primary care dermatology update - northderbyshireccg.nhs.uk · ak pathway training ... •scabies ....

Primary Care Dermatology Update

15.50 Lorraine Wooster Skin lesions – what to refer where 16.10 Liz Riches Treating Actinic Keratosis in Primary care 16.25 Lucy Scriven Update on Primary Care Dermatology Service 16.40 Louise Moss Inflammatory skin conditions – tips in diagnosis and management

North Derbyshire Primary Care Dermatology Service

Lesions seen in GPSI clinic

Dr Lorraine Wooster

31 year old woman

Firm feeling raised lesion on her forehead

Present for 18 months, possibly longer

52 year old lady

Lesion on her thigh

Present for several yrs

Noticed incidentally during an examination

- Nodular area in centre

- 9mm diameter

- Multiple colours

66 yr lady

Lesion on her upper arm

Present for 18 months

Increased in size and developed raised area within it over past 4 months

Treating Actinic Keratosis in Primary care

Dr Liz Riches

Actinic Keratosis • Common sun exposed sites in older people -

forehead, face, back of hands, bald scalp of men, and ladies legs

• Rough, raised and irregular, like stuck on cornflakes or may feel like grit

• May be hyperkeratotic

• May be single or multiple

• Risk of a single AK becoming SCC 1/1000 but marker of increased risk of skin cancer.

• The more you have the greater the risk of SCC or BCC

Red Flags

• Rapid growth

• Firm base/ nodule under scale

• Pain or tenderness

• Bleeding

• Immunosuppressed patient

Treating Actinic Keratoses

Do nothing- age/life expectancy/thin lesions/patient choice

Single AKs – depends on type

• Cryotherapy 5-10s FTC

• Curettage & Cautery

• Efudix – 5 flurouracil cream

• Actikerall for hyperkeratotic AK

Multiple AK • Field change – Efudix

• Other options – Solareze/ Picato/ Aldara/ Zyclara/PDT

Efudix

• Classified as ‘GREEN’ after specialist initiation; this includes initiation by GPwSi’s and GPs who have attended the Derbyshire AK pathway training

• Can also use for Bowens

Using Efudix Cream

• Topical cytostatic that selectively destroys sun damaged skin cells with little injury to normal skin

• Apply at night with finger or cotton bud

• Apply once daily for 2 weeks

• If there is little or no change at 2weeks increase to twice daily

• The skin should become red, tender and weepy – this takes 10-28 days. Max treatment 4 weeks

• Stop and allow skin to heal – review 4-6w

Resources

• JAPC guideline on managing AK – contains patient leaflet

• Drug rep materials

• PCDS treatment pathway www.pcds.org.uk

• www.BAD.org.uk – patient leaflets

GPSI Dermatology Service

Dr Lucy Scriven

• Referrals from NDCCG into CRHFT has reduced from ~6300 per year to ~4000 per year

• ~50% of patients seen are discharged at their 1st appointment

• 10 % of patients are referred on to the hospital at 1st appointment

• Overall ~15% onward referral rate

• High patient satisfaction with the service • 100% had confidence in the doctor treating them • 98% felt that the appointment helped them manage

their skin definitely or to some extent • 98% very satisfied or satisfied with the location • 100% extremely likely or likely to recommend the

service to family or friends

What to Refer

• Skin lesions where diagnostic uncertainty/ exists and malignancy not strongly suspected

• Bowen's Disease • Actinic keratosis • Eczema without allergic

component needing patch tests, UVB or Hospital

• Psoriasis thought not to require PUVA treatment or systemic therapies

• Acne vulgaris not requiring Isotretinoin

• Rosacea, seborrheic eczema, perioral dermatitis

• Lichen planus • Lichen simplex • Skin infections and

infestations including bacterial and fungal

• Scabies • Urticaria • Nail disorders • Non-scarring Alopecia • Disorders of

pigmentation Melasma, Vitiligo where diagnostic uncertainty exists

• Rashes

What NOT to Refer – please!

