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
Ok Doc !!
Can you
tell me
what this
rash is?
I’m afraid
you’ll need
to take
ALL
your
clothes off
first.
DON’T MISS AN INCH!
Legs and toewebs
Fingernails and hands
Face
Scalp Trunk and axilla
Arms
Groin and genitals
Natal cleft
Generalised Itchy Rash Differential diagnosis?
0%
20%
40%
60%
80%
100%
0
5
10
15
20
Eczem
a
Acne
Psori
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Hand
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folli
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Scaly
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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!