Clinical Commissioning Group (CCG) Governing Body 2014/2015

Transcription

1 Clinical Commissioning Group (CCG) Governing Body 2014/2015 Date of Meeting: 21 November 2014 Agenda Item: 8b Subject: Approval of GM Effective Use of Resource (EUR) Policy Benign Skin Lesions Reporting Officer: Dr Chris Duffy Aim of Paper: To provide the Governing Body with an update on the following EUR policy which has been approved by the GM Association Governance Group Governance route prior to this GB Meeting Date Objective/Outcome CCG Governing Body Select date of meeting. Click to Select Quality and Safety Committee Select date of meeting. Click to Select Clinical Commissioning Committee Select date of meeting. Click to Select Patient Experience Assurance Committee Select date of meeting. Click to Select Finance, Performance and Risk Committee Select date of meeting. Click to Select Audit Committee Select date of meeting. Click to Select Remuneration Committee Select date of meeting. Click to Select Locality Engagement Group Select date of meeting. Click to Select Health and Wellbeing Board Select date of meeting. Click to Select Other Click here to enter text. Governing Body Resolution Required: Recommendation To note the report For Information Only Link to Strategic Objectives SO1: To secure additional years of life for people of the Borough with treatable mental and physical health conditions SO2: To improve the health related quality of life for people with long term condition(s) including mental health conditions SO3: To reduce the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside hospital SO4: To increase the proportion of older people living independently at home following discharge from hospital SO5: To increase the number of people with mental and physical health conditions having a positive experience of hospital care and care outside of hospital (including General Practice and the Community) SO6: To make significant progress towards eliminating avoidable deaths in our hospitals, and all care settings, caused by problems in care. SO7: To develop integrated working and partnerships to ensure the best possible care for the borough SO8: To be a high performing CCG, deliver our statutory duties and use our available resources innovatively to deliver the best outcomes for our population. Contributes to: (Select Yes or No) Yes Yes Yes Yes Yes Yes Yes Yes Risk Level: (To be reviewed in line with Risk Policy) Not Applicable

2 Comments (Document should detail how the risk will be mitigated) Click here to enter text. Content Approval/Sign Off: The contents of this paper have been reviewed and approved by: Clinical Content signed off by: Financial content signed off by: Click to Select Approving Officer CCG Chair, Dr Chris Duffy Not Applicable Clinical Engagement taken place Patient and Public Involvement Patient Data Impact Assessment Equality Analysis / Human Rights Assessment completed Completed: Not Applicable Not Applicable Not Applicable Not Applicable Executive Summary To provide the Governing Body an update on the Benign Skin Lesions EUR policy which has been approved by the GM Association Governance Group:

3 GREATER MANCHESTER ASSOCIATION GOVERNING GROUP MEETING Date of Meeting 4 th November 2014 Issue Consideration Brief Paragraph Summary under Greater Manchester Effective Use of Resources (EUR) Policy Common Benign Skin Lesions This policy document outlines the conditions under which common benign skin lesions will be routinely commissioned by Clinical Commissioning Groups in Greater Manchester (CCGs). It has been produced in order to provide and ensure equity, consistency and clarity in the commissioning of the removal of common benign skin lesion by all Clinical Commissioning Groups in Greater Manchester. Adoption of this policy will alleviate any disparity faced by patients within Greater Manchester, (dependent on their registered GP/CCG) in accessing procedures to remove common benign skin lesions. Adoption of Greater Manchester EUR policies will ensure that all NHS acute trusts/providers within Greater Manchester are working to the same policy, which will also relieve any possible differences in accessing this treatment dependent on where the patient is referred. Impact of this policy across Greater Manchester Commissioning Recommendation Common Benign Skin Lesions will be commissioned in accordance with the attached policy. The adoption of the Greater Manchester EUR policy on common benign skin lesions is not anticipated to have a significant effect on Greater Manchester CCGs as the criteria is not dissimilar to the criteria currently in place, i.e. benign skin lesions are not commissioned for aesthetic purposes. Decision/Opinion Required The Association Governing Group is asked to review the attached policy and supporting documentation and approve for ratification by Greater Manchester CCG Governing Bodies. Item is for Information Author of Paper and contact details The item has been discussed previously at these meetings Lynne Duxbury, Head of Effective Use of Resources. Telephone: , Mobile: , lynneduxbury@nhs.net This policy has been developed and approved by the Greater Manchester EUR Steering Group. The Greater Manchester EUR Steering Group is quorate when all 12 CCGs are represented.

4 include the outcome Decisions taken by the Steering Group are by consensus. Consultation on the policy has taken place from 9 th July 2014 to 3 rd September 2014, with feedback being reviewed by the Greater Manchester EUR Steering Group prior to approval of the final attached policy. Notification of the policy consultation was disseminated to: Within Greater Manchester Clinical Commissioning Groups (GMCCG): CCG Chief Operating Officers; CCG Heads of Commissioning; CCG EUR Leads; CCG IFR Panel/Process Review Panel Members; Greater Manchester EUR Steering Group Members; Within the Greater Manchester Commissioning Support Unit (GMCSU): Executive Team; Medicines Management; Contracts and Performance; Service Redesign; Patient Services; Equality and Diversity; EUR team, including Clinical Triage GP members. CCG Communication teams to be disseminated to patients/public through existing CCG communication mechanisms. GPs and practice managers. The policy consultation was also sent to named contacts within each Greater Acute Trust to be disseminated to appropriate clinicians/managers within each organisation. This policy has been reviewed by the Greater Manchester Heads of Commissioning (HOC) and Greater Manchester Chief Finance Officers (CFO), virtually in October Feedback has been requested by the 3 rd November 2014 for final agreement and recommendation to CCG Governing Bodies by the Greater Manchester Association Governing Group.

5 1 Greater Manchester EUR Policy Statement Title/Topic: Common Benign Skin Lesions Date: October 2014 Reference: GM013

6 VERSION CONTROL Version Date Details Page number /03/2014 Initial draft N/A /03/2014 Amendments made by GM EUR Steering Group on 19/03/2014: Three typographical errors were corrected: Bullet point 2 under Mandatory Criteria : Lymphoma changed to read Lipoma Bullet point 4 under Lipoma. : increases changed to read increased Bullet point 4 under Lipoma. : misdiagnosis changed to read as missed diagnosis. Bullet point 2 under Mandatory Criteria - Treatment of multiple lipomatosis or neurofibromatosis has been removed, as the policy would be applied to each separate lipoma. Causing functional impairment has been included within each lesion specific criteria. Xanthelasma - the criteria has been amended to state: lager lesions causing functional impairment, such as interfering with vision. Under the treatments for Xanthelasma section, the second and third bullet points should be removed /04/2014 Statement regarding treating disabled people as more equal than other protected characteristic groups added to Equality and Equity section. Ratification through CCG Governing Bodies added to Governance Arrangements. Removal of suspicious or potentially malignant lesions from Mandatory Criteria section. Such lesions are excluded from the policy and should be referred on the appropriate pathway without prior funding approval. Rationale for policy development included /05/2014 Amendments made by GM EUR Steering Group on 21/05/2014: Mandatory criteria simplified and repetition under the additional criteria removed. Draft policy approved for consultation following the above amendments. Policy published for consultation from 09/07/2014 to 03/09/2014. N/a 7-8 N/a 2

