Primary Care Dermatology Update

Transcription

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

2 Lesions seen in GPSI clinic Dr Lorraine Wooster

3 31 year old woman Firm feeling raised lesion on her forehead Present for 18 months, possibly longer

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26 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

27 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

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30 Treating Actinic Keratosis in Primary care Dr Liz Riches

31 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

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37 Red Flags Rapid growth Firm base/ nodule under scale Pain or tenderness Bleeding Immunosuppressed patient

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41 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

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43 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

44 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 days. Max treatment 4 weeks Stop and allow skin to heal review 4-6w

45 Resources JAPC guideline on managing AK contains patient leaflet Drug rep materials PCDS treatment pathway patient leaflets

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47 GPSI Dermatology Service Dr Lucy Scriven

48 Referrals from NDCCG into CRHFT has reduced from ~6300 per year to ~4000 per year ~50% of patients seen are discharged at their 1 st appointment 10 % of patients are referred on to the hospital at 1 st 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

49 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

50 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

51 PLCV 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 Seborrhoeic warts Molluscum contagiosum Telangiectasia Spider angiomas (spider veins) Skin tags and papillomas Acquired naevi (moles) Benign haemangiomas Xanthelasma Viral warts

52 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

53 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

54 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 1 st appointment but other procedures will not

55 Any Comments / Questions?

56 Inflammatory Skin Conditions; Diagnosis and Treatment- Top Tips from the GPwSI Team! Louise Moss GPwSI Dermatology Moss Valley Medical Practice, Eckington

57 Common pitfalls and Top tips. Generalised itchy rash DON T FORGET Secondary infection Tinea Incognito Scabies

58 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!

59 Scalp Trunk and axilla Face Arms Fingernails and hands Groin and genitals Legs and toewebs Natal cleft

60 Generalised Itchy Rash Differential diagnosis?

61 Eczema Acne Psoriasis Hand eczema Urticaria Nail dystrophy Bact folliculitis Scaly scalps Lichen Planus P. versicolor Neuro dermatitis Post inflamatory hyperpigment Urticaria pigmentosa Drug eruption DLE Tinea incognito Viral exanthem Actinic porokeratosis LS & A Perioral derm GA P. rosea Trauma Chr paronychia Subungual haematoma K. pilans Alopecia Lip licking chelitis Von Reckinghanseurs café au lait spots BXO Contact allergic derm GPwSI Referrals, 2009 :- Rashes: Frequency of condition % 15 80% 60% 10 Frequency Cumulative frequency % 40% 5 20% 0 0%

62 ECZEMA Treatment tips How to get your treatment to work

63 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

64 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!

65 TREAT INFECTION GIVE WRITTEN INSTRUCTIONS CONSIDER OCCLUSION Wet wraps / Comfifast suits Clothing Increases effect of steroid and emoillient

66 Discoid Eczema Dermovate Antibiotics Zeroderm Comfifast

67 Varicose Eczema Steroid Emoillent COMPRESSION!

68 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

69 THINK COMPRESSION! Single/Double layer tubigrip <10mmHg Liner stocking preferred Flight stockings Class 1 stockings Give Stocking applicators

70 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

71 Common pitfalls

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74 Tips on fungal infections Often asymmetric. Usually scaly (Epidermal). Look at the feet! Think Tinea Incognito (grows inexorably out Eczema comes & goes).

75 Scabies

76 Psoriasis

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79 Psoriasis v Eczema

80 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

81 Lichen Planus

82 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

83 FINALLY Remember all that itches is not dermatology! Anaemia low ferritin Hypothyroidism dry skin, hair loss Liver dysfunction Renal dysfuntion Diabetes Lymphomas

84 Thank you!