Transcript Dermatology-Referral-Guidelines

Referral Guidelines for Dermatological
Conditions
East Berkshire PCT
Contents
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Acne/rosacea
Allergy testing
Eczema
Fungal nail infections
Hair disorders
Scabies
Seborrhoeic keratoses
Skin Cancer
Solar Keratoses
Pigmentary disorders
Psoriasis
Urticaria
Viral Warts
Others
Acne
Mild to moderate acne can be managed in primary care. Different agents may need to be used alone or in combination
e.g. oral antibiotic with topical retinoid. It is important to explain that the response may be slow. Allow at least 12 weeks
before review unless specific problems with the treatment
Mild acne (non-inflammatory lesions – open and closed comedones)
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Benzoyl peroxide NB. Can bleach
clothes and towels
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Topical retinoids
Mild/moderate acne (comedones and some papules/pustules)
Topical retinoids +/- topical antibiotic
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Erythromycin and zinc acetate
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Erythromycin and benzoyl peroxide
Acne
Moderate acne (more extensive inflamed lesions)
Treatment with a systemic antibiotic should continue for a minimum of 6 months and repeat if necessary.
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Lymecycline
408mg od
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Doxycycline
100mg odcompliance better
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Erythromycin
500mg bd
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Minocycline
100mg od
NB. All the tetracyclines must be avoided in pregnancy
Moderate/severe acne ( deeper inflammation and scarring)
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Consider additional hormone therapy in women eg. Dianette
Acne
Severe acne (nodular lesions with significant scarring)
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Start oral antibiotics and refer for consideration of isotretinoin
therapy
CRITERIA FOR REFERRAL
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For isotretinoin treatment:
Severe acne
Scarring
Poor response to antibiotics
Rapid relapse after antibiotics
Severe psychological problems
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Possible underlying endocrinological cause for acne eg. polycystic ovary
syndrome
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Uncertain diagnosis or unusual features
Rosacea
Clinical features:
Flushing, telangiectasia, papules, pustules, rhinophyma in advanced disease.
TOPICAL TREATMENT
Metronidazole gel/cream can be used in mild cases.
SYSTEMIC TREATMENT
NB. All tetracyclines are contra-indicated in pregnancy, lactation and renal disease
Oxytetracycline
500mg bd for 6-12 weeks
Doxycycline
50-100mg od for 6-12 weeks
Minocycline
100mg od
Lymecycline
408mg od
Erythromycin
500mg bd – can be used in pregnancy
Intermittent therapy may be required for those with occasional flare-ups but some patients will need maintenance
treatment for control.
CRITERIA FOR REFERRAL:
❖ Uncertain diagnosis
❖ Severe disease/pyoderma faciale
❖ Ocular rosacea
Allergy testing
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Allergy testing for chronic urticaria is not relevant,
do not refer.
Allergy testing for type I reactions – refer to allergy
clinic at Amersham or St Thomas’. If anaphylactic
reactions, refer St Thomas’
Extensive patch testing (type IV reactions) is
available locally. Refer to secondary care.
Eczema
PRINCIPLES OF MANAGEMENT
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emollients
topical steroids
topical steroid/antibiotic combination if infected
antihistamines
education
REFER IF:
❖ failure of first line treatments
❖ children requiring moderately potent steroids for prolonged periods
❖ erythrodermic exacerbations
NB. URGENT referral for suspected secondary infection with herpes simplex (eczema herpeticum)
1. EMOLLIENTS
The regular, intensive use of emollients is fundamentally important in the treatment of eczema. Emollients restore the water content of the skin
and prevent scaling, cracking and itching.
a. Moisturisers
Diprobase
Aqueous cream
Epaderm
Emulsifying ointment
b. Soap Substitute
Aqueous cream
Emulsifying ointment
c. Bath additives
Oilatum
Bath E45
Diprobath
Oilatum Plus and Emulsiderm have antiseptic properties
If the patient soaks in the bath for at least 15 minutes, a lipid layer is left on the skin preventing further water loss.
