Service Specification: CPO Skin Lesions This pathway description needs to be read in conjunction with the CPO Admin Service Specifications. 1. Outcomes Framework The outcomes sought from this service are a range of patient treatment and diagnosis services provided in a primary care setting. 2. Purpose & Scope Enable medium complexity skin lesion excisions for eligible people domiciled in Hawke s Bay to be delivered in the community by credentialed General Practitioners (GP) free of charge to service users. 3. Service Objectives 3.1 General The objective of this service is to: Undertake surgery to remove medium complexity skin lesions under local anaesthetic in a timely manner Refer patients with lesions needing more complex surgery to secondary or tertiary services (as per appendix two Skin Lesion Management Guidelines) To ensure funding is appropriately allocated to provide the most efficient service provision. 3.2. Maori Health The service will recognise the particular needs of Maori and the commitment to partnership as embodied in the Treaty of Waitangi. It is acknowledged that Maori presentation to emergency services and other health services may be delayed as a result of cultural and socio-economic factors. To this end, the Service Providers are expected to provide services that: Are accessible and culturally acceptable to Māori; Recognise the needs of both the individual and the whanau; Decrease the costs of accessing acute primary health care services. 4. Service User This service will be available to all Hawke s Bay domiciled people. 5. Access Access for service users is by referral in accordance with the Skin Lesion Management Guidelines from the patient s GP. The service user will exit the service within 14 days of the identified skin lesion(s) being excised, this includes removal of sutures and discussion of pathology results by the accredited GP. Service Specification Health Hawke s Bay CPO Accredited GP Skin Lesion Service Page 1 of 8
6. Service components Service users will pay for the initial appointment with their GP, but once referred will not have to pay again for the removal of the lesion or follow up for removal of sutures and discussion of pathology. There will be no claw-back charged by the patients GP when the patient sees an accredited GP. The triage of referrals to the service is to be carried out by the appointed senior clinician on the basis of completed detailed referrals as per the Skin Lesions Management Guidelines combined with a good quality clinical photograph and/or punch biopsy results. Punch biopsies will only be performed when necessary as it is clinically more appropriate to excise the lesion directly to confirm already suspected Histology. All referrals will be made on the Skin Lesion Referral Form and it is vital that referrals should continue all relevant additional medical information eg the presence of metal heart valves or recent orthopaedic prosthesis surgery and it should be the responsibility of the referring GP as to whether it is safe to stop anticoagulation/aspirin/dabigatran prior to excision based on the referring GP s extensive knowledge of their patient. The need for antibiotic prophylaxis is to be clearly stated where relevant This service will follow the Skin Lesion Management Guidelines which provides the following: Prioritisation of referrals Skin Lesion Excisions Removal of sutures Discussion of pathology 6.1 Settings The service will be preferably provided within a Cornerstone accredited clinic 6.2 Equipment Consumables, infrastructure and equipment to deliver this service are supplied by the accredited GP. 6.3 Clinical Supervisor Oversight is provided by the CPO Medical Advisor. 7. Service linkages This service will be co-ordinated to ensure appropriateness, effectiveness, accessibility and availability which will require engagement with (but not limited to) the following: Secondary Services General Practitioners 8. Exclusions This service is not for the removal of skin lesions for cosmetic purposes. 9. Quality requirements The skin lesion removal component of the service will be undertaken by accredited GP s who have the met the competency requirements as determined by the CPO Medical Advisor. Service Specification Health Hawke s Bay CPO Accredited GP Skin Lesion Service Page 2 of 8
10. Purchase Units The following purchase units apply to this service. Purchase units are defined in the Ministry of Health Data Dictionary. PU Code MS02016 PU Description CPO Skin Lesions 11. Reporting requirements You are required to provide a quarterly report in the format specified below Reporting Requirements Number of Skin Lesion Removal Procedures Number of Additional Lesions Removed Quarterly Narrative Reporting (to include but not limited to): Issues outside of business as usual To ensure consistency in reporting: Data Number of Skin Lesion Procedures Number of Additional Lesions Removed Definition Count of all procedures undertaken during the quarter Count of 2 nd (or more) lesions removed during procedures 12. Audit requirements Audit requirements to be advised by the Skin Lesion Steering Group 13. Recording of Information in Hospital Systems Individual patient information will be recorded in the HB hospital systems retrospectively Service Specification Health Hawke s Bay CPO Accredited GP Skin Lesion Service Page 3 of 8
