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Dermatology conditions should Dermatology be treated in primary care where possible. Referral Guidelines When specialist advice or treatment is needed, patients can be referred to any of the local Community Dermatology Services, who provide a comprehensive dermatology service to patients with a skin rash or skin lesions. However, there are a few exceptions to this as set out below. ANY SUSPECTED MM OR SCC SHOULD BE REFERRED URGENTLY ON A ‘2 WEEK RULE’ PROFORMA TO SECONDARY CARE. SKIN RASHES MANAGE IN PRIMARY CARE Examples of skin rashes that should be routinely managed in primary care include the following: Mild/moderate acne not requiring Isotretinoin (Roaccutane) Mild/moderate childhood atopic eczema Mild discoid eczema, xerosis or generalised pruritus Plaque psoriasis confined to discrete areas Recurrent bacterial infections/tinea including pityriasis versiculor Urticaria/angioedema Alopecia areata (always refer if there is diagnostic doubt or if scarring is present) Androgenic alopecia Hirsutism Leg ulcers – patients can only been seen in the community service to exclude basal cell carcinoma or Bowen’s Disease. REFER TO THE COMMUNITY DERMATOLOGY SERVICE Referral to the Community Dermatology Services can be made for patients with skin rashes or general skin problems: If standard treatment fails to treat the problem If there is doubt about the underlying diagnosis REFER URGENTLY INTO ACUTE (SECONDARY) CARE Patients with life-threatening severe inflammatory skin disease should be referred as an emergency (via A&E out of hours) i.e., Generalised erythroderma (>70% body surface area) Severe drug reactions Severe erythema Multiforme/Steven’s Johnsons Syndrome Generalised pustular psoriasis Severe bullous pemphigoid (>30% blisters) Moderate/severe vasculitis (necrotic skin lesions/systemic symptoms) The initial assessment of a patient with a stable inflammatory skin disease can be provided by either community service and the patient will generally be triaged to a consultant clinic. Please use the CWS Community GP referral form Patients requiring ongoing medical supervision of systemic immunosuppressive or biologic treatments can be referred on to secondary care, and therefore the patient will be referred on from the community service. SKIN LESIONS MANAGE IN PRIMARY CARE Skin conditions that are eligible for removal under the ‘Minor Surgery Locally Commissioned Service’ (also see appendices) are shown on the CCG website http://www.coastalwestsussexccg.nhs.uk/cwsccg-locally-commissionedservices BENIGN SKIN LESIONS AND ‘LOW PRIORITY PROCEDURES’ Asymptomatic benign lesions should be considered cosmetic and the patient should be either advised that treatment is not routinely available via the NHS or an application should be made under the ‘Individual Funding Request’ process. NB The following treatments and procedures are not routinely funded in the community services: Viral warts Acne scarring Chemical peels Dermabrasion of skin Electrolysis Hirsutism treatments Melasma/Chloasma Botulinum toxin therapy for hyperhidrosis Laser therapy/laser treatment for aesthetic reasons Laser tattoo removal Removal of benign asymptomatic skin lesions (includes papillomas, seborrhoeic keratosis, lipomas and sebaceous cysts) REFER TO THE COMMUNITY DERMATOLOGY SERVICE Skin lesions where there is diagnostic doubt and the referral is warranted to exclude a skin cancer or underlying inflammatory process Basal Cell Carcinoma Benign skin lesions that cause severe symptoms interfering with quality of life Examples would include: A recurrent discharging cyst A recurrent bleeding from a vascular angioma A recurrent infection/bleeding from an irritated seborrhoeic keratosis Please note: All referral letters must state that the referral is warranted because of diagnostic doubt or medical symptoms to be accepted and seen within the community service. REFER TO SECONDARY CARE Any patients with suspected Malignant Melanoma or Squamous Cell Carcinoma should be referred directly into two week rule referral clinics. For WSHFT, please use the referral proforma at: http://gp.westernsussexhospitals.nhs.uk/2-week-rule/ All referrals made to the community service will be triaged. Any referral considered inappropriate for a community setting will be re-directed to secondary care service as an urgent referral. Under these circumstances, both the GP and the patient will be informed that this course of action has been considered necessary. PHOTOTHERAPY Phototherapy services are provided by all Community Dermatology Services for inflammatory skin disease. October 2014