Download Referrals for benign skin lesions to Plastic Surgery and Dermatology

Title
Referrals for benign skin lesions to Plastic Surgery and Dermatology - for children and adults.
Classification
Clinical protocol
Areas For Use
General Practitioners in primary care across Sheffield, & Plastics and Dermatology
NReferral Criteria
Referral is appropriate for patients with lesions where the diagnosis of a benign condition is
uncertain, or where an endocrine cause is suspected , or where there is significant
functional or psychological impairment. This must be clearly stated in the referral letter.
The benign skin lesions listed below, are those that are not malignant or infected, and include a
range of cutaneous lesions, which will not in general be eligible for referral or treatment in
secondary care. See guidance on pages 2 and 3
1. Benign pigmented moles (except congenital hairy naevi in children – because of cosmesis
and risk of malignant change)
2. Molluscum contagiosum
3. Dermatofibromas
4. Comedones
5. Seborrhoeic keratoses (basal cell papillomata)
6. Corn/callus
7. Skin tags
8. Lipoma
9. Spider naevus (telangiectasia) / Thread veins
10. Male pattern baldness
11. Hirsutism (unless severe or associated with endocrine abnormalities)
12. Sweating / hyperhidrosis (unless socially disabling)
13. Warts (except painful plantar warts/ warts in immunocompromised patients / facial warts /
patients unable to work as a result of warts/ children being bullied because of warts)
14. Milia
15. Xanthelasma
16. Acne vulgaris (unless fails to respond to documented treatment in primary care)
The benefits of treatment for those conditions listed above are generally cosmetic, or occur in
conditions that are self-limiting without specialist treatment. Allowing dermatologists and plastic
surgeons to concentrate their efforts on those where health benefit is greater should result in
overall health benefit to the population. Clinicians are aware of the difficulty that can occur in
distinguishing benign from malignant lesions.
Objective
Acknowledgements
Evidence base
Consultation
To reduce referrals from primary to secondary care services, improve quality of referrals and
referral letters
Suffolk West Primary Care Trust
Bradford and Airedale Teaching Primary Trust
Sheffield Teaching Hospitals Foundation Trust – Dr Messenger - Dermatology; and colleagues in
plastic surgery
Prodigy: www.prodigy.nhs.uk/guidance/by_clinical_specialty/skin_and_nail
PBC leads: STH: PEC
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Treatment - Management advice for skin lesions
1. Benign Pigmented Moles:
No treatment is needed for unequivocally benign naevi. Congenital pigmented naevi in children
can undergo malignant transformation so referral is justified for consideration of excision, or if the
child is cosmetically disadvantaged.
2. Molluscum Contagiosum:
Viral infection. Will get better on its own. Treatment is often painful.
3. Dermatofibromas:
Benign lesion which does not require treatment
4. Comedones:
Skin-coloured, small bumps (papules) frequently found on the forehead and chin of those with
acne. Treatment not required unless occurring in association with severe acne when referral to
dermatology is indicated having followed the acne guidance. Topical retinoid gel can be helpful but
improvement is slow and can be limited by intolerance of drying effect of treatment. Solitary giant
comedones can occur on the face or trunk of elderly and may need referral for diagnosis.
5. Seborrhoeic Keratosis (Basal Cell Papillomata):
Treatment in general practice only if catch in clothing or cosmetic problem either by cryotherapy,
curettage or shave excision.
6. Corn/Callous:
Local thickening or hardening of the skin. Advice regarding skin care is appropriate. Chiropodists
may help if the problem is on the foot.
7. Skin Tags:
Referral to secondary care not indicated unless there is diagnostic doubt. Exceptions include skin
tags in pre-auricular area or on the hands – (these are accessory auricles and digits). Congenital
tags ought to be considered for referral.
8. Lipoma:
Benign tumour made of adipose (fatty) tissue. Removal may be needed for diagnosis but is not
otherwise required for asymptomatic lesions. There is a risk of sarcomatous change. Consider
this in large lipomas, e.g. greater than 5cms, especially if pedunculated or on the limbs.
9. Spider Naevus (Telangiectasia):
Solitary lesions on the face are very common in children and most will spontaneously disappear.
Larger numbers of spider naevi occur in pregnancy and chronic liver disease Treatment is not
indicated.
10. Male Pattern Baldness:
Most common form of hair loss typically affecting the frontal and central parts of the head. Referral
of male patients unnecessary. Male pattern loss in women is usually physiological. Check TFT’s
and full blood count. Consider referral in women with rapidly progressive hair loss, particularly if
associated with other signs of virilisation, if there is a diagnostic doubt or a significant adverse
effect on quality of life.
11. Hirsutism:
Females with excessive hair growth should be investigated for raised testosterone, and polycystic
ovary syndrome (especially if the hair growth has developed over a short period of time); these can
be carried out in Primary Care. Both are more likely if periods are irregular. Referral of female
patients should be on the basis of cause.
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12. Excessive sweating (hyperhidrosis):
Underlying pathology is very rare but hyperhidrosis can be socially disabling. Check thyroid
function. Refer if associated symptoms such as flushing, faintness, asthma or diarrhoea investigate
for other problems. Treatment of sweating: use topical agents such as Driclor or Anhydrol Forte in
Primary Care. Consider referral if other reasons exist and are identified in the letter, or there is no
response to treatment.
13. Warts:
Hand and foot warts (verrucae) are very common. 70% clear spontaneously within 2 years. A
recent Cochrane review showed that topical treatment with wart paint had a higher success rate
than cryotherapy. Both of these should be provided in Primary Care.
14. Milia:
Small epidermal cysts. Can be extruded with fine needle. In general these do not need treatment
but if so should be treated according to current guidelines.
15. Xanthelasma
Patients with xanthelasma should always have their lipid profile checked. Referral should be
qualified to confirm there are good reasons identified in the letter.
16. Acne vulgaris
Unless an adequate trial of at least two antibiotics have been undertaken and this is referenced in a
GP referral letter. Each trial should be for at least three months. One of these should be
oxytetracycline or erythromycin. A topical agent, (e.g. benzoyl peroxide, topical retinoid), should be
used along side the antibiotic.
Terminology
definitions
Additional
Information
Available From
None
Date validated by
Clinical
effectiveness dept
Date Ratified
Date Of Next Review
Authors
20th August 2007
1. Williams HC, 1997. Dermatology in Health Care Needs Assessment, edited by Stevens A,
Raftery J., Wessex. Institute for Health Research and Development, Oxford.
2. Black’s Medical Dictionary. 3 8 Edition. A & C Black. London. 1997
3. North Sheffield PCT Prioritisation of Dermatology referrals for adults and children list
Date Issued
August 2010
Nora Tebbutt
Dr Richard Oliver
Dr Andrew Messenger
Signatories
–
Primary Care Trust
Signatories –
Sheffield Teaching
Hospitals
Lead Director
Nora Tebbutt
________________________________________
Dr Richard Oliver
________________________________________
Dr Andrew Messenger
________________________________________
Mr Michael Brotherston
________________________________________
Signature
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