APPENDIX 1 Referral Form for Skin Lesion Removal by Accredited GP Fax this form to: (1) Accredited GP (Name ) (2) Name, Health Hawke s Bay (fax no.) Patient s Details: Surname... First name:... NHI No: Date of Birth.. Address... Contact Tel: Mobile No... Referring GP s Details (please print or stamp): Name:.. Surgery address.. Referral date: Surgery fax:. Clinical Details (please tick boxes below): Provisional diagnosis. Duration of lesion:... Location of lesion (mark on diagram and tick one or more): Head/neck Chest/trunk Back Arm Leg Characteristics: Indicate site: Back Front Growing in size Size (in mm) Changing shape Irregular outline Changing colour Irregular colour Inflammatory response Oozing/crusting Itch Other Risk Factors: Family history Previous melanoma/skin cancer Solar keratoses Multiple naevi Excessive UV exposure Previous treatment: Cryotherapy Fluouracil Currettage Biopsy information.. (Please attach report if applicable) Medications or treatment that might complicate surgery for this lesion: Aspirin Warfarin Clopidogrel Dipyridamole Comments:..... Service Specification Health Hawke s Bay CPO Accredited GP Skin Lesion Service Page 4 of 8
APPENDIX 2 SKIN LESIONS MANAGEMENT GUIDELINE Definition: Skin lesions, in this document refer to skin cancers pigmented lesions, non-healing ulcers and other individual skin lesions. Lesions on the head and neck are referred to ENT, lesions on the eyelid to Ophthalmology and other lesions requiring surgery to general surgery department. - Removal of lesions on the eyelids, nose, lips and ears are often beyond the skill of the average GP. - All excisions, however benign on clinical examination, should be sent for histopathological assessment. Clinical Problem Actions Implementation Pigmented Lesions Clinically certain of melanoma Clinically suspicious of malignancy Excision, full thickness, margins> 10mm Excision biopsy (not incision), full thickness, margins> 2mm Refer to Specialist Clinically not malignant Monitor in 1 care GP follow up Seborrhoeic keratosis Non-Pigmented Lesions Lesion < 5mm > 5mm and clinically typical of Squamous Cell Carcinoma (SCC) or Basal Cell Carcinoma (BCC) or keratoacanthoma Clinically suspicious of malignancy or Bowen s disease Solar keratosis Histology Known Melanoma Squamous cell Carcinoma excised with margin > 2mm Squamous cell carcinoma excised incompletely or with margin < 2mm Squamous cell carcinoma with regional nodes Cryotherapy (or excision) only if symptomatic Excision biopsy or destruction Excision, full thickness, margins> 2mm with careful follow up to confirm recurrence does not occur Punch biopsy Monitor for development of SCC OR cryotherapy OR 5- FU if very many Discuss with or refer to Specialist Monitor in 1 care Complete adequate excision Specialist assistance Discuss with or refer to Specialist. Excise in 1 care if safe. Margin of 3mm recommended Rarely justifies public specialist assistance Excise in 1 care if safe. Excise in 1 care if safe. Biopsy in 1 care if safe. GP follow up. Remove in 1 care. Punch biopsy. 5-FU requires specialist recommendation Review at 3 and 6 months then annually Excise in 1 care if safe. Refer to Specialist Service Specification Health Hawke s Bay CPO Accredited GP Skin Lesion Service Page 5 of 8
Bowen s Disease Basal Cell Carcinoma completely excised Basal Cell Carcinoma incompletely excised Miscellaneous Non-healing ulcers Chrondodermatitis nodularis helicis ears Pyogenic granuloma Epidermoid cysts, Sebaceous cysts, and Pilar tricholemmal) cysts Dermatofibroma Milia Complete excision or destruction (cautery, cryotherapy) OR 5-FU Monitor in 1 care Complete excision OR destruction (curettage and cautery) If small, excision biopsy. If large, full thickness biopsy of the margin Treat conservatively if small OR Specialist assistance for excision Excision or biopsy then cautery with care to destroy the feeding blood vessel Treat conservatively if asymptomatic OR excise completely Treat conservatively Treat conservatively OR (rarely) incise and express intact Removal in 1 care if safe.. 5-FU requires specialist recommendation Look for other skin cancers Removal in 1 care if safe. Biopsy in 1 care if safe. These are benign lesions that may be mistaken for solar keratosis. They often respond well to excision of the underlying cartilage Excise or cautery in 1 care if safe. Specialist assistance if Rarely justifies public specialist assistance Rarely justifies public specialist assistance Rarely justifies public specialist assistance The use of biopsy for lesions suspicious but not clinically diagnostic of BCC, collar keratosis or SCC is recommended. In this way those with benign lesions can be either managed within general practice, referred to a private facility or receive appropriate non-urgent prioritisation for DPH consultation. Those with solar keratosis can be promptly managed and the remainder treated either within general practice or at Hospital. Malignant melanoma. Most develop de novo, 25% arise in an existing mole. Have a high index of suspicion for any mole that has changed or any new pigmented lesion (that is not clinically a seborrheic keratosis). Clinically suspicious features of malignancy in a pigmented lesion. Include: - Asymmetry - Border irregularity or smudging of pigment over the border - Colour variegation several different colours or increase depth of pigment within the lesion - Diameter any pigmented lesion with size > 1cm or any mole that is growing - Increasing size - Any bleeding or crusting (if not clinically a seborrhoeic keratosis) Seborrheic keratosis. Otherwise known as senile wart occurs anywhere on the body in people aged over 40 years. It starts as a pale yellow or brownish macule with a slightly greasy Service Specification Health Hawke s Bay CPO Accredited GP Skin Lesion Service Page 6 of 8
