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Greater Manchester EUR Current Commissioning Title/Topic: Benign Skin Lesions Date: 18 December 2013 Reference: GM013 Introduction Clinical Commissioning Groups (CCGs) across Greater Manchester have inherited Effective Use of Resources (EUR) policies from their predecessor Primary Care Trusts (PCTs). Consequently, there are varying positions regarding the commissioning of certain procedures/treatments across Greater Manchester. Work is now being undertaken by the Greater Manchester Commissioning Support Unit’s (GMCSU) Policy Team, led by the Greater Manchester EUR Steering Group to align EUR policies across Greater Manchester. Purpose of the Report This report aims to inform the Greater Manchester EUR Steering Group of each CCG’s current commissioning arrangements in place for Benign Skin Lesions. Body of the Report The table below describes each CCG’s current policy criteria on Benign Skin Lesions: Bolton Excision of benign skin lesions Removal of benign skin lesions will only be considered for: Suspicious or potentially malignant lesions Impairment of function or significant facial disfigurement, for example large lymphoma Treatment of multiple lipomatosis or neurofibromatosis. If a General Practitioner or Consultant is concerned that any skin lesion may be malignant, the patient should continue to be referred under the 2week rule so that treatment can be carried out promptly. Excision of benign skin lesions is generally effective but they are considered to be procedures of low clinical priority and will only be carried out under exceptional circumstances. Fatty lumps (lipomata) Lipomata of any size will only be considered for treatment in the following circumstances: The lipoma(-ta) is (are) symptomatic There is functional impairment The lump(s) is (are) rapidly growing or abnormally located (e.g subfascial, sub-muscular) Other benign lesions Clinically benign lesions such as skin tags, corns, comedones (blackheads), milia, sebaceous cysts, molloscum contagium and seborrhoeic keratosis (non-viral ―warts‖) will not be treated on purely cosmetic grounds. Viral warts Because most viral warts will clear spontaneously or following application of tropical treatments, wart removal is not commissioned by NHS Bolton. However, painful, persistent or extensive warts (particularly in the immunosupporessed patient) may need specialist assessment, usually by a dermatologist. For a small proportion of warts, surgical removal (cryotherapy, cautery, laser or excision) may be considered. Applications 2 for surgical treatment should be made to the Individual Case Panel. Vascular skin lesions NHS Bolton will not fund the removal of small benign, acquired vascular lesions such as thread veins and spider naevi. Laser removal of a birthmark (port wine stain) NHS Bolton does not fund this procedure. Bury NE Sector Policy Excision of all minor skin lesions includes benign pigmented moles, comedones, corn/callous, lipoma, milia, molluscum contagiosum, sebaceous cysts (epidermoid or pilar cysts), seborrhoeic keratoses (basal cell papillomata), skin tags including anal tags, keloid scars, spider naevus (telangiectasia), warts, xanthelasma and neurofibromata. Removal of lumps and bumps (in secondary care) Not commissioned unless there is clinical exceptionality. The following lesions should be managed within primary care unless there are clinical limitations such as size and location that warrant secondary care excision. Lesions should not be removed for cosmetic reasons. Epidermoid or sebaceous cysts including cysts on scalp. Lipomas (size and position dependant) Diagnostic excisions on lesions not felt to be malignant – including punch or elipse biopsies if needed. Fibroepithelial polyps if causing irritation or discomfort but not for cosmetic reasons – includes multiple skin tag pick and snip if tags causing problems Dermatofibromas or histiocytomas also not for cosmetic reasons Lesion curettage – irritated basal cell papilomas, warty lesions for diagnosis or due to functional limitation or irritation. The excision of lesions for suspected cancer are excluded from the EUR Process. No lesions suspected to be melanomas or SCC in primary care. BCCs can be done in primary care if in line with 2010 NICE criteria for low risk BCCs – ie below clavicle, <1cm, not recurrent or persistent, not morphoeic or infiltrative and in area where primary closure is possible etc. Heywood, Middleton and Rochdale Local Policy Excision of non-cancerous skin lesions in secondary care The removal of non-cancerous skin lesions are not commissioned for purely cosmetic reasons. 