7 0.5 25/09/2014 Amendments made by GM EUR Steering Group on 17/09/2014 following a review of the feedback from the consultation: 17/09/2014 Policy renamed Common Benign Skin Lesions. Spelling of Nevi changed to Naevus within the glossary Separate definition for pigmented naevus relating to moles included in the glossary. Additional statement included to confirm that any lesions where there may be diagnostic uncertainty should be referred. Statement added under policy exclusions section to confirmed that this policy does not apply to minor surgery undertaken in primary care, which falls under the commissioning responsibility of NHS England. Bullet point added to the lipoma section, in section 4, to state the soft tissue guidelines should be followed if there are any concerns. Chalazion, xanthelasma and dermatochalasis removed from policy and included in a separate eyelid lesion policy. Statement regarding actinic/solar keratosis amended to state that there is a small risk that they can transform to Squamous Cell Carcinoma. Specific criteria for actinic/solar keratosis included under section 4 mandatory criteria to state that referrals may be made if there is a risk of transforming into squamous cell carcinoma/malignant change. All lesions definitions included under section 5 description of epidemiology and need, moved to section 2 definition. Original statement under section 2 definition moved to section 1 introduction. Squamous Cell Carcinoma included in glossary. Policy approved by GM EUR Steering Group, subject to amendments above. All N/a /10/2014 Branding changed following creation of North West CSU on 01/10/ /09/2014 Policy approved by GM EUR Steering Group required amendments have been made. All N/a 3

8 POLICY STATEMENT Title/Topic: Common Benign Skin Lesions Issue Date: To be confirmed Commissioning Recommendation: The removal of non-malignant skin lesions for aesthetic reasons is not commissioned. All suspected malignant lesions are excluded from this policy these should be managed via the 2 week wait with the exception of Basal Cell Carcinoma (BCC), where low risk BCC may be removed in the community in line with NICE recommendations and high risk BCC should be referred through the usual pathway. See Section 4: Criteria for Commissioning Date of Review: One year from the date of approval by Greater Manchester Association Governing Group and annually thereafter. Prepared By: The Greater Manchester Commissioning Support Unit Effective Use of Resources Policy Team Approved By Date Approved Variance Greater Manchester Effective Use of Resources Steering Group 17/09/2014 Greater Manchester Chief Finance Officers / Greater Manchester Heads of Commissioning Greater Manchester Association Governing Group Bury Clinical Commissioning Group Bolton Clinical Commissioning Group Heywood, Middleton & Rochdale Clinical Commissioning Group Central Manchester Clinical Commissioning Group North Manchester Clinical Commissioning Group Oldham Clinical Commissioning Group Salford Clinical Commissioning Group South Manchester Clinical Commissioning Group Stockport Clinical Commissioning Group 4

9 Tameside & Glossop Clinical Commissioning Group Trafford Clinical Commissioning Group Wigan Borough Clinical Commissioning Group 5

10 CONTENTS Policy Statement... 7 Equality & Equity Statement... 7 Governance Arrangements Introduction Definition Aims and Objectives Criteria for Commissioning Description of Epidemiology and Need Evidence Summary Rationale behind the Policy Statement Adherence to NICE Guidance Mechanism for Funding Audit Requirements Documents which have informed this Policy Links to other Policies Date of Review Glossary References Appendix 1 Evidence Review

11 Policy Statement The Greater Manchester Commissioning Support Unit (GMCSU) has developed this policy on behalf of Clinical Commissioning Groups (CCGs) within Greater Manchester, who will commission the removal of benign skin lesions in accordance with the criteria outlined in this document. In creating this policy the GMCSU has reviewed this clinical condition and the options for its treatment. It has considered the place of this treatment in current clinical practice, whether scientific research has shown the treatment to be of benefit to patients, (including how any benefit is balanced against possible risks) and whether its use represents the best use of NHS resources. This policy document outlines the arrangements for funding of this treatment for the population of Greater Manchester. Equality & Equity Statement The GMCSU/CCG has a duty to have regard to the need to reduce health inequalities in access to health services and health outcomes achieved, as enshrined in the Health and Social Care Act The GMCSU/CCG is committed to ensuring equality of access and non-discrimination, irrespective of age, gender, disability (including learning disability), gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex (gender) or sexual orientation. In carrying out its functions, the GMCSU/CCG will have due regard to the different needs of protected characteristic groups, in line with the Equality Act This document is compliant with the NHS Constitution and the Human Rights Act This applies to all activities for which they are responsible, including policy development, review and implementation. In developing policy the GMCSU policy team will ensure that equity is considered as well as equality. Equity means providing greater resource for those groups of the population with greater needs without disadvantage to any vulnerable group. The Equality Act 2010 states that we must treat disabled people as more equal than any other protected characteristic group. This is because their starting point is considered to be further back than any other group. This will be reflected in GMCSU evidencing taking due regard for fair access to healthcare information, services and premises. An Equality Analysis has been carried out on the 10 th April 2014 (to be completed following the consultation and final approval of the policy). For more information about the Equality Analysis, please contact policyfeedback.gmscu@nhs.net. Governance Arrangements Greater Manchester EUR policy statements will be ratified by the Greater Manchester Association Governing Group (AGG) prior to formal ratification through CCG Governing Bodies. Further details of the governance arrangements can be found in the Greater Manchester EUR Operational Policy. 1. Introduction This commissioning policy has been produced in order to provide and ensure equity, consistency and clarity in the commissioning of procedures to treat Benign Skin Lesions by Clinical Commissioning Groups in Greater Manchester. When this policy is reviewed all available additional data on outcomes will be included in the review and the policy updated accordingly. The vast majority of skin tumours are benign. There are a few very common benign skin tumours including: benign pigmented moles, comedones, corn/callous, lipoma, milia, molluscum contagiosum, sebaceous cysts (epidermoid or pilar cysts), seborrhoeic keratoses (basal cell papillomata), skin tags 7

12 including anal tags, keloid scars, spider naevus (telangiectasia), warts, xanthelasma and neurofibromata. Whilst removal of these lesions are very effective, they are of low therapeutic value and not commissioned for aesthetic reasons. 2. Definition Actinic/Solar keratosis Actinic keratoses, also known as solar keratoses, are dry scaly patches of skin caused by damage from years of sun exposure. The patches are usually harmless but can be itchy and look ugly; there is a small risk of Actinic/Solar Keratosis progressing into squamous cell carcinoma (SCC). Basal Cell Papilloma / Seborrhoeic Keratosis / Keratotic Warts Non-cancerous (benign) warty growths that occur on the skin. They usually do not need any treatment. Benign pigmented moles A benign growth on the skin (usually tan, brown, or flesh-coloured) that contains a cluster of melanocytes and surrounding supportive tissue. Epidermoid / Sebacous cyst Epidermoid and pilar cysts look like small smooth lumps under the skin surface. They are benign (noncancerous) and usually cause no harm or problems. If required, they can usually be removed easily by a small operation done under local anaesthetic. The main reason why some people want them removed is for cosmetic reasons, as they can look unsightly. Lipoma A lipoma is a soft fatty lump. It is a non-cancerous (benign) growth made up from fat cells that clump together. A lipoma can occur in any part of the body where there are fat cells. Neurofibromata A benign neoplasm composed of the fibrous elements of a nerve. Skin Tags Skin tags are small, often pedunculated, skin-coloured or brown papules that occur most frequently where there are skin folds. Common sites are the neck, axilla, groins and eyelids. They are also known as acrochordons. They are usually 0.2 to 0.5 cm in diameter. Thread Veins and Telangectasia Thread Veins Thread veins are a common problem and occur in about half of adults in western countries. These are very fine dilated veins lying in the skin. They come from normal veins in the skin which grow much bigger than their usual size. They often occur near the ankle, over the inside of the knee and outside of the thigh. Telangectasia A condition characterized by dilatation of the capillaries causing them to appear as small red or purple clusters, often spidery in appearance, on the skin or the surface of an organ. Warts and Verrucas Warts are small rough lumps on the skin. They are caused by a virus (human papillomavirus) which causes a reaction in the skin. Warts can occur anywhere on the body but occur most commonly on hands and feet. They range in size from 1 mm to over 1 cm. Sometimes only one or two warts develop. Sometimes several occur in the same area of skin. The shape and size of warts vary, and they are sometimes classed by how they look. For example, common warts, plane (flat) warts, filiform (finger-like) warts, mosaic warts, etc. 8

