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Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks Buckinghamshire Dermatology Referral Guidance 1 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks CONTENTS PAGE Notes 3 Sub Specialities 1. Atopic Eczema in Children & Adults 4 2. Viral Warts & Molluscum Contaginosum 10 3. Hand Eczema 12 4. Acne 14 5. Psoriasis 16 6. Skin Cancer 19 7. Scabies 20 8. Actinic/Solar Keratoses 21 9. Rosacea 26 10. Urticaria & Angioedema 28 11. Generalised pruritus 30 12. Onychodystrophy 31 Supplementary Information 13. Referral Criteria Title of Guideline Guideline Number Version Effective Date Review Date Original Version Produced Approvals: Buckinghamshire Healthcare NHS Trust Formulary Management Group Buckinghamshire Area Prescribing Committee Clinical Guidelines Subgroup Author/s 32 Dermatology Referral Guidelines 311 1 August 2013 January 2015 November 2012 January 2013 October 2013 February 2013 November 2013 April 2013 September 2013 Mrs Sarah Crotty, Interface Pharmacist, Aylesbury Vale and Chiltern CCGs Dr R Ratnavel, Consultant Dermatologist Bucks Healthcare NHS Trust (BHNHST) Mrs Maire Stapleton, Formulary Pharmacist, Bucks Healthcare NHS Trust (BHNHST) Dermatology (BHNHST) and Medicines Management of Aylesbury Vale and Chiltern CCGs SDU(s)/Department(s) responsible for updating the guideline Buckinghamshire Healthcare NHS Trust/Aylesbury Vale and Chiltern Clinical Commissioning Groups Consulted: Dr Ravi Ratnavel, Dr Raj Bajwa, Dr Stuart Logan, Dr Saj Zaib, Mrs Maire Stapleton, Mrs Sarah Crotty, Dr Raj Thakkar, Dr Christine Campling, Dr Sophie Grabczynska 2 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks Dermatology This is intended as a guide only. It is not exhaustive and appropriate clinical judgement should be used for individual cases. When referring to Dermatology (either community or Acute) please provide information in accordance with the core required information fields of the referral letter with particular attention to the following sections: Past history: Relevant family history, H/O any co-morbidity, presence of risk factors Investigations: State whether the patient has had any relevant investigations (and attach results if available): e.g. Renal function tests, FBC, X-ray, USG reports and specific tests like PSA. Please note, if you are concerned about your patient's condition and require urgent assessment it is not necessary to undertake routine tests unless this will significantly alter your referral decision. Emergency admission likely to be appropriate Suggested referral to Secondary Care or GPSI Continue to manage in Primary Care if appropriate Note: All follow up appointments following inpatient stays in hospitals, for the same condition, should be arranged via secondary care and NOT booked by GPs. 3 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks 1) ATOPIC ECZEMA IN CHILDREN AND ADULTS http://publications.nice.org.uk/atopic-eczema-in-children-cg57 What to consider in Primary Care before referring: General Atopic eczema is a common disease affecting up to 15% of children. It may also affect adults. Involvement of the face frequently occurs in infants with adoption of characteristic flexural distribution by the age of 18 months. Realistic treatment aims to be discussed with the patient and parent. General treatment measures: Soaps and detergents including bubble bath and shower gels should be avoided. Cotton clothing should be used and avoid wool next to the skin. Fingernails should be kept short to reduce skin damage from scratching. Bathing is not harmful but an emollient must be used. Emollients Emulsifying Ointment, 500g, Hydrous (oily cream) Ointment, 500g, Diprobase Cream or Ointment, 500g, ointment or cream E45, 500g, Cetraben, 500g, Doublebase, 500g, Unguentum M Cream, 500g. Greasier preparations are better at hydrating the skin e.g: Liquid Paraffin / White Soft Paraffin Ointment 50:50, 500g, White or Yellow Soft Paraffin, 500g, Soap Substitutes Emulsifying ointment Aqueous Cream Bath Emollients Bath emollients are of particular value for children less than 5 years. Adults do not routinely need prescribed bath emollients unless they have areas that they cannot reach to apply creams. Diprobath additive Oilatum – non-fragrance preparation, 250ml and 500ml Oilatum junior 500ml 4 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks Some combination preparations have niche uses: Those containing antiseptics can be useful for infective episodes. Dermol® 500 (contains antiseptic) Emulsiderm (contains antiseptic) Oilatum Plus (contains antiseptic) Urea acts as a Keratin softener and so can be useful for areas of hard skin which also require hydration: Calmurid (contains Urea) Barrier Creams Drapolene, or Metanium Treatment in Primary Care Emollients should be prescribed in all cases & in adequate quantities. Some patients react to one and may need an alternative, therefore you need several options. Persist until the patient finds something they like and will therefore use. Use directly on the skin during and after bathing. Emulsifying Ointment, 500g, Hydrous (oily cream) Ointment, 500g, E45, 500g, Diprobase Cream or Ointment, 500g ointment or cream Cetraben, 500g Doublebase, 500g Unguentum M Cream, 500g Greasier preparations are better at hydrating the skin e.g: Liquid Paraffin / White Soft Paraffin Ointment 50:50, 500g White or Yellow Soft Paraffin, 500g 5 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks Topical Corticosteroids Although potent preparations can cause skin atrophy, mild corticosteroids such as 1% hydrocortisone do not and are safe to use in the long term. Hydrocortisone 1% is the strength of choice for the face and flexures. Topical Corticosteroids are often underused because of