3 Non-cancerous skin lesion removal are not commissioned within Secondary Care unless there is clinical exceptionality – Refer to NE Sector EUR Policy 2011-12. Non-cancerous skin lesions that may be painful or become infected, or are causing functional problems are not defined as cosmetic for these purposes. Skin lesions, including dermoid cysts and lipomas or other subcutaneous nodules up to 5 cm diameter should be undertaken within Primary Care Services. Removal of skin lesions within secondary care will only be considered if: The size or location of the lump makes it unsuitable for removal within extended primary care. . THE EXCISION OF LESIONS FOR SUSPECTED CANCER AND/OR WHERE THERE IS DIAGNOSTIC UNCERTAINTY ARE EXCLUDED FROM THE EUR PROCESS. -------------------------------------------------------------------------------------------NE Sector Policy Excision of all minor skin lesions includes benign pigmented moles, comedones, corn/callous, lipoma, milia, molluscum contagiosum, sebaceous cysts (epidermoid or pilar cysts), seborrhoeic keratoses (basal cell papillomata), skin tags including anal tags, keloid scars, spider naevus (telangiectasia), warts, xanthelasma and neurofibromata. Removal of lumps and bumps (in secondary care) Not commissioned unless there is clinical exceptionality. The following lesions should be managed within primary care unless there are clinical limitations such as size and location that warrant secondary care excision. Lesions should not be removed for cosmetic reasons. Epidermoid or sebaceous cysts including cysts on scalp. Lipomas (size and position dependant) Diagnostic excisions on lesions not felt to be malignant – including punch or elipse biopsies if needed. Fibroepithelial polyps if causing irritation or discomfort but not for cosmetic reasons – includes multiple skin tag pick and snip if tags causing problems Dermatofibromas or histiocytomas also not for cosmetic reasons Lesion curettage – irritated basal cell papilomas, warty lesions for diagnosis or due to functional limitation or irritation. The excision of lesions for suspected cancer are excluded from the EUR Process. No lesions suspected to be melanomas or SCC in primary care. 4 Manchester (Central, North and South) BCCs can be done in primary care if in line with 2010 NICE criteria for low risk BCCs – ie below clavicle, <1cm, not recurrent or persistent, not morphoeic or infiltrative and in area where primary closure is possible etc. Dermatology Minor surgery (for cosmetic and benign skin lesions) (Please note these apply to both Secondary or Tier 2 services) Purely cosmetic procedures are not commissioned, generally in the NHS. Dermatology procedures that are purely cosmetic in nature are not commissioned in either primary or secondary care. Lipomas and sebaceous cysts that may be painful or become infected are not defined as cosmetic for these purposes. Removal of skin lesions within secondary care will only be considered if: Lesions are suspicious or potentially malignant There is impairment of function or significant facial disfigurement All referrals to secondary care will be reviewed by the dermatology extended care team before processing Cutaneous and plantar warts (Please note these apply to both Secondary or Tier 2 services) Warts normally resolve spontaneously although this may take up to 2 years. Treatment for warts should only be considered if warts: are symptomatic i.e. painful or itchy OR interfere with functioning OR have been present for more than two years OR have spread extensively. Treatment should initially be by duct tape occlusion; if this is unsuccessful then treatment with topical salicylic acid should be considered. Treatment with cryotherapy should only be considered if treatment with both duct tape occlusion and topical salicylic acid has not cleared the wart. Patients with these exceptional symptoms may need specialist assessment, usually by a dermatologist. Referral to the tier 2 dermatology service should only be considered if: there is genuine doubt about the diagnosis OR the wart is recalcitrant or rapidly growing OR malignancy is suspected (malignant changes in warts are extremely rare but should be excluded in older people or people with immunosuppression or subungual warts.). For a small proportion surgical removal (cryotherapy, cautery, laser or excision) may be appropriately performed within Primary Care. Removal of Haemorrhoid Skin Tags This procedure should not be performed. There may be consideration of 5 special circumstances e.g. recurrent bleeding. Minor Surgery Minor surgery (defined as removal of lumps and bumps and including surgery for ingrown toenails) is not routinely commissioned in a secondary care setting. Only patients that have been referred to secondary care via an ICATS are legitimate. Treatment of vascular lesions (including port wine stains) Not commissioned for small, benign, acquired vascular lesions such as thread veins and spider naevi. Oldham NE Sector Policy Excision of all minor skin lesions includes benign pigmented moles, comedones, corn/callous, lipoma, milia, molluscum contagiosum, sebaceous cysts (epidermoid or pilar cysts), seborrhoeic keratoses (basal cell papillomata), skin tags including anal tags, keloid scars, spider naevus (telangiectasia), warts, xanthelasma and neurofibromata. Removal of lumps and bumps (in secondary care) Not commissioned unless there is clinical exceptionality. The following lesions should be managed within primary care unless there are clinical limitations such as size and location that warrant secondary care excision. Lesions should not be removed for cosmetic reasons. Epidermoid or sebaceous cysts including cysts on scalp. Lipomas (size and position dependant) Diagnostic excisions on lesions not felt to be malignant – including punch or elipse biopsies if needed. Fibroepithelial