13 Verrucas are warts that occur on the soles of the feet. They are the same as warts on any other part of the body. However, they may look flatter, as they tend to get trodden in. 3. Aims and Objectives Aim This policy document aims to specify the conditions under which removal of benign skin lesions will be routinely commissioned by Clinical Commissioning Groups in Greater Manchester. Objectives To reduce the variation in access to the removal of benign skin lesions. To ensure that the removal of benign skin lesions are commissioned where there is acceptable evidence of clinical benefit and cost-effectiveness. To reduce unacceptable variation in the commissioning of the removal of benign skin lesions across Greater Manchester. To promote the cost-effective use of healthcare resources. 4. Criteria for Commissioning Mandatory Criteria Removal of benign skin lesions will only be considered for: Impairment of function or significant facial disfigurement, e.g. large lipoma. Rapidly growing or abnormally located (e.g. sub-fascial, sub-muscular). There is significant pain as a direct result of the lesion. There is a confirmed history of recurrent infection / inflammation. There is reason to believe that a commonly benign or non-aggressive lesion may be changing to a malignancy, or there is sufficient doubt over the diagnosis to warrant removal. The following additional criteria are also applicable to the lesions listed below and referral may be made if the patient meets the criteria for that specific lesion and/or the mandatory criteria above. Lipoma (Fatty Lump) will only be considered for treatment in the following circumstances: The lump is over 5cm in diameter (due to the increased risk of missed diagnosis of a liposarcoma). Where there are any concerns, the soft tissue guidelines should be followed. Warts and Verrucas Warts Verrucas The diagnosis is uncertain. There are multiple recalcitrant warts and the person is immunocompromised. The person has areas of skin that are extensively affected, for example, mosaic warts. The person has diabetes. 9

14 Actinic/Solar Keratosis Actinic/solar keratosis may be referred for treatment if there is any reason to suspect that it is one of the small percentage at high risk of undergoing malignant change and transforming into a squamous cell carcinoma. The referral should include details of the reasons the referrer has for this suspicion. Policy Exclusions All suspected malignant lesions are excluded from this policy these should be managed via the 2 week wait with the exception of Basal Cell Carcinoma (BCC), where low risk BCC may be removed in the community in line with NICE recommendations and high risk BCC should be referred through the usual pathway. This policy does not apply to minor surgery undertaken in primary care which is outside of the remit of this policy as it falls under the commissioning responsibility of NHS England. The removal of benign skin lesions for cosmetic reasons or outside of the criteria detailed above are not routinely commissioned. Funding may be considered on an individual patient basis, if there is evidence of clinical exceptional circumstances. Clinicians can submit an Individual Funding Request (IFR) if they feel there is a good case for exceptionality in line with the procedures described in the Greater Manchester EUR Operational Policy. Exceptionality means a person to which the general rule is not applicable. Greater Manchester sets out the following guidance in terms of determining exceptionality; however the over-riding question which the IFR process must answer is whether each patient applying for exceptional funding has demonstrated that his/her circumstances are exceptional. A patient may be able to demonstrate exceptionality by showing that s/he is: Significantly different to the general population of patients with the condition in question. and as a result of that difference They are likely to gain significantly more benefit from the intervention than might be expected from the average patient with the condition. 5. Description of Epidemiology and Need Benign skin lesions are very common and the vast majority cause no problems other than aesthetic ones. Whilst these can be removed effectively they are of low clinical value. Lipomas: - about 1 in 1,000 people develop one or more lipomas. 6. Evidence Summary The vast majority of benign skin lesions are harmless, many are self-limiting. Most removals are requested for aesthetic reasons; however, for some specific conditions treatment is clinically indicated. Full details of the Evidence Review are contained with Appendix Rationale behind the Policy Statement The vast majority of benign skin lesions are harmless but may be unsightly. There are occasional circumstances in which the removal of a benign skin lesion is clinically indicated, these circumstances are listed in this policy. The policy ensures that lesions are not removed for solely aesthetic reasons. 10

15 8. Adherence to NICE Guidance NICE have not currently issued guidance on this treatment. 9. Mechanism for Funding Funding will be monitored approval and referrals may be made and accepted in line with the criteria detailed above. 10. Audit Requirements There is currently no national database. Service providers will be expected to collect and provide audit data on request. 11. Documents which have informed this Policy Individual CCG referral criteria and policy statements. Greater Manchester EUR Operational Policy. 12. Links to other Policies This policy follows the principles set out in the ethical framework that govern the commissioning of NHS healthcare and those policies dealing with the approach to experimental treatments and processes for the management of individual funding requests (IFR). 13. Date of Review One year from the date of approval by Greater Manchester Association Governing Group and annually thereafter. 14. Glossary Term Acrochordon (Skin tags) Basal Cell Carcinoma Benign Callous Cellulitis Comedones Corn Meaning An acrochordon is a small benign tumor that forms primarily in areas where the skin forms creases, such as the neck, armpit, and groin. They may also occur on the face, usually on the eyelids. Acrochorda are harmless and typically painless, and do not grow or change over time. A type of skin cancer, also known as a rodent ulcer or BCC, that occurs most commonly on the face or neck. (Of a disease) not harmful in effect. a thickened and hardened part of the skin or soft tissue, especially in an area that has been subjected to friction. Inflammation of subcutaneous, loose connective tissue (formerly called cellular tissue). Technical term for blackhead (a plug of sebum in a hair follicle, darkened by oxidation). An accumulation of dead skin cells on the foot, forming thick, hardened areas. They contain a cone-shaped core with a point that can press on a nerve 11

16 Term Meaning below, causing pain. Epidermoid or Pilar cyst Fascia A common cyst of the skin. A sheet or band of fibrous tissue such as lies deep to the skin or invests muscles and various body organs. Immunocompromised Having the immune response attenuated by administration of immunosuppressive drugs, by irradiation, by malnutrition, or by certain disease processes (e.g., cancer). Keloid scar Lipoma Liposarcoma A keloid is the formation of a type of scar which, depending on its maturity, is composed mainly of either type III or type I collagen. It is a result of an overgrowth of granulation tissue at the site of a healed skin injury which is then slowly replaced by collagen type 1. A benign tumour of fatty tissue. Sarcoma of fat cells. Malignant Unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invading nearby parts of the body. Milia Molluscum contageosum Mosaic warts Neurofibromata Naevus Pigmented Naevus Preseptal Prophylactic Recalcitrant Rosacea Sarcoma Sebaceous cyst A small, hard, pale keratinous nodule formed on the skin, typically by a blocked sebaceous gland. A chronic viral disorder of the skin characterised by groups of small, smooth, painless pinkish nodules with a central depression that yield a milky fluid when squeezed. Plantar growth of numerous closely aggregated warts forming a mosaic appearance, frequently caused by human papillomavirus type 2. A benign neoplasm composed of the fibrous elements of a nerve. A birthmark (or a mole on the skin see below), especially a birthmark in the form of a raised red patch often referred to as a strawberry naevus. = mole a brown lesion of the skin sometimes raised sometimes hairy which can in certain circumstance become malignant (= malignant melanoma) Infection involving the superficial tissue layers anterior to the orbital septum. Preventing disease Not responsive to treatment Chronic vascular and follicular dilation involving the nose and contiguous portions of the cheeks; may vary from mild but persistent erythema to extensive hyperplasia of the sebaceous glands, seen especially in men in the form of rhinophyma and of deep-seated papules and pustules; accompanied by telangiectasia at the affected erythematous sites. A malignant tumour of connective or other non-epithelial tissue. A swelling in the skin arising in a sebaceous gland, typically filled with yellowish sebum. 12

17 Term Seborrhoeic keratosis (basal cell papilloma) Spider naevus / Telangiectasia Squamous Cell Carcinoma Sub-facial Sub-muscular Symptomatic Tumour Verruca / Plantar wart Warts Meaning A seborrheic keratosis is a noncancerous benign skin growth that originates in keratinocytes. A cluster of minute red blood vessels visible under the skin Squamous cell carcinoma (SCC) is an uncontrolled growth of abnormal cells arising in the squamous cells, which compose most of the skin s upper layers (the epidermis). SCCs often look like scaly red patches, open sores, elevated growths with a central depression, or warts; they may crust or bleed. SCCs may occur on all areas of the body including the mucous membranes and genitals, but are most common in areas frequently exposed to the sun, such as the rim of the ear, lower lip, face, bald scalp, neck, hands, arms and legs. Beneath a fascia. Situated underneath a muscle or muscles. Exhibiting or involving medical symptoms. A swelling of a part of the body, generally without inflammation, caused by an abnormal growth of tissue, whether benign or malignant. A contagious and usually painful wart on the sole of the foot. A small, hard, benign growth on the skin, caused by a virus. References N/a 13