Eczema
KEY POINTS
Emollients are usually not applied frequently or liberally enough
Ointments are more effective than creams
Prescribe large quantities e.g. 500g
2. TOPICAL STEROIDS
Face and flexures
Trunk and limbs
Child
1% hydrocortisone
Fucidin H*
Clobetasol butyrate 0.05%
(Eumovate)
Mometasone fuorate (Elocon)
Fucidin H*
Adult
Eumovate
Elocon
Mometasone fuorate (Elocon)
Betamethasone valerate (Betnovate RD)
Fucibet cream*
* for secondary infection. This is a common cause of flares of atopic eczema. It is important to revert to a pure steroid
preparation once the infection is treated (generally after 10-14 days) to prevent bacterial resistance. Oral antibiotics may
be needed for widespread infection.
Tips about topical steroids
The majority of patients do not use topical steroids adequately. Often, they will not use them at all, but are happy to take
oral steroids when they are unnecessary! Hydrocortisone is usually too weak but this is the steroid that patients are often
most concerned about
if used correctly, they are safe
choose the correct steroid for the body site
a moderate to potent steroid is used to bring the eczema under control before reducing the potency for maintenance
As a guide to quantities that are needed, some patients may find the finger tip unit helpful
Eczema
3. ANTIHISTAMINES
Sedative antihistamines can be used if itching prevents sleep eg. trimeprazine, hydroxyzine. The nonsedating antihistamines are not very helpful in eczema.
4. WET WRAPS/BANDAGING TECHNIQUES
These can be helpful in certain situations but require a lot of time, skill and motivation to be used properly.
The parents also need expert tuition to make these work.
5. GENERAL POINTS
keep nails short
wear cotton clothing - wool tends to irritate
Eczema
TREATMENT
REFERRAL
ACUTE POMPHOLYX
❖ Itchy blisters on palms and soles
❖ Emollients and topical steroid (at least moderately potent)
❖ Treatment failure
❖ Potassium permanganate soaks - 1:10000 for 20 mins/day
❖ Repeated episodes
❖ Treat secondary infection
❖ Severe disease
CRONIC HAND ECZEMA
❖ Fissured or scaly dry skin
❖ Exclude fungal infection
❖ Can be chronic problem
❖ Emollients
❖ Potent topical steroids
❖ Treatment failure
❖ Patch testing if allergic contact
dermatitis suspected
Eczema
TREATMENT
REFERRAL
VARICOSE ECZEMA
❖ Usually elderly, lower legs
❖ Varicose veins
❖ Moderately potent topical steroid with liberal emollients
❖ Remove Keratotic debris
❖ May require e.g. Fucibet around ulcers for infected skin
❖ Use compression bandaging if circulation adequate
DISCOID ECZEMA
❖ Discrete round patches often
starts on lower legs
❖ Usually secondarily infected
❖ Moderately potent topical steroid
❖ Steroid plus antibiotic combination if infected
❖ Warn patient it may recur and require repeated
treatment from time to time
❖ Patch testing may be
needed for resistant cases
Eczema
TREATMENT
REFERRAL
CONTACT DERMATITIS
❖ Common sites affected - hands, feet, face
❖ Consider in pruritus ani, pruritus vulvae
❖ Potent topical steroid
❖ Avoid obvious allergens e.g. nickel
❖ Need for patch testing
SEBORRHOEIC ECZEMA
❖ Face, scalp, central chest
❖ Greasy and/or scaly patches
❖ Ketoconazole shampoo
❖ Steroid scalp preparation
❖ Daktacort and tar shampoo
❖ Severe
condition
indicate HIV infection
may
Fungal nail infections
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Clinical features are
hyperkeratosis under the nail with
thickening and crumbling often of
several nails.
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If clinically typical, check cultures,
but can treat empirically if
symptomatic. Fungal cultures may
be unreliable.
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Treat for 12-16 weeks but nail
may not look normal then. Wait for
it to grow out normally, can take
>6 months
Hair disorders
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Refer scarring alopecia eg. Discoid lupus
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Most patients with alopecia areata will regrow within
6-9 months.
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Physiological hair loss in older women – no need to
refer. Check ferritin and thyroid function.
Refer young women <25years to secondary care,
may need endocrinological investigation
Scabies
SCABIES
The mites are most easily transmitted by close contact eg. children holding hands, sharing a bed. The symptoms may not
develop until 4-6 weeks after being infested. Warn patients that the pruritus may take several weeks to settle after the
treatment.
CLINICAL CLUES:
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Widespread popular eruption
Burrows in web spaces
Inflammatory nodules on the genitalia
There may be a secondary eczematous or urticarial response.
