Dermatology GP Education & Networking Event

Dermatology

GP Education & Networking Event

24th September 2014

Dr James HalpernConsultant Dermatologist

Requested Topics

• What should be sent as a 2WW referral?

• Which patients should be referred to secondary care dermatology?

• Allergy testing

• How to use a Dermatoscope

2WW Referrals

What should be sent as a 2WW referral?

Melanoma & Lentigo Maligna

What should be sent as a 2WW referral?

SCC & Keratoacanthoma

What should be sent as a 2WW referral?

Rare skin cancers*

*Cutaneous sarcomas, DFSP, angiosarcoma, KS, Merckle Cell, Cutaneous mets of internal malignancy

What should be sent as a 2WW referral?

BCC

What should be sent as a 2WW referral?

Bowen’s & AK’s

What should be sent as a 2WW referral?

Cutaneous Lymphoma

Improving 2WW Referrals

• Avoid referring BCC’s

• Mole checks, dysplastic naevi

• Children

• Multiple naevi

• Inflammatory referrals

Referrals to Secondary Care

What not to refer

• Cosmetic removal of benign skin lesions – moles, SK’s, cysts etc.

• Laser hair removal

• Treatment of acne scarring

• Molluscum Contagiosum

• ‘Simple’, low grade or minor rashes

What to refer

• All suspected skin cancers:– Melanoma, SCC, BCC, rare skin cancers– Cutaneous lymphomas– Cutaneous deposits of internal malignancy– Pre-malignant skin disease

• simple AK’s can be treated in primary care

– Paraneoplastic rashes

What to refer

• Surgical referrals:– All skin cancers and pre-malignant disease requiring a

biopsy or excision– Lesions that are to large to remove in primary care– All inflammatory rashes which require a biopsy– Paediatric biopsies– Patients on Warfarin, with pacemakers or other CI’s eg.

Myasthenia Gravis

What to Refer

• Moderate or severe inflammatory rashes that:– require systemic therapy, patch

testing, phototherapy etc.– Have not responded to topical

therapies– Are having a significant impact of

patients quality of life

• All bullous disorders except insect bites

What to Refer

• Acne that:– Is scarring– Failed on standard therapies– Significant psychological impact

• Hyperhidrosis that:– Has failed antiperspirants– Significant psychological impact

What to Refer

• Rare skin disorders:– Genetic skin disease– Tropical skin disease– Photodermatoses– Psychiatric skin disease– HIV & immunosuppression related skin

disease– Pregnancy related rashes– Cutaneous manifestations of connective

tissue disease and vasculitis– Genital skin disease

• Disorders of the hair and nails

Urgency of Referrals• 2WW – Cancer only

• Routine / C&B – 12 Weeks:• BCC• Inflammatory referrals eg. eczema, psoriasis

• Very Urgent / Life Threatening referrals:• We do not offer a same-day / urgent / On-call / Advice referral service• If you have a life or limb threatening skin problem eg. TEN

– Within working hours call dermatology secretaries– OOH send to A&E / MAU– 24/7 on-call dermatologist at Birmingham Skin Centre (City Hospital)

• Please Note – A&E if only for those with life threatening skin disease associated with systemic upset. A&E does not have access to dermatologists and can not expedite dermatology appointments

Semi-Urgent referrals• The most challenging group of patients to know what to do with:

– Not sick enough to justify admission to hospital or same day referral– Can not wait 12 weeks to be seen

• From my perspective:– Very difficult to ‘ring-fence’ slots for– Great variability in number and quality of referrals– Causes a lot of frustration for GPs and us!

• Good examples: New diagnosis bullous pemphigoid, stable suberythrodermic rashes, vasculitic rashes

• Bad examples: Patients with stable skin disease who keep consulting yourself / A&E, ‘unknown’ rashes in systemically stable well patients

• Send urgent fax and we will triage – we will try our best!

Example of a Good Referral

• Concise• Relevant• Appropriate

Allergy Testing

When do you Allergy Test?

