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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. Page 1 of 6 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 Page 2 of 6 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. Page 3 of 6 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 Page 4 of 6 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 Page 5 of 6 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 Page 6 of 6