18 Appendix 1 Evidence Review Title/Topic: Common Benign Skin Lesions Ref: GM013 Search Strategy The standard databases were searched for references relating to benign skin lesions and the more common specific types of benign skin lesions. The results are given below. Summary of the evidence The vast majority of benign skin lesions are harmless, many are self-limiting. Most removals are requested for aesthetic reasons however for some specific conditions there are criteria for consideration of referral for further treatment over and above the general criteria of: Lesion is symptomatic Lesion is causing functional impairment Lesion is rapidly growing or abnormally located There is significant pain as a direct result of the lesion There is a confirmed history of recurrent infection / inflammation/injury The evidence Levels of evidence Level 1 Level 2 Level 3 Level 4 Level 5 Meta-analyses, systematic reviews of randomised controlled trials Randomised controlled trials Case-control or cohort studies Non-analytic studies e.g. case reports, case series Expert opinion Benign Skin Lesions Database NICE NHS Evidence and NICE CKS SIGN Cochrane York BMJ Clinical Evidence BMJ Best Practice Result Referral to patient.co.uk only 14

19 General Search (Google) The management of benign skin lesions Steven Lamb, Consultant Dermatologist, Department of Dermatology, Green Lane Clinical Centre and Auckland Dermatology NZCGP Volume 33 Number 5, October 2006 Common Benign Skin Tumors Mark C. Luba, M.D. et al American Family Physician February 15, 2003 / Volume 67, Number 4 Various websites including Patient.co.uk, medscape and clinic sites (general information not cited below) TEXTBOOK: British Association of Dermatologists' Management GuidelinesNeil Cox (Editor), John English (Editor) ISBN: pages March 2011, Wiley-Blackwell (textbook not cited below) Other Searches of the British Association of Dermatologists and the British association of aesthetic and plastic surgeons found no specific guidance. 1. Level 5: Expert Opinion The management of benign skin lesions Steven Lamb, Consultant Dermatologist, Department of Dermatology, Green Lane Clinical Centre and Auckland Dermatology NZCGP Volume 33 Number 5, October 2006 Benign skin lesions are often encountered in day-to-day general practice. The majority of lesions do not require treatment; however, occasionally patients will request the removal of lesions which are symptomatic or unsightly. It is important to make the correct diagnosis to avoid the inappropriate treatment of malignant lesions. Making the diagnosis of a benign skin lesion is often based on the history and then recognising the clinical appearance, but taking a biopsy is sometimes necessary in situations when uncertainty arises. It is also important to be aware that occasionally malignant lesions can appear within, or adjacent to, some benign lesions, and malignant lesions can mimic some benign lesions, i.e. keratoacanthomas. 2. Level 5: Expert Opinion Common Benign Skin Tumors Mark C. Luba, M.D. et al American Family Physician February 15, 2003 / Volume 67, Number 4 Benign skin tumors are commonly seen by family physicians. The ability to properly diagnose and treat common benign tumors and to distinguish them from malignant lesions is a vital skill for all family physicians. Any lesions for which the diagnosis is uncertain, based on the history and gross examination, should be biopsied for histopathologic examination to rule out malignancy. Lipomas are technically subcutaneous soft tissue tumors, not skin tumors, and controversy exists about whether keratoacanthomas have malignant potential; however, both are discussed in this article because they are common tumors evaluated by family physicians. Diagnosis usually is based on the appearance of the lesion and the patient s clinical history, although biopsy is sometimes required. Treatment includes excision, cryotherapy, curettage with or without electrodesiccation, and pharmacotherapy, and is based on the type of tumor and its location. Generally, excision is the treatment of choice for lipomas, dermatofibromas, keratoacanthomas, pyogenic granulomas, and epidermoid cysts. Cherry angiomas and sebaceous hyperplasia are often treated with laser therapy and electrodesiccation. Common treatments for acrochordons and seborrheic keratoses are cryotherapy and shave excision. Referral is indicated if the family physician is not confident with the diagnostic evaluation or treatment of a lesion, or if a biopsy reveals melanoma. (Am Fam Physician 2003;67: Copyright 2003 American Academy of Family Physicians.) 15

20 Lipoma Database NICE NHS Evidence and NICE CKS SIGN Cochrane York BMJ Clinical Evidence Result Referral to NHS choices, patient.co.uk and cancerhelp.uk BMJ Best Practice Information on diagnosis and management of Lipomas with references to cases, case series and unusual presentations. Lipoma Excision GOHAR A. SALAM, M.D. American Family Physician MARCH 1, 2002 / VOLUME 65, NUMBER (article on how to not cited below) General Search (Google) Various websites including NHS choices, Patient.co.uk, Cancer Research UK and clinic sites 3. Level 4/5: Patient.co.uk professional website article Tumours that have characteristics consistent with a malignant liposarcoma include those that are: [14] Greater than 5 cm in diameter Located in the extremities, retroperitoneally, in the groin, in the scrotum or in the abdominal wall [14] Deep (beneath or fixed to superficial fascia) Exhibiting malignant behaviour (rapid growth or invasion into nerve or bone) (14) Costea R, Vasiliu E, Zarnescu NO, et al; Large thigh liposarcoma--diagnostic and therapeutic features. J Med Life May 15;4(2): Epub 2011 May 25 Epidermoid / Sebacous Cyst Database NICE NHS Evidence and NICE CKS SIGN Cochrane York Result British Association of Dermatologists Information leaflet (13 April 2012): Epidermoid and Pilar Cysts Some case studies and series of unusual presentations and different 16

21 removal techniques (not cited below) BMJ Clinical Evidence BMJ Best Practice General Search (Google) Various websites including NHS choices, dermnet, patient.co.uk, and clinic sites (not cited below) 4. Level 5: Expert Opinion British Association of Dermatologists Information leaflet (13 April 2012): Epidermoid and Pilar Cysts In the past, pilar and epidermoid cysts were wrongly known as sebaceous cysts but this term should be used only for a quite different and much less common type of cyst that is filled with a clear oily liquid made by sebaceous (grease) glands. Epidermoid cysts affect young and middle aged adults. They can come up after a hair follicle has been inflamed, so they are common in acne. Pilar cysts affect women more often than men, and tend to come up in middle age. They run strongly in families. Both types grow slowly. Some become infected (red and sore) from time to time. They may then discharge cheesy foul-smelling pus. Those on the scalp can catch on the comb: others may look embarrassing. They can occur anywhere on the skin, but: Pilar cysts are most common on the scalp, where several can often be found. Epidermoid cysts are most common on the face, neck and upper trunk. Epidermoid and pilar cysts are harmless, and small ones that give no trouble can safely be left alone. Your doctor may give you an antibiotic if your cyst becomes infected. Both types of cyst are easy to remove under a local anaesthetic but this does leave a scar. Reasons for removal include the following: 1. If the cyst is embarrassing and easily seen by others. 2. If it interferes with everyday life, for example by catching on your comb. 3. If the cyst becomes infected. It is important that the doctor removes the whole of the lining during the operation as doing so cuts down the chance of the cyst growing back. 17

22 Skin Tags Database NICE NHS Evidence and NICE CKS SIGN Cochrane York BMJ Clinical Evidence BMJ Best Practice General Search (Google) Result Various websites including NHS choices, medscape, patient.co.uk, and clinic sites Basal Cell Papilloma / Seborrhoeic Keratosis / Keratotic Warts Database NICE NHS Evidence and NICE CKS SIGN Cochrane York BMJ Clinical Evidence BMJ Best Practice General Search (Google) Result Reviews for BCC found nil for BCP Info found on BCC found nil for BCP Various websites including NHS choices, medscape, Dermnet NZ, and clinic sites Neurofibromata Database NICE NHS Evidence and NICE CKS Result 18

