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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
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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.
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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.
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
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
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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
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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
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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.
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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
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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
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