• 2 WW referrals Suspected melanoma, Suspected SCC

• Urgent referrals

• Generalised Pruritus with no rash

• Scarring alopecia

• Blistering conditions

• PLCV

• Warts

• Cosmetic procedures

PLCV

• Seborrhoeic warts

• Molluscum contagiosum

• Telangiectasia

• Spider angiomas (spider veins)

• Skin tags and papillomas

• Acquired naevi (moles)

• Benign haemangiomas

• Xanthelasma

• Viral warts

The GPSI Dermatology Service will only accept referral for surgical removal or cryotherapy of the following benign skin lesions if there is:

• significant pain • recurrent infection • recurrent bleeding • rapid growth or other

features suspicious of dysplasia/ malignancy

• subject to recurrent trauma leading to bleeding

Removal of Sebaceous cysts

• The CCG will only fund surgical removal if one or more of the following criteria are met:

• On the face (not scalp or neck) and greater than

1cm diameter • Greater than 1cm diameter on body (including scalp

and neck) and • is associated with significant pain • or loss of function • or susceptible to recurrent trauma

• Please refer sebaceous cysts >2cm diameter to General surgery lumps and bumps

Removal of Lipomas

• Only funded if • > 5cms and

• Associated with functional disability, significant pain or recurrent trauma

• Lipomas < 5cm should be observed

• NOT suitable for the GPSI service

• Refer to general surgery lumps and bumps

• NB – if >5cm, rapid growth and/or painful – refer to 2ww Sarcoma clinic

Notes on Referring to the GPSI service • Must be done via e-referral

• Waiting times usually < 4 weeks

• The shortest wait may not be at your closest clinic!

• If referral criteria not met your referral may be rejected – please include as much information as possible in the letter and describe the rash or lesion

• Cryotherapy will be done at 1st appointment but other procedures will not

Any Comments / Questions?

Inflammatory Skin Conditions; Diagnosis and Treatment- Top Tips from the GPwSI Team!

Louise Moss

GPwSI Dermatology Moss Valley Medical Practice, Eckington

Common pitfalls and Top tips….

• Generalised itchy rash

DON’T FORGET…

• Secondary infection

• Tinea Incognito

• Scabies

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Legs and toewebs

Fingernails and hands

Face

Scalp Trunk and axilla

Arms

Groin and genitals

Natal cleft

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GPwSI Referrals, 2009 :- Rashes: Frequency of condition

Frequency

Cumulative frequency %

ECZEMA – Treatment tips • How to get your treatment to work

EMOLLIENTS

• for ALL patients with eczema

• USE ENOUGH! –at least 500g/mth

• The greasier the better

• Use one the patient likes

• Use instead of soap

• Consider allergic component - face/severe hand dermatitis with work Hx- use emoillient with no sensitisers-MIMs

TOPICAL STEROIDS

• Start HIGH and step down

• Weekender regimen- daily 1wk, alt days 1 wk, 2x/wk 1 month

• cream for wet weepy eczema

• ointment for dry scaly eczema

• Give ENOUGH!

TREAT INFECTION

GIVE WRITTEN INSTRUCTIONS

CONSIDER OCCLUSION

• Wet wraps / Comfifast suits

• Clothing

• Increases effect of steroid and emoillient

Discoid Eczema

• Dermovate • Antibiotics • Zeroderm • Comfifast

Varicose Eczema………………………

• Steroid

• Emoillent

• COMPRESSION!

Chronic Venous Stasis Disease

• Always consider compression

• Ok to use >0.8 APPM

• If wet use potassium permanganate soaks, viscopaste bandages or ZipZoc

• If infected soak in Eczmol lotion

• Consider topical steroids

• TREAT OEDEMA

THINK COMPRESSION!

• Single/Double layer tubigrip

<10mmHg

• Liner stocking preferred

• Flight stockings

• Class 1 stockings

• Give Stocking applicators

Seborrhoeic Eczema

• Erythema and greasy fine yellowish scale

• scalp, eyebrows, eyelids ears, sides of nose, ant chest and axillae

• Overgrowth pityrosporum may be a trigger

• Extensive and stubborn ?HIV

• Anti-fungal/hydrocortisone combination Rx

Common pitfalls…

Tips on fungal infections

• Often asymmetric.

• Usually scaly (Epidermal).

• Look at the feet!

• Think Tinea Incognito (grows inexorably out – Eczema comes & goes).

Scabies

Psoriasis

Psoriasis v Eczema

Treating Psoriasis

GP Treatment

• Copious Emoillents!

• Urea & Salicytic Acid

• Steroid for face, hands, scalp and flexures

….or in combination

• Vitamin D analogues

• Tar creams

• Dithranol

Hospital Treatment

• Phototherapy - UVB & PUVA

• Methotrexate

• Ciclosporin

• Acitretin

• Biologics- TNF blockers

Lichen Planus

Drug Rash

• Usually urticated, papular generalised rash including face

• History important – new drug, change in dose?

• Common drugs :-

penicillins, sulphonamides, thiazides, allopurinol, phenylbutazone, Gold – later onset

FINALLY …Remember all that itches is not dermatology!

• Anaemia – low ferritin

• Hypothyroidism – dry skin, hair loss

• Liver dysfunction

• Renal dysfuntion

• Diabetes

• Lymphomas

Thank you!