concern about the side effects. Ointment preparations are more effective than creams and contain fewer additives. Creams can be used if the eczema is weeping or on the face. There are four groups of potency. Within each potency group there is no evidence for increased efficacy or safety of any one particular product. Mild Hydrocortisone 1% cream or ointment. Moderate Ciobetasone Butyrate (Eumovate). OR Betamethasone Valerate 0.025% cream or ointment (Betnovate RD). Potent Betamethasone Valerate 0.1% cream ointment and scalp appln. OR lotion (Betnovate). Mometasone (Elocon) reserved as 2 nd line if Betnovate does not suit. Beclomethasone Diproprionate cream and ointment (0.025%) (Propaderm). Very Potent Clobetasol Propionate (Dermovate) 0.05% cream, ointment and scalp application. Try to avoid the use of very potent steroids due to the increased risk of skin atrophy and the fact that these super potent steroids can affect the appearance of the rash so that diagnosis is much more difficult. Mild or moderately potent preparations should control most cases of eczema when prescribed in appropriate amounts. It may be necessary to gain control with moderately potent preparation and then reduce to a mild strength. 1 to 2 weeks of a potent strength product may be required, particularly for resistant, lichenfied lesions in older children. Avoid repeat prescriptions for potent strength corticosteroids. In dry eczema try steroid / urea Alphaderm cream (moderate potency as urea increase the penetration of the hydrocortisone). Assessment of severity of disease and progress on treatment The Nottingham patient eczema questionnaires are an excellent way of assessing severity. They are available for adults and children. http://www.nottingham.ac.uk/scs/divisions/evidencebaseddermatology/resources/nottinghame czemaseverityscale(ness).aspx It is very difficult to give guidance on amounts of topical steroids for the treatment of eczema. If the right strengths for the site and severity of eczema are being used repeatedly without any steroid free gaps, then patients should probably be considered for alternative treatments or investigation. 6 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks Infection Control Antihistamines Suitable for short-term use to control itch especially at night. Sedative antihistamines Chlorphenamine Hydroxyzine Infective Eczema Infection should be suspected whenever eczema worsens. Eczema that weeps or crusts is probably infected with staphylococcus aureus- if in doubt take swabs for microbiology. The commonest infecting organism is Staph. aureus which produces characteristic yellow crusting. Consider antiseptic moisturiser combination in the bath: Oilatum Plus bath oil OR Directly onto the skin: Dermol® 500 If the infection is widespread or severe treat with systemic antibiotics (for 7 to 10 days): Flucloxacillin 500mg QDS OR Erythromycin 2 x 250mg QDS (if penicillin allergic) Widespread infected eczema should be treated with a systemic antibiotic and plain topical steroid ointment. If recurrent infections occur take nasal swabs from the family members and if positive: Consider MSSA eradication according to the local BHT policy. Link to be added when available Bandaging Recommended products Cheapest Standard conforming bandage range is currently Easyfix K (K band is more expensive) Elasticated Viscose Stockinette Bandage. E.g. Tubifast 3.5 cm, red line (small limb) 5 cm, green line (medium limb) 7.5 cm, blue line (large limb) 10.75 cm, yellow line (child trunk) 20 cm, purple line (adult trunk) Vests, leggings, gloves and socks provide no advantages over old clothes and prescribing these are low priority. Zinc paste bandages alone or Zinc paste and ichthammol (e.g. Icthopaste), may be useful in chronic lichenified eczema, Ichthammol is believed to reduce pruritus. Apply creams such as 7 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks st steroids and emollients 1 before applying Icthopaste, a final bandage over the Icthopaste is also required. Initial training techniques may be required which can be given by a suitably trained nurse or nurse specialist. Zinc paste bandages used over emollients or over topical corticosteroids can result in rapid improvement of resistant, particularly lichenified eczema. Wet wrap using tap water to dampen a standard bandage over emollients or steroids or both – may also be helpful, particularly at night in small children. Wet wrap garments are both cost effective and acceptable to patients. Allergies The house dust mite can aggravate eczema in some patients. Vacuum mattress and keep dust level down. In severe cases try protective coverings to pillows and bedding (e.g. INTERVENT) – not prescribable on FP10 No tests are available to confirm or refute food allergy as a cause of worsening of eczema. RAST tests and skin prink tests are not helpful. Patch testing is used to investigate specific contact allergic eczema if from an occupational cause. Food allergies, especially to egg, wheat and dairy products rarely cause worsening of eczema. Consider exclusion diets only in difficult cases. Seek advice of dietician for young children and abandon if no improvement is apparent after 2 – 4 weeks. Food intolerance is often a temporary phenomenon. An attempt should therefore be made every few months to re-introduce the food in question. Dietetic advice is required if exclusion diets are used for more than 2 – 4 weeks. Evening Primrose Oil There is no consistent evidence that it helps, therefore NOT RECOMMENDED Chinese herbs There are no product licenses and currently standardisation is poor. Serious adverse effects have been recorded and they cannot be recommended. Some contain potent topical steroids. 