23 SIGN Cochrane York BMJ Clinical Evidence BMJ Best Practice General Search (Google) Various medical notebook websites, patient information and clinic sites Warts and Verrucas Database NICE NHS Evidence and NICE CKS SIGN Cochrane York Result NICE CKS warts and verrucas Review of topical treatments (not cited) BMJ Clinical Evidence Clinical evidence summary warts non-genital June 2008 BMJ Best Practice General Search (Google) Information on specific treatments only Various websites including NHS choices, patient.co.uk, Dermnet NZ, and clinic sites 5. Level 4/5: NICE CKS NICE CKS: Warts and Verrucas In general, warts can be managed in primary care, however a number of specialized treatments are available in secondary care. Refer to a dermatologist if: The person has a facial wart and requests treatment. The diagnosis is uncertain. There are multiple recalcitrant warts and the person is immunocompromised. The person has areas of skin that are extensively affected, for example mosaic warts. The person is bothered by persistent warts which are unresponsive to both topical salicylic acid and cryotherapy. The person is bothered by persistent warts which are unresponsive to topical salicylic acid and cryotherapy is contraindicated. For those people with diabetes and a verruca refer to diabetic foot services for management. 19

24 Thread Veins and Telangectasia Database NICE NHS Evidence and NICE CKS SIGN Cochrane York BMJ Clinical Evidence BMJ Best Practice General Search (Google) Result Sclerotherapy for Lower Limb Telangiectasias Schwartz L, Maxwell H. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD DOI: / CD pub2 NHS choices and various clinic websites, Primary Care Dermatology society website general information (neither cited below) 6. Level 3: Prospective Cohort Study Sclerotherapy for Lower Limb Telangiectasias Schwartz L, Maxwell H. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD DOI: / CD pub2 Spider or thread veins (telangiectasias) are small superficial veins that widen and become visible, often on the legs. They are sometimes, but not always, associated with chronic venous disease affecting the deeper veins. Risk factors for developing spider veins include a family history, pregnancy, taking female hormones, topical steroid use, local trauma, and prolonged sitting or standing. Some people experience pain, cramps, burning, throbbing, itching or leg fatigue, and women in particular may be concerned about the cosmetic appearance. People are increasingly seeking treatment. Sclerotherapy has been used for centuries to treat spider veins. The technique involves the injection of a chemical into the veins. This is sometimes followed by compression with bandages or stockings. The liquid or foam sclerosing agent is injected into the vein to cause localised damage to the inner lining (endothelium) of the vein. This leads to inflammation, a blood clot, collapse and thickening or scarring of the vessel. The blood stops flowing and the vein loses its red or purple appearance. There is currently no agreement about which sclerosing agent is most effective with the fewest side effects and least discomfort to patients. We included 10 randomised controlled trials involving 484 people in our review. Sodium tetradecyl sulfate (STS), polidocanol (POL), and heparsal (20% saline mixed with heparin 100 units/ml) cleared the veins more effectively than an injection of normal saline. There was no evidence that one agent was better than any other sclerosant, that patients were more satisfied with one agent than another, and which dose of an agent was best. There was some evidence that POL was less painful than heparsal and STS, and that STS was more painful than heparsal. At higher doses, some of the agents appeared to cause more pain 20

25 and side effects such as mild brown discoloration, a flare or blush next to the injected vein, or itching; however, we do not have enough evidence to determine the optimal concentration to use. The trials were designed in very different ways and used various agents, which meant we were unable to combine the studies to help form firm conclusions. The amount of available evidence was limited and the overall methodological quality of the research was poor, as was the quality of reporting. Molluscum Contagiosum Database Result NICE Nil specific mention in TA 82 NHS Evidence and NICE CKS PH England website page British association for sexual health website page SIGN Cochrane York BMJ Clinical Evidence BMJ Best Practice General Search (Google) Interventions for Cutaneous Molluscum Contagiosum (Review) Van der Wouden JC et al 2009 (not cited below) Nil specific mention in a systematic review of eczema UK Guidelines on the Management of molluscum contageosum Patient.co.uk, NHS choices 7. Level 4/5: Expert Opinion UK Guidelines on the Management of Molluscum Contageosum General advice As the natural history is of spontaneous regression of lesions, treatment is offered for cosmetic reasons only. Further investigation As other STIs may co-exist, a full screen for these should be undertaken. HIV testing is recommended in patients presenting with facial lesions. Treatment The aim is tissue destruction with viral demise accompanying this. There are no medicines licensed for the treatment of MC in the UK. See guidelines for detail. 21

26 Actinic/Solar Keratosis Database NICE NHS Evidence and NICE CKS SIGN Cochrane York BMJ Clinical Evidence BMJ Best Practice Result IPG 155: Photodynamic therapy for non-melanoma skin tumours (including premalignant and primary non-metastatic skin lesions) Primary Care Dermatology society website general information European dermatology forum Guidelines on the management of actinic keratosis (not cited below available on request) General Search (Google) British Association of Dermatologists information leaflet Patient.co.uk and NHS choices as well as clinic websites 8. Level 4/5: Expert Opinion British Association of dermatologists Information Leaflet: Actinic Keratoses also known as Solar Keratoses It is advisable to protect the skin from further sun damage (for example, by wearing a hat, long sleeves and a sunscreen with a high sun protection factor). Occasionally, small actinic keratoses may go away spontaneously, but generally they are treated as there is a small risk that some might transform into a skin cancer. Treatments used for actinic keratoses include the following: Freezing with liquid nitrogen (Cryotherapy). This is an effective treatment which does not normally leave a scar, but it can be painful. (See Patient Information Leaflet on Cryotherapy). Surgical removal. This requires local injection into the affected skin with anaesthetic, after which the actinic keratosis can be scraped off with a sharp spoon-like instrument (a curette), or it can be cut out and the wound closed with stitches. Surgical removal leaves a scar but provides a specimen that can be analysed in the laboratory to confirm the diagnosis. Creams. Courses of creams containing drugs which may include 5-fluorouracil, imiquimod or Ingenol mebutate gel are useful treatments for actinic keratoses, especially if there are many of them. These preparations appear to selectively destroy the abnormal cells in sun-damaged skin. However, they often cause a lot of temporary inflammation of the treated areas. Diclofenac and retinoic acid are other drugs in cream or ointment form that are helpful when applied to milder actinic keratoses. Photodynamic therapy. A special light activates a cream which has been applied to the affected area of skin. This treatment is only available in certain hospitals. Laser treatment may be useful particularly for actinic keratosis on the lips. 22

27 Benign Pigmented Moles Database NICE NHS Evidence and NICE CKS SIGN Cochrane York BMJ Clinical Evidence BMJ Best Practice General Search (Google) Result NIL found NICE CKS melanoma and pigmented lesions Nil specific mentioned in SIGN 72 Cutaneous Melanoma General information on the management of naevi patient.co.uk 23