polyps if causing irritation or discomfort but not for cosmetic reasons – includes multiple skin tag pick and snip if tags causing problems Dermatofibromas or histiocytomas also not for cosmetic reasons Lesion curettage – irritated basal cell papilomas, warty lesions for diagnosis or due to functional limitation or irritation. The excision of lesions for suspected cancer are excluded from the EUR Process. No lesions suspected to be melanomas or SCC in primary care. BCCs can be done in primary care if in line with 2010 NICE criteria for low risk BCCs – ie below clavicle, <1cm, not recurrent or persistent, not morphoeic or infiltrative and in area where primary closure is possible etc. Salford 6 Excision of Benign skin lesions (excluding suspected cancer) This procedure is not commissioned, unless there is demonstrated evidence of clinical exceptionality. Thread Veins This procedure is not commissioned, unless there is demonstrated evidence of clinical exceptionality. Viral Wart Surgery This procedure is not commissioned, unless there is demonstrated evidence of clinical exceptionality. Stockport Cutaneous and plantar warts Warts normally resolve spontaneously although this may take up to 2 years. Treatment for warts should only be considered if warts: are symptomatic i.e. painful or itchy; or interfere with functioning; or have been present for more than two years; or have spread extensively. Treatment should initially be by duct tape occlusion; if this is unsuccessful then treatment with topical salicylic acid should be considered. Treatment with cryotherapy should only be considered if treatment with both duct tape occlusion and topical salicylic acid has not cleared the wart. Referral to the tier 2 dermatology service should only be considered if: there is genuine doubt about the diagnosis; or the wart is recalcitrant or rapidly growing; or malignancy is suspected (malignant changes in warts are extremely rare but should be excluded in older people or people with immunosuppression or subungual warts.) Dermatology Minor surgery (for cosmetic and benign skin lesions) Dermatological procedures that are purely cosmetic in nature are considered low priority and hence not commissioned. Lipomas and sebaceous cysts that may be painful of become infected are not defined as cosmetic for these purposes. Removal of skin lesions within secondary care will only be considered if: lesions are suspicious or potentially malignant; or there is impairment of function or significant facial disfigurement. Lipoma over 15cm in size are at risk of being malignant and should be sent on a 2 week pathway proforma. Under no circumstances should a biopsy/excision of lipomas over 15cm in size be undertaken by anyone who is unable to perform / coordinate a compartmental resection if required. Removal of Haemorrhoidal Skin Tags This procedure should not be performed. There may be consideration of special circumstances e.g. recurrent bleeding. Tameside and Glossop 7 Excision of benign skin lesions This policy is not intended to apply to cases where the diagnosis of a benign condition is uncertain, where the lesion causes significant pain or when the nature of the condition requires immediate treatment. The immediate treatment category can include benign lesions that are significantly traumatised and/or have become infected. The following procedures are generally performed for aesthetic reasons and not routinely funded by the PCT. If secondary referrals are made for these conditions for reasons stated above, they should be made to Dermatologists [and not general surgeons] who have the best expertise to assess suitability of minor surgery. Definition: skin tags; warts; corns; comedones (blackheads); milia (whitish spots which occur on the face); spider naevi (spider-like capillaries visible below the skin); sebaceous cysts (sac-like lesions filled with fatty substance); seborrhoeic keratoses (brown warts); molluscum contagiosum (dome shaped, pearly lesions caused by a viral infection); xanthelasma (yellow plaques which occur on the eye-lids); lipomata (fatty lumps found below the skin); benign pigmented moles; male pattern baldness. Removing these skin lesions for cosmetic reasons is not commissioned. Prior approval for removing these skin lesions can be obtained from the PCT for certain defined situations. For a non-cancerous skin lesion surgical excision will only be funded if there is recorded evidence that one of the following criteria are met: it is an unidentified lesion requiring biopsy a lesion displaying unusual behaviour e.g. bleeding, change in colour it is basal cell carcinoma it is a lesion causing symptoms such as persistent itching, bleeding, recurrent inflammation and pain it is a lesion causing restrictions on movement or activity it is a moderate to large facial lesion which causes disfigurement Lesions on a site subjected to recurrent trauma Lesions obstructing an orifice or vision There are no restrictions on treatment of genital warts. [GMEUR 19] Trafford Dermatology Minor Surgery Dermatology procedures that are cosmetic in nature are not commissioned. Lipomas and sebaceous cysts that may be painful or become infected are not defined as cosmetic for these purposes. Please treat according to