8 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks Referral Threshold - Community Dermatology Service Community Dermatology service Only cases of severe or difficult eczema need to see a Dermatologist: Diagnostic difficulty For second line treatment such as photochemotherapy and cytotoxic drugs. Eczema herpeticum. If allergic contact dermatitis is suspected – consider patch testing in secondary care Referral Threshold 999 for emergency Urgent referral to Dermatology 9 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks 2) VIRAL WARTS AND MOLLUSCUM CONTAGIOSUM All treatment is low priority What to consider in Primary Care before referring: General Comments Viral Warts and Verrucae all treatments are LOW PRIORITY These two viral induced lesions are common, especially in children and are selflimiting There are no easy or guaranteed treatments or magic cures and lesions are best left to resolve spontaneously. Greater than 60% of hand and facial warts clear within two years. Plantar warts tends to be most persistent. Molluscum Contagiosum 90% of mollusca clear spontaneously within one year. All treatments are LOW PRIORITY Treatment in primary care Viral Warts and Verrucae all treatments are LOW PRIORITY Use a high concentration salicyclic acid preparation such as: - Occlusal = Salicyclic acid 26% Many products also available over the counter. Instruct the patient that this should be applied daily after bathing and rubbing down the softened skin with pumice stone or sandpaper. This may need to be continued for many months. Cryotherapy is available in many but not all GP practices: Best performed at one to three weekly intervals with two freeze thaw cycles, (hands 70% cure rate after four treatments, plantar warts less than 40%). If there is no sign of improvement after six treatments then it is unlikely to be effective and should be discontinued. Higher cure rates with combined cryotherapy and topical agents. Molluscum Contagiosum all treatments of the condition are LOW PRIORITY except eczema and infections Observation only is the usual option. Treatment associated eczema or impetigisation with: Emollients Mild topical steroids +/- antibiotic therapy Affected children should have their own towels to reduce the risk of transmission to siblings Individual lesions will resolve if the central core is damaged by any modality including cryotherapy but this is not recommended in young children, as it is too painful. 10 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks Referral Threshold – Community dermatology Community Dermatology Service In general patients with viral warts/verrucae and molluscum should not be referred. Patients may be referred if: Severe disabling warts despite six months of topical salicylic acid treatment +/cryotherapy. Significant warts or mollusca in immunocompromised patients Referral – 999 for emergency admission Urgent referral to Dermatology 11 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks 3) HAND ECZEMA What to consider in Primary Care before referring: Clinical Features A Endogenous Eczema (e.g. atopic) B Exogenous Eczema (i) Irritant Contact Eczema (ICD) Due to substances coming into contact with the skin, usually repeatedly causing damage and irritation. Substances such as: Water Detergents Shampoos Household cleaning products (ii) Allergic Contact Dermatitis (ACD) Due to type IV allergic reaction to a substance the skin is in contact with. All types of endogenous and exogenous eczema can present with either ‘wet’ (blistering and weeping) or ‘dry’ (hyperkeratotic and fissured) eczema General Comments Other skin conditions can mimic eczema and should be kept in mind. It is usually worth examining the patient’s skin all over as this can provide clues to other diagnoses e.g. plaques in extensor distribution in psoriasis, scabetic nodules in scabies. If an eczematous looking rash is present on only one hand, a fungal infection needs to be excluded by taking skin scrapings for mycology. If contact dermatitis is suspected a careful occupational and social history should be taken and the patient may benefit from Patch Testing Patch Testing is only of value in patients with eczema - It is of no use with type 1 reactions (e.g. food allergies causing anaphylaxis or urticaria). In practice the cause of eczema is often multi-factorial with external factors precipitating eczema in a constitutionally predisposed individual, in which case patch tests are usually unhelpful. Resistant hand eczema does however, merit consideration of these to exclude type 4 reactions. Treatment in Primary Care Avoidance of irritants Soap substitutes such as Emulsifying Ointment should be used. Gloves e.g. Household rubber or PVC gloves should be used for wet work such as dishwashing. Gloves may also be required for dry work e.g. gardening. 12 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks Recommended emollients Emulsifying Ointment, 500g, Hydrous (oily cream) ointment, 500g, Diprobase cream or ointment, 500g, ointment or cream E45 cream, 500g, Cetraben cream, 500g, Doublebase gel, 500g, Unguentum M cream, 500g. Greasier preparations are better at hydrating the skin e.g. – Liquid paraffin / White soft paraffin Ointment 50:50, 500g, White or Yellow Soft Paraffin, 500g, Topical Steroids The strength of topical steroids required varies from case to case It may be necessary to use a potent steroid in the short term Use cream formulation if wet – use ointment if dry Potassium permanganate – Permitab 400mg. Can be purchased OTC Dilute 1 tab in 4L of water to pale pink (rose wine colour) and soak for fifteen minutes 2 to 3 times daily for acute wet eczema until blistering weeping has dried. Make up a pale pink/rose colour using warm water Antibiotics (topical/systemic) Exclude secondary infection and treat if appropriate Referral – Community