TREATMENT:
Malathion 0.5% aqueous solution (Derbac M) or permethrin 5% (Lyclear dermal cream) applied to all skin below the neck.
Malathion should be left on for 24 hours and permethrin for 8-12 hours. Warn patients that it will need to be re-applied after
hand washing.
NB. Ensure that all members of the household and close contacts are treated at the same time.
TIPS:
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Topical crotamiton cream (Eurax) can be helpful for residual itching
Avoid repeated application of scabicides for residual itching as this exacerbates any eczematous reaction.
Failure of treatment is most likely to be poor compliance with treatment.
Seborrhoeic keratoses
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Stuck on waxy/warty appearance
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Often multiple
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Can become irritated and
inflamed
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No malignant potential
Seborrhoeic keratoses
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Do not need treatment – patient can be reassured
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If symptomatic, cryotherapy or curettage most useful
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Referral guidance
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Do not send under 2 week rule
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If diagnostic difficulty, refer to Pigmented Lesion Clinic. This is held monthly at
King Edward VII
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For multiple symptomatic lesions, approval of Low Priority Committee
required before referral for any treatment
Skin Cancer
SKIN CANCER
❖All suspicious and changing pigmented lesions should be referred via the 2 week wait system. Basal cell
carcinomata are excluded from this system, and can be referred via the normal route, as routine referrals.
Basal cell carcinoma
❖ Slow growing, locally invasive tumours. Pearly edge is a common feature.
Squamous cell carcinoma
❖ Often rapidly growing and can metastasise. It is reasonable to refer keratoacanthomas via the 2 week wait
system, especially if they have been present for more than 2 months as these are more likely to be SCCs.
Malignant melanoma
❖ Most serious skin malignancy. Early detection and treatment is vital to improve the prognosis
Pigmented Lesions
CRITERIA FOR REFERRAL OF PIGMENTED LESIONS – those TRULY
SUSPICIOUS of a melanoma can be referred via the 2 week wait rule.
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Change in size
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Change in colour (variability of pigmentation)
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Change in shape (irregularity of edge)
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Size >6mm
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Inflammation
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Bleeding/crusting
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Itch
Lesions suspicious of lentigo maligna in young patients should be referred via the 2
week wait system.
Solar Keratoses (Actinic Keratoses)
Usually flat red, scaly lesions on face, scalp, backs of hands. Often multiple.
TREATMENT:
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Cryotherapy – 10 seconds freezing time
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Topical 5-fluorouracil (Efudix ) cream – can be helpful for diffuse areas of damage. Use once daily for
10-14 days. It may need to be used for longer (up to 4 weeks) at non-facial sites. Warn patient to expect
a brisk inflammatory response.
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Topical imiquimod 5% (Aldara) can also be used. This needs to be used 5 days a week for about 6
weeks. A marked inflammatory reaction can result.
CRITERIA FOR REFERRAL
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Any suspicion of malignancy
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Failure to respond to treatment
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Immunosuppressed patient
Pigment disorders
Chloasma/melasma – no need to refer if mild. Only treatment
available on NHS is Pigmanorm (contains hydroquinone )which is
only available via hospital pharmacy. Can ask advice by letter to
dermatology consultant.
Consider referral for cosmetic camouflage
Vitiligo – refer extensive vitiligo if phototherapy to be considered. This
may not have long term benefit.
Consider referral for cosmetic camouflage
Check auto-antibody screen as may be associated with auto-immune
disease.
Psoriasis
HISTORY
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Duration
Triggers
Medical History
Drug HIstory e.g. beta blockers, lithium, chloroquine
ASSESSMENT FOR TREATMENT
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Extent
Plaque size/thickness
Inflammation
Practicalities of treatment
Compliance
Adequate prescribing quantities
Psoriasis
TYPE
TREATMENT
All forms
❖ Emollients
Limited disease or thin
plaques
❖ Tar preparations eg. Alphosyl cream bd
❖ Calcipotriol bd
Limited thick plaques
❖ Salicylic acid to break down scale
❖ Calcipotriol bd
❖ Dovobet® ointment
❖ Short contact dithranol (with patient education)
Psoriasis
TYPE
TREATMENT
Inflamed sore plaques
❖ Emollients
❖ Moderately potent topical steroid
❖ Avoid calcipotriol and dithranol
Scalp psoriasis
❖ Tar/salicylic acid shampoo
❖ Steroid scalp application
❖ Xamiol® gel
❖ Ung cocois for thick plaques, and then steroid scalp application
Psoriasis
OTHER TYPES
Guttate
TREATMENT
❖ Emollients
❖ Tar preparations
❖ UVB
❖ Avoid dithranol - can burn
Guttate psoriasis typically self resolves within 6-8 weeks. Do not refer unless
recurrent episodes or evolving into more extensive chronic disease.