feel. With time it often becomes dark or even black, with a warty, sometimes dimpled surface (like a cauliflower). It appears to be stuck on the skin rather than arising in it. Occasionally they can be pedunculated. They never become malignant so they are removed only for cosmetic reasons or because they catch on clothing. Squamous Cell Carcinoma (SCC). Early changes can show a flat scaly erythematous macule. This usually demonstrates reasonably rapid growth resulting in a nodule that may bleed earlier than a BCC. Often tender this nodule usually has an eroded or heaped up cauliflower appearance. It can present as an ulcer with everted edges. Generally SCCs arise in sun exposed sites, common on the lip and back of the hand. SCC metastasize in 2-3% of patients, and this is more likely if on the lips or ears. Solar Keratosis. Solar, actinic or senile keratoses arise on skin exposed to sunshine. The lesions are superficial scaly roughenings of the skin, often more easily felt than seen. They are found mainly on the face, bald scalp and the back of the hands and wrists. A small percentage may progress to SCC. Basal Cell Carcinoma (BCC). Early: small smooth papule, which over months enlarges to a rounded lesion with pearly nodules in a rolled edge over which dilated blood vessels course. The pearly edge is best seen when the skin is stretched. Sometimes there will be an ulcer and the central scab/crust will need to be removed to reveal the characteristic pearly edge. Rarely tender. Generally slow growing and develop over months to years. BCC can be locally invasive but rarely metastasize. Kerato-acanthoma. This lesion is on the borderline between hyperplasia and neoplasia. Considered to be a self limiting form of SCC. Generally it shows rapid enlargement for about 2 months, often reaching 1-2 cm in diameter. It remains static for a further 2 months, then over a similar period involutes often leaving a somewhat unsightly pitted scar. At its maximum it is a dome-shaped yellowish nodule with a rounded edge across which blood vessels course and a central keratinous plug, which can look, like a crater. If this plug is removed it reveals more keratin; this helps to distinguish it from a BCC. The speed of growth is much more rapid than that of a SCC. Clinical features of malignancy in non-pigmented lesions. Are any new lesion or a lesion increasing in size; a heaped up or rolled edge; a pearly appearance when stretched; dilated blood vessels on the surface of a nodule; ulceration in an existing lesion or chronic non-healing ulcer with everted edges. SCC generally are more rapidly growing than BCC. Ulceration or bleeding may occur early in SCCs. SCC are often tender. BCC are rarely tender. Bowen s Disease. This is intra-epidermal carcinoma in-situ (SCC in-situ). Usually presents in those aged over 50 years, more commonly in women. It can occur anywhere on the body (not just on sun exposed skin). It is often itchy or erythematous plaques and may resemble solar/actinic keratosis or a patch of psoriasis or eczema that has been present for many years and may steadily enlarge. The edge is well defined and usually irregular. Chondro-dermatitis Nodularis Helicis. Also known as Winkler s Disease, this is an inflammatory condition caused by degeneration of cartilage. It characteristically presents as an exquisitely tender nodule on the top of the pinna. It can often be painful to lie on and unless the patient can find another comfortable sleeping position may need excision. Can be confused with a SCC. While it can be treated conservatively by cortisone injection this generally only provides short-term relief. Pyogenic Granuloma. This is a misnomer as it is in fact a capillary haemangioma which grows rapidly, distends and then usually ruptures the overlying skin. This leaves a naked mass of delicate blood vessels, which bleed copiously with minimal trauma. Epidermoid Cysts. Commonly known as sebaceous cyst and occurring anywhere on the body, it is a firm, slightly soft welling with a central punctum. The cheesy material it contains is keratin not sebum. Similar to this, usually found on the scalp, is a pilar (or tricholemmal) cyst which arises from the hair follicle but is without the central punctum. Dermatofibroma. Is most common on exposed parts of the limb in women but can occur anywhere on the body and in men. It is a fibrous nodule that looks and feels like a lentil in the Service Specification Health Hawke s Bay CPO Accredited GP Skin Lesion Service Page 7 of 8
skin. It can often be larger than 5mm. Milia. These are pinhead sized glistening white epidermoid cysts most commonly seen on the upper cheeks and around the eyes in young adults, especially females. They are best treated by using a sterile hypodermic needle to incise the overlying skin, and can usually be expressed intact. References: Parkin DM, Whelan SL, Ferlay J, Raymond L and Young J, eds (1997). Cancer Incidence in Five Continents. Vol VII (IARC Publications No 143), Lyon, IARC Friedman RJ, Rigel DS, Kopf AW, et al. Cancer of the Skin. Philadelphia: Saunders, 1991 Specialist assistance in this document includes Public hospital skin lesion service (which may include accredited GPs) and Plastic/General surgical service. Dermatology service may offer surgery and Ophthalmology service may offer Oculo-plastic surgery. Radiotherapy may be used to treat SCC. In Dunedin the ENT Department provides a service for malignant lesions affecting the face, head and neck. Service Specification Health Hawke s Bay CPO Accredited GP Skin Lesion Service Page 8 of 8