28 Greater Manchester Clinical Commissioning Groups Cost and Activity for Common Benign Skin Lesions

29 Introduction Clinical Commissioning Groups (CCGs) across Greater Manchester have inherited Effective Use of Resources (EUR) policies from their predecessor Primary Care Trusts (PCTs). Consequently, there are varying positions regarding the commissioning of certain procedures/treatments across Greater Manchester. Work is now being undertaken by the North West Commissioning Support Unit s (NWCSU) Policy Team, led by the Greater Manchester EUR Steering Group to align EUR policies across Greater Manchester. Purpose of the Report This report aims to inform the Greater Manchester Chief Finance Officers and Heads of Commissioning of the activity and spend on common benign skins lesions during financial years 2011/12, 2012/13, 2013/14 and 2014/15 (April to August) for each CCG. Body of the Report The tables attached at Appendix 1 provide details of each CCG s activity and costs on common benign skin lesions (Source Data: Inpatient Spell PbR). The following procedures were selected to inform the report: OPCS S061 Marsupialisation of lesion of skin of head or neck OPCS S062 Marsupialisation of lesion of skin NEC OPCS S063 Shave excision of lesion of skin of head or neck OPCS S064 Shave excision of lesion of skin NEC OPCS S065 Excision of lesion of skin of head or neck NEC OPCS S066 Re-excision of skin margins of head or neck OPCS S067 Re-excision of skin margins NEC OPCS S068 Other specified other excision of lesion of skin OPCS S069 Unspecified other excision of lesion of skin OPCS S081 Curettage and cauterisation of lesion of skin of head or neck OPCS S082 Curettage and cauterisation of lesion of skin NEC OPCS S083 Curettage of lesion of skin of head or neck NEC OPCS S088 Other specified curettage of lesion of skin OPCS S089 Unspecified curettage of lesion of skin OPCS S091 Laser destruction of lesion of skin of head or neck OPCS S092 Laser destruction of lesion of skin NEC OPCS S093 Photodestruction of lesion of skin of head or neck NEC OPCS S094 Infrared photocoagulation of lesion of skin of head or neck OPCS S095 Infrared photocoagulation of lesion of skin NEC OPCS S098 Other specified photodestruction of lesion of skin OPCS S099 Unspecified photodestruction of lesion of skin OPCS S101 Cauterisation of lesion of skin of head or neck NEC OPCS S102 Cryotherapy to lesion of skin of head or neck OPCS S103 Chemical peeling of lesion of skin of head or neck OPCS S104 Electrolysis to lesion of skin of head or neck OPCS S105 Electrodessication of lesion of skin of head or neck OPCS S108 Other specified other destruction of lesion of skin of head or neck OPCS S109 Unspecified other destruction of lesion of skin of head or neck OPCS S111 Cauterisation of lesion of skin NEC OPCS S112 Cryotherapy to lesion of skin NEC OPCS S113 Chemical peeling of lesion of skin NEC OPCS S114 Electrolysis to lesion of skin NEC OPCS S115 Electrodessication of lesion of skin NEC OPCS S118 Other specified other destruction of lesion of skin of other site

30 ICD D170 Benign lipomatous neoplasm of skin and subcutaneous tissue of head, face and neck ICD D171 Benign lipomatous neoplasm of skin and subcutaneous tissue of trunk ICD D172 Benign lipomatous neoplasm of skin and subcutaneous tissue of limbs ICD D173 Benign lipomatous neoplasm of skin and subcutaneous tissue of other and unspecified sites ICD D174 Benign lipomatous neoplasm of intrathoracic organs ICD D175 Benign lipomatous neoplasm of intra-abdominal organs ICD D176 Benign lipomatous neoplasm of spermatic cord ICD D177 Benign lipomatous neoplasm of other sites ICD D179 Benign lipomatous neoplasm, unspecified ICD D230 Benign neoplasm: Skin of lip ICD D232 Benign neoplasm: Skin of ear and external auricular canal ICD D233 Benign neoplasm: Skin of other and unspecified parts of face ICD D234 Benign neoplasm: Skin of scalp and neck ICD D235 Benign neoplasm: Skin of trunk ICD D236 Benign neoplasm: Skin of upper limb, including shoulder ICD D237 Benign neoplasm: Skin of lower limb, including hip ICD D239 Benign neoplasm: Skin, unspecified All Greater Manchester CCGs, excluding Salford, have criteria relating to the commissioning of common benign skin lesions which is not dissimilar from the Greater Manchester EUR policy, i.e. the removal of benign skin lesions is not commissioned for cosmetic reasons, although it may be commissioned if there are clinical reasons, such as pain, functional issues etc. Salford CCG currently has a policy not to commission the excision of benign skin lesions unless there are clinical exceptional circumstances; however, the activity (see Appendix 1) over the previous 3 financial years implies that this policy may not have been effectively applied as the CCG s activity is not significantly different to other Greater Manchester CCGs. It should also be noted that currently all dermatology services at Salford Royal Foundation Trust (Salford CCG s main provider) are commissioned by NHS England. The removal of benign skin lesions in primary care also fall under the commissioning responsibility of NHS England and this policy would not apply to primary care. It is not anticipated that the adoption of this policy will have a significant effect on Greater Manchester CCGs. The activity and costs provided in Appendix 1 may be used as a baseline to measure the impact of the Greater Manchester EUR policy. Conclusion The information contained in Appendix 1 has been produced in order to support the policy decision making process across Greater Manchester. The Greater Manchester Chief Finance Officers and Greater Manchester Heads of Commissioning are asked to review this report to assist in the consideration of the Greater Manchester EUR Policy for common benign skin lesions.

31 Appendix 1 Activity Report for Common Benign Skin Lesions OPCS Codes Used : S06.1, S06.2, S06.3, S06.4, S06.5, S06.6, S06.7, S06.8, S06.9, S08.1, S08.2, S08.3, S08.8, S08.9, S09.1, S09.2, S09.3, S09.4, S09.5, S09.8, S09.9, S10.1, S10.2, S10.3, S10.4, S11.2, S11.3, S11.4, S11.5, S11.8. ICD Diagnosis Used : D17.0, D17.1, D17.2, D17.3, D17.4, D17.5, D17.6, D17.7, D17.9, D23.0, D23.2, D23.3, D23.4, D23.5, D23.6, D23.7, D23.9. Source used : InpatientPbR Procedure Group Provider Group Primary Procedure (All) Financial Year Values 2011/ / / /2015 No of No of No of Commissioner Name No of Spells Cost in 's Spells Cost in 's Spells Cost in 's Spells Cost in 's Total No of Spells Total Cost in 's BOLTON 69 44, , , , ,061 BURY 58 42, , , , ,412 CENTRAL MANCHESTER 56 40, , , , ,770 HEYWOOD, MIDDLETON AND ROCHDALE 59 37, , , , ,702 NORTH MANCHESTER 69 49, , , , ,195 OLDHAM 67 47, , , , ,732 SALFORD , , , , ,487 STOCKPORT , , , , ,836 TAMESIDE AND GLOSSOP , , , , ,179 TRAFFORD , , , , ,505 WIGAN BOROUGH , , , , ,048 SOUTH MANCHESTER 47 33, , , , ,205 Grand Total 1, , , , ,797 3,238 2,054,132

32 Greater Manchester EUR Current Commissioning Title/Topic: Benign Skin Lesions Date: 18 December 2013 Reference: GM013

33 Introduction Clinical Commissioning Groups (CCGs) across Greater Manchester have inherited Effective Use of Resources (EUR) policies from their predecessor Primary Care Trusts (PCTs). Consequently, there are varying positions regarding the commissioning of certain procedures/treatments across Greater Manchester. Work is now being undertaken by the Greater Manchester Commissioning Support Unit s (GMCSU) Policy Team, led by the Greater Manchester EUR Steering Group to align EUR policies across Greater Manchester. Purpose of the Report This report aims to inform the Greater Manchester EUR Steering Group of each CCG s current commissioning arrangements in place for Benign Skin Lesions. Body of the Report The table below describes each CCG s current policy criteria on Benign Skin Lesions: Bolton Excision of benign skin lesions Removal of benign skin lesions will only be considered for: Suspicious or potentially malignant lesions Impairment of function or significant facial disfigurement, for example large lymphoma Treatment of multiple lipomatosis or neurofibromatosis. If a General Practitioner or Consultant is concerned that any skin lesion may be malignant, the patient should continue to be referred under the 2- week rule so that treatment can be carried out promptly. Excision of benign skin lesions is generally effective but they are considered to be procedures of low clinical priority and will only be carried out under exceptional circumstances. Fatty lumps (lipomata) Lipomata of any size will only be considered for treatment in the following circumstances: The lipoma(-ta) is (are) symptomatic There is functional impairment The lump(s) is (are) rapidly growing or abnormally located (e.g subfascial, sub-muscular) Other benign lesions Clinically benign lesions such as skin tags, corns, comedones (blackheads), milia, sebaceous cysts, molloscum contagium and seborrhoeic keratosis (non-viral warts ) will not be treated on purely cosmetic grounds. Viral warts Because most viral warts will clear spontaneously or following application of tropical treatments, wart removal is not commissioned by NHS Bolton. However, painful, persistent or extensive warts (particularly in the immunosupporessed patient) may need specialist assessment, usually by a dermatologist. For a small proportion of warts, surgical removal (cryotherapy, cautery, laser or excision) may be considered. Applications 2