the Minor Surgery LES. Removal of skin lesions within secondary care will only be commissioned if: They are suspicious or potentially malignant; or There is impairment of function or significant facial disfigurement; or The affected area is on the face. Treatment of cutaneous and plantar warts Warts normally resolve spontaneously although this may take up to 2 years. Treatment for warts should only be considered if warts are symptomatic. i.e: Painful or itchy; or Interfere with functioning; or Have been present for more than two years; or Have spread extensively. Treatment should initially be by duct tape occlusion; if this is unsuccessful then treatment with topical salicylic acid should be considered. Treatment with cryotherapy should only be considered if treatment with both duct tape occlusion and topical salicylic acid has not cleared the wart. Referral to the secondary care should only be considered if: there is genuine doubt about the diagnosis; or the wart is recalcitrant or rapidly growing; or malignancy is suspected. 8 Patients with the above exceptional symptoms may need specialist assessment, usually by a dermatologist. For a small proportion surgical removal (cryotherapy, cautery, laser or excision) may be appropriately performed within Primary Care. Surgery for removal of haemorrhoid skin tags Surgical removal of haemorrhoid skin tags is not commissioned. Treatment of cutaneous vascular lesions (including port wine stains) This service is not commissioned and will only be considered in exceptional clinical circumstances. Wigan Borough Excision of benign skin lesions Removal of benign skin lesions will only be considered for: Suspicious or potentially malignant lesions Impairment of function or significant facial disfigurement, for example large lymphoma Treatment of multiple lipomatosis or neurofibromatosis. If a General Practitioner or Consultant is concerned that any skin lesion may be malignant, the patient should continue to be referred under the 2week rule so that treatment can be carried out promptly. Excision of benign skin lesions is generally effective but they are considered to be of low priority and will only be carried out under exceptional circumstances. Therefore prior funding approval is required for such procedures. Fatty lumps (lipomata) Lipomata of any size should be considered for treatment by the NHS in the following circumstances: The lipoma (-ta) is / are symptomatic There is functional impairment The lump is rapidly growing or abnormally located (e.g. sub-fascial, submuscular) Excision of non-cancerous skin lesions for cosmetic reasons Non-cancerous skin lesions include: skin tags; warts; corns; comedones (blackheads); milia (whitish spots which occur on the face); spider naevi (spider-like capillaries visible below the skin); sebaceous cysts (sac-like lesions filled with fatty substance); seborrhoeic keratoses (brown warts); molluscum contagiosum (dome shaped, pearly lesions caused by a viral infection); xanthelasma (yellow plaques which occur on the eye-lids); lipomata (fatty lumps found below the skin) Removing these skin lesions for cosmetic reasons is not commissioned. Prior approval for removing these skin lesions can be obtained from the CCG for certain defined situations 9 For a non-cancerous skin lesion surgical excision will only be funded if there is recorded evidence that one of the following criteria are met: it is an unidentified lesion requiring biopsy a lesion displaying unusual behaviour e.g. bleeding, change in colour it is basal cell carcinoma it is a lesion causing symptoms such as persistent itching, bleeding, recurrent inflammation and pain it is a lesion causing restrictions on movement or activity it is a moderate to large facial lesion which causes disfigurement Lesions on a site subjected to recurrent trauma Lesions obstructing an orifice or vision Viral warts Most viral warts will clear spontaneously or following application of tropical treatments. Painful, persistent or extensive warts (particularly in the immunosupporessed patient) may need specialist assessment, usually by a dermatologist. For a small proportion surgical removal (cryotherapy, cautery, laser or excision) may be appropriate. Vascular skin lesions NHS treatment is allowed for all vascular skin lesions except for small benign, acquired vascular lesions such as thread veins and spider naevi. As detailed above, there are differing commissioning positions across the 12 Greater Manchester CCGs, however, all Greater Manchester CCGs do not commission the removal of benign skin lesions for aesthetic purposes. There are 3 CCGs who follow the same criteria (NE Sector Policy). There are a further 3 CCGs (Manchester Central, North and South) who follow the same criteria, which is different to the NE Sector. The remaining CCGs use their own criteria which varies from other CCGs. Conclusion The above information has been produced in order to support the policy decision making process across Greater Manchester. The Greater Manchester EUR Steering Group are asked to review the above information, along with the Policy Options and make a decision regarding the policy criteria which will be used across Greater Manchester. Author: Stephanie Joubert Date: 18/12/2013 10