Dermatology Severe chronic hand dermatitis, which is unresponsive to treatment described above. Occupational difficulty after standard therapy in primary care falls. If allergic contact dermatitis is suspected, Patch Testing may be considered. Referral - 999 for emergency admission Urgent referral to Dermatology 13 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks 4) ACNE What to consider in Primary care before referring: General Comments Mild & moderate acne should be managed in primary care. Several different agents may need to be tried alone or in combination. DO NOT use combinations of agents with similar properties or actions e.g. topical plus systemic antibiotics. Inform patient that response is usually slow and allow at least 12 weeks before review. Try treatments individually so you can assess what works, rather than using combinations. Treatment Aims To reduce the severity and length of illness. To reduce the psychological impact on the individual. To prevent long-term sequelae such as scarring. Treatment in primary care Mild Acne (Uninflamed lesions – open and closed comedones (blackheads), sometimes with papules/pustules) Topical benzoyl peroxide preparations +/- topical antibiotic e.g. benzoyl peroxide 2.5%, 4%, 5% or 10% when available. Quinoderm - if supply problems with benzoyl peroxide persist. (Use topical retinoids at all stages of acne to help minimise formation of comedone) Topical antibiotic combination preparations e.g. Clindamycin 1%, 30ml It is cheaper to use constituent parts than the combination products. Moderate Acne Defined as: A greater number of more extensive inflamed lesions, with scarring risk. Systemic antibiotics In cost order: (Treatment should continue for 6 months minimum and repeat if necessary) Oxytetracycline, 500mg, twice daily, Erythromycin 2 x 250mg, twice daily, – 1st line A/B in pregnancy Lymecycline 408mg daily, Topical benzoyl peroxide or retinoids may be used in combination. Use topical retinoids at all stages of acne to help minimise formation of comedone. 14 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks Moderate or Severe Acne Defined as – Papules/pustules with deeper inflammation and some scarring. Systemic treatment with antibiotics plus topical therapy. Consider additional hormone therapy in women. Ethinylostradiol/Cyproterone acelate – (cocyprindiol 2000/35) – only if there is a clear hormonal association / Polycystic Ovary Disease. Note CSM warning suggests single courses in primary care but long term use over 4 – 6 months should be under specialist supervision. Stopping co-cyprindol can cause rebound acne. Severe Acne i.e. Confluent or nodular lesions usually with significant scarring. Referral to community dermatology, or secondary care service. Isotretinoin is not currently available from GPSI service Commence systemic therapy and refer for systemic isotretinoin treatment. The main reason for referring a patient with acne is for isotretinoin treatment. Females of child bearing age should be established on an effective contraceptive prior to treatment with isotretinoin. The indications for isotretinoin treatment are as follows: Risk of scarring Severe nodulocystic acne / acne fulminans (immediate referral) Moderate acne that has failed to respond to prolonged courses of two oral antibiotics (e.g. 6 months of each oral antibiotic) in addition to topical treatment. Mild to moderate acne in patients who have an extreme psychological reaction to their acne and have failed to respond to prolonged courses of systemic antibiotic treatment and topical treatment. Referral Threshold - 999 for emergency admission Urgent referral to Dermatology Isotetinoin systemic treatment is a reason for secondary care referral 15 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks 5) Psoriasis What to consider in Primary Care before referring: General Comments Psoriasis is a chronic relapsing condition: mild & moderate involvement can usually be managed in primary care. Prior to referral, basic treatment should be tried as outlined. Nursing input by an appropriately skilled nurse at this stage will decrease need for referral to dermatology service. Ensure patients understand how and when to use their treatments. Treatment in primary care Chronic Plaque Psoriasis First line therapy: calcipotriol Calcipotriol (Dovonex) – Apply twice daily (up to 100g weekly) ointment Calcitriol (Silkis) – Apply twice daily (max 200g weekly) Calcitriol can be used in flexures, but is possibly less potent than calcipotriol Expect improvement to be gradual, achieving maximum effect over 12 weeks treatment. If useful can be continued long term or intermittently. If used correctly many patients will achieve at least flattening and partial clearance of plaques Calcipotriol & potent topical steroid with e.g. Betnovate RD (Note: Dovobet ointment is more expensive than constituent part– so avoid) – Apply each accurately to plaques once daily for 4 week. This combination provides rapid improvement over a 4 week course; use calcipotriol alone for maintenance therapy – steroid can cause irritation Exorex lotion – coal tar extract 1% lotion +/- a mild or moderate steroid ointment Apply away from flexures twice daily Refined tar products are less smelly or messy than old unrefined preparations. May stain clothes or irritate. Expect slow response over 6 – 12 weeks 16 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks Dithranol preparations Dithrocream (dithranol) 0.1%, 0.25%, 0.5%, 1%, 2% Micanol (dithranol 1% or 3% in a lipid stabilised basis) Start with the lowest strength, applied daily to plaques for 15 to 30 minutes, then wash off. Increase through strengths weekly unless irritancy occurs. Can be used as ‘short contact therapy’ at home, away from face, flexures and