34 for surgical treatment should be made to the Individual Case Panel. Vascular skin lesions NHS Bolton will not fund the removal of small benign, acquired vascular lesions such as thread veins and spider naevi. Laser removal of a birthmark (port wine stain) Bury NHS Bolton does not fund this procedure. NE Sector Policy Excision of all minor skin lesions includes benign pigmented moles, comedones, corn/callous, lipoma, milia, molluscum contagiosum, sebaceous cysts (epidermoid or pilar cysts), seborrhoeic keratoses (basal cell papillomata), skin tags including anal tags, keloid scars, spider naevus (telangiectasia), warts, xanthelasma and neurofibromata. Removal of lumps and bumps (in secondary care) Not commissioned unless there is clinical exceptionality. The following lesions should be managed within primary care unless there are clinical limitations such as size and location that warrant secondary care excision. Lesions should not be removed for cosmetic reasons. Epidermoid or sebaceous cysts including cysts on scalp. Lipomas (size and position dependant) Diagnostic excisions on lesions not felt to be malignant including punch or elipse biopsies if needed. Fibroepithelial polyps if causing irritation or discomfort but not for cosmetic reasons includes multiple skin tag pick and snip if tags causing problems Dermatofibromas or histiocytomas also not for cosmetic reasons Lesion curettage irritated basal cell papilomas, warty lesions for diagnosis or due to functional limitation or irritation. The excision of lesions for suspected cancer are excluded from the EUR Process. Heywood, Middleton and Rochdale No lesions suspected to be melanomas or SCC in primary care. BCCs can be done in primary care if in line with 2010 NICE criteria for low risk BCCs ie below clavicle, <1cm, not recurrent or persistent, not morphoeic or infiltrative and in area where primary closure is possible etc. Local Policy Excision of non-cancerous skin lesions in secondary care The removal of non-cancerous skin lesions are not commissioned for purely cosmetic reasons. 3

35 Non-cancerous skin lesion removal are not commissioned within Secondary Care unless there is clinical exceptionality Refer to NE Sector EUR Policy Non-cancerous skin lesions that may be painful or become infected, or are causing functional problems are not defined as cosmetic for these purposes. Skin lesions, including dermoid cysts and lipomas or other subcutaneous nodules up to 5 cm diameter should be undertaken within Primary Care Services. Removal of skin lesions within secondary care will only be considered if: The size or location of the lump makes it unsuitable for removal within extended primary care.. THE EXCISION OF LESIONS FOR SUSPECTED CANCER AND/OR WHERE THERE IS DIAGNOSTIC UNCERTAINTY ARE EXCLUDED FROM THE EUR PROCESS NE Sector Policy Excision of all minor skin lesions includes benign pigmented moles, comedones, corn/callous, lipoma, milia, molluscum contagiosum, sebaceous cysts (epidermoid or pilar cysts), seborrhoeic keratoses (basal cell papillomata), skin tags including anal tags, keloid scars, spider naevus (telangiectasia), warts, xanthelasma and neurofibromata. Removal of lumps and bumps (in secondary care) Not commissioned unless there is clinical exceptionality. The following lesions should be managed within primary care unless there are clinical limitations such as size and location that warrant secondary care excision. Lesions should not be removed for cosmetic reasons. Epidermoid or sebaceous cysts including cysts on scalp. Lipomas (size and position dependant) Diagnostic excisions on lesions not felt to be malignant including punch or elipse biopsies if needed. Fibroepithelial polyps if causing irritation or discomfort but not for cosmetic reasons includes multiple skin tag pick and snip if tags causing problems Dermatofibromas or histiocytomas also not for cosmetic reasons Lesion curettage irritated basal cell papilomas, warty lesions for diagnosis or due to functional limitation or irritation. The excision of lesions for suspected cancer are excluded from the EUR Process. No lesions suspected to be melanomas or SCC in primary care. 4

36 Manchester (Central, North and South) BCCs can be done in primary care if in line with 2010 NICE criteria for low risk BCCs ie below clavicle, <1cm, not recurrent or persistent, not morphoeic or infiltrative and in area where primary closure is possible etc. Dermatology Minor surgery (for cosmetic and benign skin lesions) (Please note these apply to both Secondary or Tier 2 services) Purely cosmetic procedures are not commissioned, generally in the NHS. Dermatology procedures that are purely cosmetic in nature are not commissioned in either primary or secondary care. Lipomas and sebaceous cysts that may be painful or become infected are not defined as cosmetic for these purposes. Removal of skin lesions within secondary care will only be considered if: Lesions are suspicious or potentially malignant There is impairment of function or significant facial disfigurement All referrals to secondary care will be reviewed by the dermatology extended care team before processing Cutaneous and plantar warts (Please note these apply to both Secondary or Tier 2 services) Warts normally resolve spontaneously although this may take up to 2 years. Treatment for warts should only be considered if warts: are symptomatic i.e. painful or itchy OR interfere with functioning OR have been present for more than two years OR have spread extensively. Treatment should initially be by duct tape occlusion; if this is unsuccessful then treatment with topical salicylic acid should be considered. Treatment with cryotherapy should only be considered if treatment with both duct tape occlusion and topical salicylic acid has not cleared the wart. Patients with these exceptional symptoms may need specialist assessment, usually by a dermatologist. Referral to the tier 2 dermatology service should only be considered if: there is genuine doubt about the diagnosis OR the wart is recalcitrant or rapidly growing OR malignancy is suspected (malignant changes in warts are extremely rare but should be excluded in older people or people with immunosuppression or subungual warts.). For a small proportion surgical removal (cryotherapy, cautery, laser or excision) may be appropriately performed within Primary Care. Removal of Haemorrhoid Skin Tags This procedure should not be performed. There may be consideration of 5

37 special circumstances e.g. recurrent bleeding. Minor Surgery Minor surgery (defined as removal of lumps and bumps and including surgery for ingrown toenails) is not routinely commissioned in a secondary care setting. Only patients that have been referred to secondary care via an ICATS are legitimate. Oldham Treatment of vascular lesions (including port wine stains) Not commissioned for small, benign, acquired vascular lesions such as thread veins and spider naevi. NE Sector Policy Excision of all minor skin lesions includes benign pigmented moles, comedones, corn/callous, lipoma, milia, molluscum contagiosum, sebaceous cysts (epidermoid or pilar cysts), seborrhoeic keratoses (basal cell papillomata), skin tags including anal tags, keloid scars, spider naevus (telangiectasia), warts, xanthelasma and neurofibromata. Removal of lumps and bumps (in secondary care) Not commissioned unless there is clinical exceptionality. The following lesions should be managed within primary care unless there are clinical limitations such as size and location that warrant secondary care excision. Lesions should not be removed for cosmetic reasons. Epidermoid or sebaceous cysts including cysts on scalp. Lipomas (size and position dependant) Diagnostic excisions on lesions not felt to be malignant including punch or elipse biopsies if needed. Fibroepithelial polyps if causing irritation or discomfort but not for cosmetic reasons includes multiple skin tag pick and snip if tags causing problems Dermatofibromas or histiocytomas also not for cosmetic reasons Lesion curettage irritated basal cell papilomas, warty lesions for diagnosis or due to functional limitation or irritation. The excision of lesions for suspected cancer are excluded from the EUR Process. Salford No lesions suspected to be melanomas or SCC in primary care. BCCs can be done in primary care if in line with 2010 NICE criteria for low risk BCCs ie below clavicle, <1cm, not recurrent or persistent, not morphoeic or infiltrative and in area where primary closure is possible etc. Excision of Benign skin lesions (excluding suspected cancer) This procedure is not commissioned, unless there is demonstrated evidence of clinical exceptionality. 6