Facial
❖ Emollients
❖ Mild topical steroids
Psoriasis
OTHER TYPES
TREATMENT
Flexural
❖ Moderately potent topical steroid and anti-yeast e.g. trimovate
Arthropathy
❖ Refer to Rheumatology
Psoriasis
OTHER TYPES
TREATMENT
Nail dystrophy
❖ Mild changes often resolve
spontaneously
❖A potent topical steroid rubbed
into the nail may help
Pustular psoriasis of palms and soles
❖ Diprosalic ointment bd under occlusion
Criteria for referral
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CRITERIA FOR REFERRAL
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Erythrodermic
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Unstable/generalised pustular psoriasis
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Extensive/severe disease
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Failure to respond or relapse post topical therapies
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Recurrent attacks
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DIfficulty with diagnosis
Urticaria
Chronic idiopathic urticaria is common. Explain to the patient that it is benign and self-limiting. Antihistamines are the mainstay of treatment.
Tests are generally unhelpful. Patch tests are of no use in urticaria
Tips:
❖ Avoid aspirin and NSAIDs - these can exacerbate the problem.
❖ ACE inhibitors can cause angioedema
❖ Exclude C1 esterase deficiency if angioedema is the only sign
❖ Steroids should NOT be used in chronic urticaria
ANTIHISTAMINES
Patients can vary in their response to different antihistamine agents and several may need to be tried.
❖ Cetirizine or Loratidine 10mg od or bd
❖ Fexofenadine 180mg od
❖ Add sedating antihistamine at night eg. doxepin 25 mg or hydroxyzine 25mg if no response
❖ Ketotifen (1mg bd) is sometimes helpful as a mast cell stabiliser
NB. Do not give terfenadine or astemizole with doxepin, imidazole antifungals or macrolide antibiotics to avoid cardiac arrythmias.
CRITERIA FOR REFERRAL
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Suspicion of urticarial vasculitis ie. persistence of weals >24 hours, systemic illness
Urticaria associated with systemic features
Urticaria poorly responsive to antihistamines
Hereditary angioedema
Viral Warts
VIRAL WARTS
Viral warts are self-limiting and are very common. There is no cure until host immunity develops and they are
usually best left to resolve spontaneously.
Topical salicylic acid
Use a high concentration eg Occlusal. The patient will need to apply this for many months. It is best applied after
bathing and the area rubbed down with a pumice stone or sandpaper.
Cryotherapy
May be helpful but if no sign of improvement after 4-5 treatments, it is unlikely to work and should be stopped. It is
best performed at 3-4 weekly intervals. It is uncomfortable and best avoided in children under 6 years of age.
Viral Warts - criteria for referral
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Referral letters can be accepted where any one of the following are true:
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Diagnosis of viral warts is not clearly stated (eg. 'warty lesion' is not stating the diagnosis)
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Patient is immunosuppressed
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Periocular warts associated with recurrent conjunctivitis
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There is any suspicion of malignancy
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There is obstruction of an orifice or vision
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There is functional limitation on movement or activity
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There is an attached agreement from the Low Priorities Committee
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The following may be funded but the GP will have to apply through the Low Priorities Committee:
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Moderate to large facial lesions which cause disfigurement
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Removal for other indications such as itching, bleeding, pain, recurrent trauma.
Others....
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Refer patients with genital disease (other than infections which can be
referred to Garden Clinic at Upton) to secondary care. The vulval clinic is held
at King Edward VII.
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Patients with generalised pruritus may need referral for diagnosis and
investigation
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Photosensitivity needs specialist investigation, refer secondary care
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Patients with cutaneous lichen planus only do not need referral as this is self
limiting. Any patient with mucosal involvement should be referred to
secondary care – oral involvement only to Oral Medicine, those with genital
involvement to dermatology.