genitals. Often very effective if performed correctly with good remission time but time consuming to do therefore only useful if patient is well motivated and psoriasis localised. Stains everything including skin, linen, bathroom furniture and may cause irritation of the skin. Give adequate quantities of topical preparations appropriate for extent of disease. Guttate Psoriasis Numerous small lesions, mostly on trunk, generally affecting children / young adults acutely. Often follows sore throat and is self-limiting over 3 – 6 months. Treat with emollients plus trials of tar preparations. Calcipotriol or moderate potency steroids e.g. clobetasone butyrate 0.05%. If severe consider referral for phototherapy. Facial Psoriasis Can be treated with mild potency steroid with antifungal initially e.g. Dakacort (=1% hydrocortisone & miconazole 2%) If very itchy a moderate potency topical steroid could be substituted e.g. Betnovate RD or Eumovate Scalp Psoriasis For mild psoriasis consider T-gel which may be purchased over the counter. For moderate scalp psoriasis consider Betnovate scalp application. Use daily, apply to dry hair, leave on for 15 minutes and then add water, lather and shampoo out. Review after 4 weeks. Some require combination of agents such as steroid and a tar based scalp application. E.g. Calcipotriol scalp solution, Sebco, Polytar, Alphosyl 2 in 1 or Capasal. In more severe cases: st 1 use keratolytic e.g. Sebco Scalp ointment massaged into scalp &left overnight, wash out in the morning then apply a topical potent steroid e.g. Betamethasone 0.1% scalp application or Synalar gel. 17 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks If very severe: Sebco Scalp ointment (Coaltar solution 12%, Salicyclic acid 2, precipitated sulphur 4% in coconut oil) can be applied for 3 – 4 hours in the evening and washed out with tar shampoo before bed. Calcipotriol scalp application or a topical steroid could then be applied overnight in addition. Flexural Psoriasis Smooth well demarcated areas in axillae, groins, intra-mammary folds and natal cleft. May occur alone or with chronic plaques elsewhere. Use a mild to moderate potency steroids combined with antibiotic / antifungals e.g: Daktacort cream Trimovate creams Apply once to twice daily. OR can be treated with: Calcitriol Often partial response only is achieved. Avoid potent steroids to the face. Referral Criteria – Community Dermatology Service Community Dermatology Service Extensive / severe or disabling psoriasis – covering 20% body surface are or more. Failure to respond to adequate treatment or rapid relapse post treatment. Extensive acute guttate psoriasis. Unstable and generalised pustular psoriasis – URGENT REFERRAL. Diagnostic uncertainty. Use of dithranol Referral Threshold – 999 for emergency admission Urgent referral to Dermatology 18 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks Skin Cancer What to consider in Primary Care before referring: General Comments Basal Cell Carcinoma (BCC) These are common slow growing and locally invasive tumours. Most are easily recognised with a pearly rolled edge and later central ulceration. Pigmented and morphoeic (scar like, poorly defined) BCCs are less common variants. The following malignancies are much less common: Squamous Cell Carcinoma (SCC) They may be slow growing, well differentiated, keratinising or rapidly enlarging, poorly differentiated tumours. 5% may metastasise to regional lymph nodes. Malignant Melanoma (MM) This is the most dangerous skin malignancy. Early detection and excision is vital for good prognosis. Melanoma subtypes Superficial spreading Nodular Amelanotic Lentigo Mailgna Acral lentignous and subungual Criteria for diagnosis The six following point checklist may be useful in deciding whether to refer a changing pigmented lesion: Major features: Change in size Change in colour (variation of pigmentation) Change in shape (irregular of edge) Minor features: Size ≥ 7mm diameter Inflammation Bleeding / crusting Itch is not a good indicator of malignancy or otherwise, but may draw attention to a mole. 19 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks Treatment in primary care is by referral: Basal Cell Carcinoma (BCC) They are best managed by complete excision by the dermatology surgeons within the department and should be referred in the usual manner. In some cases radiotherapy mat be a preferred option but tissue diagnosis (e.g. biopsy) is still required prior to referral for radiotherapy and will be carried out in the Dermatology clinic. BCC’s (low risk, not on face) can only be removed in primary care by GPSI in the intermediate service. Squamous Cell Carcinoma (SCC) Lesions with a high index of suspicion, especially if rapidly growing, should be referred by fax within 24 hours. USE 2 week wait SKIN CANCER REFERRAL PROFORMA Malignant Melanoma (MM) All referrals for suspicious moles should be faxed to the dermatology service to be seen within 2 weeks. Any lesion felt to be highly suspicious of melanoma will be excised on the day of clinic or as soon as possible afterwards. Use 2 week wait skin cancer referral proforma available on CCG website Referral – Community Dermatology Service Community Dermatology Service All skin cancer should be referred to dermatologists for confirmation of diagnosis and treatment plan. Suspicious lesions, SCC and MM refer under 2/52 rule via faxed proforma Referral Threshold – 999 for emergency admission Urgent referral to Dermatology 20 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks 7) Scabies What to consider in Primary care before referring: General Comments Human scabies is an infestation of the skin caused by the mite Sarcoptes scabiei. The mites are most readily transmitted from one person to another by close physical