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REFREC002
DERMATOLOGY REFERRAL RECOMMENDATIONS
Diagnosis / Symptomatology
Problems include:
 Acne
 Adverse Drug Reactions
 Bullous eruptions
 Inflammatory Dermatoses
 Naevi
 Skin Cancers
 Skin Infections
Diagnosis / Symptomatology
Acne
Diagnosis / Symptomatology
Adverse Drug Reactions
Last updated February 2006
Evaluation
Management Options
Referral Guidelines
A thorough history and physical
examination is required to determine
the specific diagnosis (see below)
Specific treatments depend on the
specific diagnosis identified, as noted
below.
Circumstances for referral are
indicated below with reference to the
appropriate specialty/specialties.
Evaluation
Management Options
Referral Guidelines
Initially treat with topical agents
(Retinoids, Benzol Peroxide or
Topical Antibiotics).
Then add in oral antibiotics e.g.
tetracyclines for minimum of three
months. A treatment course of nine
to eighteen months is not unusual. In
female patients consider hormonal
therapy.
Referral to dermatologists for
nodulocystic acne, widespread acne,
acne unresponsive to previous
treatments or acne in female over the
age of 25. (These groups usually
need oral isotretinoin) – Category 3.
Clinical diagnosis
Evaluation
Evaluation by history of drug usage.
Management Options
Stop responsible agent(s) and report
case to ADRAC. See Schedule of
Pharmaceutical Benefits for
reporting form.
Referral Guidelines
Severe skin reactions e.g. erythema
multiforme – Category 1.
Tests for drug allergy are usually not
available.
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REFREC002
Diagnosis / Symptomatology
Bullous Eruptions
eg. Pemphigus, pemphigoid
Evaluation
Clinical diagnosis
Exclude insect bites, and trauma as
cause for blistering
Diagnosis / Symptomatology
Inflammatory Disease
Evaluation
Management Options
Prevent secondary infection
Management Options
Referral Guidelines
Refer to dermatologist. Patients with
extensive blistering or who are
systemically unwell – Category 1.
Referral Guidelines
Clinical diagnosis
Biopsy may occasionally be indicated
General principles of management:
General Principles of referral for
inflammatory dermatoses
Eczema/Dermatitis
Regular use of moisturisers
Treatment of secondary infection
Control of inflammation with
intermittent courses of topical
corticosteroids.
Those patients with conditions
causing significant distress or
interfering with work should be
referred to dermatologists – Category
3.
Trial of tar based preparations,
dithranol, topical corticosteroids,
and/or vitamin D3 analogues.
Failed treatment by GP (usually eight
weeks or more) – Category 3.
Extensive disease where there is
diagnostic difficulty – Category 1.
Psoriasis
Last updated February 2006
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REFREC002
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Naevi
Pigmented Naevi
Use the ABCD criteria.
As a general principle:
Melanomas and skin cancers are
rare in prepubertal children. So very
few naevi clinically need to be
removed in children.
Changing naevi particularly in a
patient with a family or personal
history of melanoma, patients with
multiple atypical naevi (greater than
seven mm in size, variable shape
and border) and in cases of
diagnostic doubt – Category 2.
Changing naevi should be either
reviewed within three months,
referred or in very few circumstances
excised.
Excised naevi require a narrow
margin and should only be done
within the operator’s skill level.
Removed tissue to be reviewed by a
Pathologist.
Congenital Naevi
Clinical diagnosis
As a general principle:
It is extremely rare for congenital
naevi to become malignant. Those
that do, generally do so in adulthood.
Last updated February 2006
Refer to Dermatologist - Category 23.
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REFREC002
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Skin cancer
BCC
Speed of growth, site and type of
lesion e.g. morpheic, infiltrative and
micro nodular have higher recurrence
rates.
For BCC and SCC
Speed of growth, site and type of
lesion.
The treatment chosen depends on
the activity of the lesion, induration,
site and skill of the operator.
Cryosurgery requires a gun delivery
apparatus using liquid nitrogen to
enable cancer destruction.
Response rates are lower than other
modalities especially so for high risk
areas like the lip or ear.
Use ABCD criteria (Australian
Cancer Foundation Guidelines).
For Melanoma:
Primary narrow excision with
histology.
1.
2.
3.
4.
5.
Excision and histology
Curettage with cautery
Cryosurgery
Superficial Radiotherapy
Topical Therapy eg.
Imiquimod, Photodynamic
therapy.
Refer for confirmation and
management if the clinical lesion
requires.
SCC/Bowen’s Disease
Suspected melanoma
Refer for confirmation and
management if the clinical lesion
requires.
Further management as per the
Melanoma Guidelines.
Last updated February 2006
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REFREC002
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Skin infections
Bacterial
Skin swabs are generally not
indicated.
Treat with antiseptics and/or topical
antibiotics. Oral antibiotics for
recurrent or more extensive disease.
Refer to dermatologists recurrent or
extensive infections, infections
complicating inflammatory
dermatoses, immunosuppressed
patients – Category 1-2.
Abscesses should be drained
whenever appropriate or indicated
Viral
Ectoparasites
Cellulitis : treat initially with oral
antibiotics and compressive
bandaging. Treatment is required for
several weeks
Referral to General Physicians, if
patient systemically unwell –
Category 1. Urgent referral to
Plastic/General surgeons for hand
infections or if necrotizing fascitis
suspected – Category 1. Referral to
vascular surgeons if significant
underlying venous disease –
Category 2-3.
Viral exanthema.
Do not treat with antibiotics.
Herpes Simplex (Genital).
Oral Acyclovir for first attack consider
prophylactic acyclovir for recurrent
herpes simplex.
Consider referral to dermatology for
recurrent infections (6 per annum) or
eczema herpeticum – Category 1 –
2.
Herpes Simplex (Non-Genital).
Symptomatic therapy.
Herpes Zoster.
Follow prescription guidelines in
Schedule of Pharmaceutical Benefits.
Scabies.
Treat whole family group.
1. Permethrin
2. Benzyl Benzoate as alternative
agent
Treatment failure (two months) –
Category 3.
Refer: Guidelines for scabies.
Last updated February 2006
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REFREC002
Head/Pubic Lice.
A.
B.
Permethrin preparations. Treat
all contacts. Consider public
health issues.
Maldison as alternative agent.
Refer to Public Health Nurse.
Note : resistance of organisms to
topical therapies is a practical clinical
concern.
Viral Warts
Clinical diagnosis.
Consider not treating. Three months
of wart paint followed by three
months of regular cryotherapy.
After six months of failed treatment
refer to dermatology – Category 3.
Genital warts: investigate for sexually
transmitted diseases (see Sexual
Health Referral Recommendations).
Genital Warts : Three months wart
paint, podophyllotoxin cream,
Imiquimod or regular cryotherapy.
Recommend yearly cervical smears
in female patients.
Advise on safe sex.
Consider referral to Sexual Health
Service for investigation and
treatment.
Consider possibility of sexual abuse,
majority are not.
Referral to Princess Margaret
Hospital if sexual abuse is suspected
– Category 1.
Anogenital warts in children.
Last updated February 2006
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