38 Thread Veins This procedure is not commissioned, unless there is demonstrated evidence of clinical exceptionality. Stockport Viral Wart Surgery This procedure is not commissioned, unless there is demonstrated evidence of clinical exceptionality. Cutaneous and plantar warts Warts normally resolve spontaneously although this may take up to 2 years. Treatment for warts should only be considered if warts: are symptomatic i.e. painful or itchy; or interfere with functioning; or have been present for more than two years; or have spread extensively. Treatment should initially be by duct tape occlusion; if this is unsuccessful then treatment with topical salicylic acid should be considered. Treatment with cryotherapy should only be considered if treatment with both duct tape occlusion and topical salicylic acid has not cleared the wart. Referral to the tier 2 dermatology service should only be considered if: there is genuine doubt about the diagnosis; or the wart is recalcitrant or rapidly growing; or malignancy is suspected (malignant changes in warts are extremely rare but should be excluded in older people or people with immunosuppression or subungual warts.) Dermatology Minor surgery (for cosmetic and benign skin lesions) Dermatological procedures that are purely cosmetic in nature are considered low priority and hence not commissioned. Lipomas and sebaceous cysts that may be painful of become infected are not defined as cosmetic for these purposes. Removal of skin lesions within secondary care will only be considered if: lesions are suspicious or potentially malignant; or there is impairment of function or significant facial disfigurement. Lipoma over 15cm in size are at risk of being malignant and should be sent on a 2 week pathway proforma. Under no circumstances should a biopsy/excision of lipomas over 15cm in size be undertaken by anyone who is unable to perform / coordinate a compartmental resection if required. Tameside and Glossop Removal of Haemorrhoidal Skin Tags This procedure should not be performed. There may be consideration of special circumstances e.g. recurrent bleeding. Excision of benign skin lesions This policy is not intended to apply to cases where the diagnosis of a benign condition is uncertain, where the lesion causes significant pain or when the nature of the condition requires immediate treatment. The immediate treatment category can include benign lesions that are significantly traumatised and/or have become infected. The following procedures are generally performed for aesthetic reasons and not routinely funded by the PCT. If secondary referrals are made for these conditions for reasons stated above, they should be made to Dermatologists [and not general surgeons] who have the best expertise to assess suitability of minor surgery. Definition: skin tags; warts; corns; comedones (blackheads); milia (whitish spots which occur on the face); spider naevi (spider-like capillaries visible below the skin); sebaceous cysts (sac-like lesions filled with fatty substance); seborrhoeic keratoses (brown warts); molluscum contagiosum 7

39 (dome shaped, pearly lesions caused by a viral infection); xanthelasma (yellow plaques which occur on the eye-lids); lipomata (fatty lumps found below the skin); benign pigmented moles; male pattern baldness. Removing these skin lesions for cosmetic reasons is not commissioned. Prior approval for removing these skin lesions can be obtained from the PCT for certain defined situations. For a non-cancerous skin lesion surgical excision will only be funded if there is recorded evidence that one of the following criteria are met: it is an unidentified lesion requiring biopsy a lesion displaying unusual behaviour e.g. bleeding, change in colour it is basal cell carcinoma it is a lesion causing symptoms such as persistent itching, bleeding, recurrent inflammation and pain it is a lesion causing restrictions on movement or activity it is a moderate to large facial lesion which causes disfigurement Lesions on a site subjected to recurrent trauma Lesions obstructing an orifice or vision Trafford There are no restrictions on treatment of genital warts. [GMEUR 19] Dermatology Minor Surgery Dermatology procedures that are cosmetic in nature are not commissioned. Lipomas and sebaceous cysts that may be painful or become infected are not defined as cosmetic for these purposes. Please treat according to the Minor Surgery LES. Removal of skin lesions within secondary care will only be commissioned if: They are suspicious or potentially malignant; or There is impairment of function or significant facial disfigurement; or The affected area is on the face. Treatment of cutaneous and plantar warts Warts normally resolve spontaneously although this may take up to 2 years. Treatment for warts should only be considered if warts are symptomatic. i.e: Painful or itchy; or Interfere with functioning; or Have been present for more than two years; or Have spread extensively. Treatment should initially be by duct tape occlusion; if this is unsuccessful then treatment with topical salicylic acid should be considered. Treatment with cryotherapy should only be considered if treatment with both duct tape occlusion and topical salicylic acid has not cleared the wart. Referral to the secondary care should only be considered if: there is genuine doubt about the diagnosis; or the wart is recalcitrant or rapidly growing; or malignancy is suspected. 8

40 Patients with the above exceptional symptoms may need specialist assessment, usually by a dermatologist. For a small proportion surgical removal (cryotherapy, cautery, laser or excision) may be appropriately performed within Primary Care. Surgery for removal of haemorrhoid skin tags Surgical removal of haemorrhoid skin tags is not commissioned. Wigan Borough Treatment of cutaneous vascular lesions (including port wine stains) This service is not commissioned and will only be considered in exceptional clinical circumstances. Excision of benign skin lesions Removal of benign skin lesions will only be considered for: Suspicious or potentially malignant lesions Impairment of function or significant facial disfigurement, for example large lymphoma Treatment of multiple lipomatosis or neurofibromatosis. If a General Practitioner or Consultant is concerned that any skin lesion may be malignant, the patient should continue to be referred under the 2- week rule so that treatment can be carried out promptly. Excision of benign skin lesions is generally effective but they are considered to be of low priority and will only be carried out under exceptional circumstances. Therefore prior funding approval is required for such procedures. Fatty lumps (lipomata) Lipomata of any size should be considered for treatment by the NHS in the following circumstances: The lipoma (-ta) is / are symptomatic There is functional impairment The lump is rapidly growing or abnormally located (e.g. sub-fascial, submuscular) Excision of non-cancerous skin lesions for cosmetic reasons Non-cancerous skin lesions include: skin tags; warts; corns; comedones (blackheads); milia (whitish spots which occur on the face); spider naevi (spider-like capillaries visible below the skin); sebaceous cysts (sac-like lesions filled with fatty substance); seborrhoeic keratoses (brown warts); molluscum contagiosum (dome shaped, pearly lesions caused by a viral infection); xanthelasma (yellow plaques which occur on the eye-lids); lipomata (fatty lumps found below the skin) Removing these skin lesions for cosmetic reasons is not commissioned. Prior approval for removing these skin lesions can be obtained from the CCG for certain defined situations 9

41 For a non-cancerous skin lesion surgical excision will only be funded if there is recorded evidence that one of the following criteria are met: it is an unidentified lesion requiring biopsy a lesion displaying unusual behaviour e.g. bleeding, change in colour it is basal cell carcinoma it is a lesion causing symptoms such as persistent itching, bleeding, recurrent inflammation and pain it is a lesion causing restrictions on movement or activity it is a moderate to large facial lesion which causes disfigurement Lesions on a site subjected to recurrent trauma Lesions obstructing an orifice or vision Viral warts Most viral warts will clear spontaneously or following application of tropical treatments. Painful, persistent or extensive warts (particularly in the immunosupporessed patient) may need specialist assessment, usually by a dermatologist. For a small proportion surgical removal (cryotherapy, cautery, laser or excision) may be appropriate. Vascular skin lesions NHS treatment is allowed for all vascular skin lesions except for small benign, acquired vascular lesions such as thread veins and spider naevi. As detailed above, there are differing commissioning positions across the 12 Greater Manchester CCGs, however, all Greater Manchester CCGs do not commission the removal of benign skin lesions for aesthetic purposes. There are 3 CCGs who follow the same criteria (NE Sector Policy). There are a further 3 CCGs (Manchester Central, North and South) who follow the same criteria, which is different to the NE Sector. The remaining CCGs use their own criteria which varies from other CCGs. Conclusion The above information has been produced in order to support the policy decision making process across Greater Manchester. The Greater Manchester EUR Steering Group are asked to review the above information, along with the Policy Options and make a decision regarding the policy criteria which will be used across Greater Manchester. Author: Stephanie Joubert Date: 18/12/