contact in a warm atmosphere e.g. sharing a bed, holding hands, adults tending to children, children playing with each other. An individual who has never had scabies before may not develop itching or a rash until one month to three months after becoming infested. There is usually: Widespread inflammatory papular eruption. Burrows on non-hair bearing skin of the extremities. Pruritic papules around the axilla, nipples, umbilical region and buttocks. Inflammatory nodules on the penis and scrotum. The reactive rash to scabies can be eczematous or urticarial – Impetigo may also occur. Usually more than one family member is affected. It is mandatory that all members of the household and any other close social contacts of an infested person should receive treatment at the same time as the patient. Treatment in primary care Treat patients when there is a strong clinical suspicion that they may be infested. If unsure whether eczema or scabies, treat eczema first and review. If diagnosis of scabies – the essential step is to kill all the mites in the skin using a scabicide. Scabicide Apply either: Malathion 0.5%, Aqueous solution (Derbac M) Rub it in to all parts of the body, 200ml Permethrin 5% (Lyclear Dermal Cream), 60g Treat all the skin other than the face. Remove rings and use a nail brush to apply under the nails. Remind patients to re-apply the scabicide after washing their hands. Malathion should be left on the skin for 24 hours and Permethrin for between 8 and 12 hours. At the end of this period the patients can bath, they must also change their underclothes, nightclothes, sheets and pillowcases. 21 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks Disinfestation of clothing and bedding other than by ordinary laundering is not necessary. One treatment is probably curative but a second application after 1 week is recommended. If these directions have been followed, all mite in the skin will have been killed but the pruritis may take 3 to 6 weeks to settle. Do not keep using scabicides as repeated applications may irritate the skin. Treat residual itchy areas with: Topical anti-pruritic e.g. Crotamiton cream (Eurax) Crotamiton / hydrocortisone (Eurax HC or constituent parts) A higher potency of steroid may be needed to treat areas of secondary eczema. Referral Threshold – Community Dermatology Service Community Dermatology Service Diagnostic Uncertainty Failure of response to treatment Referral Threshold – 999 for emergency admission Urgent referral to Dermatology 22 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks 8) Actinic Keratoses Treatment of actinic keratosis Actinic keratoses (AKs) present in a variety of ways: Rough and dry textured skin lesions (single or multiple) Flesh-coloured, grey, pink, or red macules, papules or plaques Limited to a discrete area (localised) or diffuse Flat and scaly on the surface, becoming slightly raised, hard and wart-like, or rough and ‘sandpapery’ Horn-like texture from overgrowth of the keratin layer (hyperkeratosis) Generally asymptomatic but some cause pruritus or burning sensation There are no distinct clinical boundaries between AK and invasive squamous cell carcinoma (SCC). AKs are risk markers for SCC and an early phase of a process which may turn into an invasive SCC. It is therefore recommended that all AKs are treated. Treatment selection is based upon: Disease related factors: the type of lesion (e.g. thickness) the site, the number and localisation. Patient characteristics: e.g. age, frailty, ability to follow instructions, comorbidities, other risk factors e.g. immunosuppression, pre-existing skin cancers. Patient preference: Most treatments are associated with some level of discomfort, restrictions and alteration of appearance. Treatment may be lesion directed or field directed. Depending upon the lesion characteristics, a field-directed approach to treatment is preferable. It involves the application of topical treatment to the area of photo damaged skin, containing both visible and sub-clinical lesions. The aim of field directed therapy are: Eradicate clinically evident AKs, sub-clinical AKs and smaller foci of transformed clones. Prevent development of invasive SCC. Provide longer remission (e.g. prolong the time to new AK development in the treated field). Many (10 or more AK lesions) may indicate a preference for a field-directed treatment approach. Because lesions on different sites may have different tolerability levels, and because different types of actinic keratosis may be present in the same patient, it is normal practice to use different treatments simultaneously. For more detailed advice see Eur J Dermatol 2008; 18(6) 651-9 23 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks Medicines All patients should be advised to use UV protection and emollients Also known as solar keratosis are usually multiple, flat reddish brown lesions with a dry adherent scale. The vast majority of AKs DO NOT progress to squamous cell carcinoma. Evidence suggests that the annual incidence of transformation of individual solar keratosis to SCC is less than 0.1%. This risk is higher in immunocompromised patients. It is not necessary to refer all patients with solar keratosis. 24 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks Treatment in primary care 1. 2. 3. Diclofenac Sodium 3% in sodium hylauronate (Solaraze) – twice daily for 3 months. Actikerall (5-FU / salicyclic acid) – for isolated lesions Topical 5-fluorouracil (Efudix) – apply once to twice daily for 3 to 4 weeks. Usually used on smaller volume areas. 