• Type 1 (immediate reactions)• Suspected allergic contact dermatitis

•Atopic eczema•Urticarias•Generalised itching•Unknown rashes

Atopic Eczema and Allergy

• 99% of atopic eczema in not due to allergy

• Serum specific IgE’s (RAST) and prick testing is of no use in atopic eczema

• Dermatology does not offer allergy testing for children with eczema – Do NOT refer for this

Atopic Eczema and Food Allergy

• Very rare

• Presents at weaning

• ‘All over’ eczema, not confined to flexural areas

• Best test is an exclusion diet and food diary +/- dietician input

• No role for allergy ‘testing’

Urticaria and Allergy

• 99% of urticaria is idiopathic in nature

• There is no role for allergy testing in the investigation of urticarial rashes

Type 1 Allergic Reactions - Anaphylaxis

• Immediate (within 2 hours)

• Often due to food

• May be life threatening

• Investigated with Prick Testing

• NOT Dermatology

• Refer children to Dr Ferdinand & adults to clinical immunology

Type IV – Allergic Contact Dermatitis

• Occurs 72 hours after exposure of a substance on the skin and presents as an eczematous reaction

• Commonly Nickel, Hair Dye (PPD) or Occupational

• Investigated by Dermatology with patch testing

Dermoscopy

What is Dermoscopy?

• The use of a dermatoscope to diagnose skin lesions

• A dermatoscope gives 10x magnification and polarised light

What is Dermoscopy?

• Used to diagnose melanoma• Can distinguish naevi from dysplastic

naevi and melanoma

• Used to diagnose benign skin lesions• Can distinguish naevi from seb

keratosis and vascular lesions

Diagnosing skin lesions

90%History

5%Examination

5%Dermoscopy

Reticular Pattern

• Most common pattern in melanocytic naevi

• Also seen in melanoma, lentigo simplex & dermatofibroma

Typical regular reticular network seen in a benign naevus

Reticular Pattern

Atypical reticular network seen in a melanoma-in-situ

Note:AsymmetryVariable thickness of

networkVariability of colour

Globular Pattern

• Numerous, variously sized, round/oval structures with brown/gray/black colour

• Seen in benign naevi, atypical naevi, congenital naevi and seborrhoeic keratosis

Note variation in size and colour of globules in this atypical compound naevus

Cobblestone Pattern

• Similar to the globular pattern, numerous closely aggregated, larger, angular globules resembling a cobblestone

• Often seen in papillomatous naevi

Typical cobblestone pattern in this very benign looking compound naevus

Homogenous Pattern

• Diffuse brown/gray/blue/black colour with an absent network

• Seen in blue naevi, benign naevi, atypical naevi, melanoma, haemangiomas, tattoos and pigmented BCC

A very typical pattern seen in a benign blue naevus

Homogenous Pattern

Homogenous pattern with reddish halo seen in a melanoma metastasis

Dark red/black homogenous seen in subcutaneous haemorrhage

Starburst Pattern

• Pigmented streaks in a radial pattern at the edge of the lesion

• Classical of Spitz naevi, occasionally melanomas can present with this pattern

Starburst pattern seen in a spitz naevus

Parallel Pattern

• Seen with naevi on acral skin

Typical parallel pattern seen in a benign acral naevus

Parallel Pattern

Parallel-ridge pattern seen in acral melanoma in situ

Note the pigmentation crossing the ridges and variability within the pigmented ridges

Multicomponent Pattern• Combination of 3 or more

other patterns previously described

• Suggestive of melanoma but also seen in benign naevi, BCC and non-melanocytic lesions

Highly atypical network with multiple colours, asymmetry, central white halo and multiple network types seen in a melanoma

Lacunar pattern

• Several to numerous smooth bordered, round red structures

• Seen in haemangiomas and angiokeratomas

Typical haemangioma

Should you buy a dermatoscope?

• Useful in diagnosing benign skin lesions• May reduce unnecessary referrals to

secondary care

• Good ones cost ~£1000• Difficult learning curve and easy to

become deskilled• Overconfidence/reliance can be

dangerous

Questions?