatments, prescription of hospital only drugs)
Criteria for referral directly to A&E
Steven Johnson syndrome/toxic epidermal necrolysis or acute rash e.g. blistering
erythrodema
Referral forms are available on CCG intranet sites.
Please feedback any comments on this guideline to [email protected]
The authors value your input and will make revisions if needed.
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