5FU is safe, efficacious, with little systemic absorption. Marked inflammation occurs prior to resolution and the patient must be warned to expect this. Other treatments (for isolated, well-defined lesions): - Cryotherapy – light freezing for 5 – 10secs. Topical imiquimod. Specialist/Hospital only in Bucks Photodynamic therapy. Specialist/Hospital only in Bucks Surgery Referral Threshold – Community Dermatology Service Community Dermatology Service If there is suspicion of malignancy. If the lesions have not responded to treatment. If the individual is on immunosuppressant (e.g. postrenal transplants). For specialist only treatments e.g. imiquimod, photodynamic therapy, surgery Referral Threshold – 999 for emergency admission 25 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks 9) Rosacea What to consider in Primary Care before referring: Clinical features Flushing often made worse by alcohol, spicy foods, hot drinks, temperature changes or emotion Telangiectasia Papules on an erythematous background Pustules Rhinophyma Absence of comedones Treatment in Primary Care Early treatment of rosacea is considered to be important as each exacerbation leads to further skin damage and increases the risk of more advanced disease. Intermittent therapy can be considered for those with very occasional flare-ups, but frequency of recurrences can be reduced by maintenance therapy. Systemic treatment may be needed to provide initial clearance with topical therapy to keep the condition at bay. Clinical response to either systemic or topical treatment expected within 4 weeks. Topical Treatment (For mild to moderate cases or where systemic treatment is contraindicated) st 1 line – Metronidazole 0.75% (e.g. Rozex) Gel or Cream (e.g. Rosex, Rosiced) twice daily. nd 2 line – Azelaic acid 15% gel (e.g. Finacea) twice daily. May be introduced at the end of a course of oral antibiotics to allow their tapering and withdrawal. Preparations with a cellulose base (e.g. Metrogel) tend to be less cosmetically acceptable to patients & this product is not recommended. Avoid topical steroids. Systemic Treatment st 1 line – Oxytetracycline, 500mg twice daily. nd 2 line – Lymecycline, 408mg once daily. rd 3 line – Doxycycline. st If pregnant erythromycin 2 x 250mg twice daily – 1 line Continue therapy until benefit is obtained and reduce to antibiotics / topicals as required NB. Tetracyclines are contraindicated in pregnancy, lactation and renal disease. Both drugs classes can cause photosensitivity. Patients should be advised to avoid direct sunlight and to wear a suitable sun block when going outside. 26 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks Surgical Treatments all LOW PRIORITY in Bucks Vascular Laser / Hyfrecator (used in the treatment of telangiectasia but requires an exceptional case application) Dermabrasion Surgical shaving Laser therapy (For the treatment of rhinophyma) Patient Counselling Patient Counselling can be advised on a number of issues: Heat and cold Alcohol and spicy foods all of which can provoke Flushing, stress management Camouflage / cosmetic advice Ocular Rosacea Ocular rosacea must be treated to prevent keratosis and blindness – Advise patient on lid hygiene to manage blepharitis Treatment use systemic tetracyclines (as above) Referral Threshold – Community Community Dermatology Service Dermatology Service Doubt over diagnosis. Severe disease associated with development of pyoderma faciale. the Severe Ocular Rosacea with keratitis or uveitis Referral Threshold – 999 for emergency admission Urgent referral to Dermatology 27 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks 10) Urticaria and Angioedema What to consider in Primary Care before referring: General Comments Urticaria / Angioedema is believed to be an autoimmune process. In the vast majority of patients with urticaria no underlying trigger factor associated disease is found and the condition is self-limiting. Prick test and RAST tests are not useful as a screening test of potential allergens in chronic ordinary urticaria. Food allergy is usually obvious and trigger factors such a crustaceans, fish and nuts can be easily identified. Contact urticaria is generally suggested by the history and can be confirmed by contact urticaria tests that are different to patch tests, which have no place in the investigation of urticaria. Physical urticaria including: Dermagraphism Cholinergic urticaria Cold urticaria Solar urticaria Pressure urticaria Can usually be identified on history. Urticaria may follow non-specific infections, hepatitis, streptococcal infections, campylobacter and parasitic infestation. Rarely, it may be a symptom of an underlying systemic disease such as thyroid disease or connective tissue disease. Management in Primary Care / Advice for self-care Explain the condition to the patient and reassure that it is benign and usually self-limiting. Minimise: Overheating Alcohol Caffeine Stress Review Drug history – Both prescribed and non-prescribed, many drugs have been reported to cause urticaria such as penicillins, ACE inhibitors, statins, NSAID’s, in particular aspirin. Additionally opiates and NSAID’s may exacerbate existing urticaria. Exclude: C1 Esterase Deficiency (If angioedema is the only sign) 28 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks Insect bites Treatment in Primary Care: Antihistamines There is little to choose between different antihistamines but individuals may vary in their response to different agents. Sedative or non-sedative antihistamine choice depends on the need for sedation. Many antihistamines block histamine wheals and itching but do not suppress the rash completely. Use continuous medication if attacks occur regularly. Use fast acting antihistamines as required for sporadic attacks. If there is no response to one agent after four weeks, try an alternative second and even then a third agent. In some cases of severe acute urticaria, such as a penicillin reaction, a short reducing course of prednisolone starting at 30mgs – 40mgs daily may be useful. Systemic steroids should not be used in chronic urticaria. Summary of low-sedating antihistamines. Name st 1 Choice Equal 1 choice rd st 3 choice Drug Interactions Comments Loratadine None Avoid in pregnancy Cetirizine None Minimally sedating. Half the dose in renal impairment. Avoid in pregnancy. Fexofenadine 180 None Avoid in pregnancy If ineffective consider also more sedating antihistamines e.g. chlorphenamine, hydroxyzine. Hydroxyzine not usually 1 choice in pregnancy. st Note: In pregnancy it is suggested that the long established antihistamines be used e.g. chlorphenamine Double doses of antihistamines are used off license locally – the local experts believe they are more effective in urticaria at higher doses. Referral Threshold – Community Dermatology Service Referral Threshold – 999 for emergency admission Urgent referral to Dermatology 29 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks 11) Generalised Pruritus What to consider in Primary Care before referring: General Comments Dry skin, eczema and scabies are the commonest cause of generalised pruritus. If someone is itching all over, take a full history and examine the skin very carefully. Check lymph nodes and blood tests as below. Management in Primary Care If NO RASH can be seen other than excoriations consider the following: Anaemia – Especially iron deficiency. Uraemia. Obstructive jaundice. Thyroid disease both hypo and hyperthyroidism. Lymphoma, especially in young adults. Carcinoma, especially in middle aged and elderly. Psychological A full general examination may be helpful. Organise the following investigations: FBC and differential ESR Urea and electrolytes LFT’s Thyroid function tests Iron Studies Abdominal USS (Consider if clinically indicated) Chest X-ray (Consider if clinically indicated) NB: Be aware that pruritus may occasionally predate a malignancy by several years. Treatment: Emollients, sedative anti-histamines, anti-pruritic bath oils. Referral Threshold – Community Community Dermatology Service Dermatology Service Refer to Dermatology if treatment fails. - Referral Threshold – 999 for emergency admission Urgent referral to Dermatology 30 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks 12) Onychodystrophy (thickened and dystrophic nails) What to consider in Primary Care before referring: for onchodystrophy General Comments In Bucks we have a LOW PRIORITY statement around fungal nail infections. The priorities committee considers the treatment of onychomycosis (fungal nail infection) with terbinafine to be a low priority and not normally prescribed, with the exception of infection in the frail elderly, diabetic or other immunocompromised patients. In these patients, take nail clippings: start therapy only if infection is confirmed by laboratory. Terbinafine is more effective than azoles. Liver reactions are rare with oral antifungals. In the unusual situation where treatment is indicated on the NHS: st 1 line – terbinafine, 250mg, daily 6 – 12 weeks (fingers) 3 – 6 months (toes) (intermittent regimens are not as effective as daily treatment with terbinafine) nd 2 line – Itraconazole, 200 mg, orally twice a day for 7 days a month -2 courses (for fingers) -3 courses (for toes) General cutaneous examination and examination of all the nails is necessary. Send samples (nail clippings including scrapings of thickened crumbly material on the underside of the nail if present) for microbiology. If repeatedly negative, advise regular filing of nails to keep nails short and thin. Asymptomatic patients should be advised to ‘leave well alone’. Treatment in Primary Care If mycology is positive and dystrophy does not extend to nail matrix (distal onychromycosis) consider no treatment. If treatment is required consider: Oral antifungals: Always obtain +ve mycology before starting oral antifungal agents. Terbinafine (Lamisil), 250mg od 3 – 6 months for toenails, 6 – 12 weeks for fingernails Itraconazole (Sporanox) Pulse treatment, each pulse of itraconazole 200mg twice a day for 7 days repeated monthly (3 cycles for toenails, 2 for fingernails). Referral Threshold – Community Community Dermatology Service Dermatology Service Do not refer patients with this condition Referral Threshold – 999 for emergency admission Urgent referral to Dermatology 31 Buckinghamshire Joint Dermatology Referral Guidance 2013 Adapted from a document from NHS Hounslow with thanks 13) Referral Criteria for Secondary Care Dermatology Primary Care Treatment All mild and some moderate disease should be treated initially in primary care before considering referral to a dermatologist. Criteria for referral to Community Dermatology Mild to moderate acute or chronic rash where unsure of diagnosis Moderate inflammatory conditions where treatments in primary care have been unsuccessful e.g. - Moderate acne (where treatments in primary care have been unsuccessful) - Moderate Eczema (where suggested primary care treatments have failed) Urticaria (where suggested primary care treatments have failed) Tinea/Bacterial Infections Pruritus (where suggested primary care treatments have failed) Criteria for referral to Acute Service Severe acne Severe psoriasis Severe eczema Blistering disorders e.g. bullous pemphigoid Severe rash where unsure of diagnosis Any condition requiring hospital treatment (e.g. phototherapy, patch testing, day treatments, prescription of hospital only drugs) Criteria for referral directly to A&E Steven Johnson syndrome/toxic epidermal necrolysis or acute rash e.g. blistering erythrodema Referral forms are available on CCG intranet sites. Please feedback any comments on this guideline to [email protected] The authors value your input and will make revisions if needed. 32