Dermatology
GP Education & Networking Event
24th September 2014
Dr James Halpern
Consultant Dermatologist
Requested Topics
• What should be sent as a 2WW referral?
• Which patients should be referred to secondary care
dermatology?
• Allergy testing
• How to use a Dermatoscope
2WW Referrals
What should be sent as a 2WW
referral?
Melanoma & Lentigo Maligna
What should be sent as a 2WW
referral?
SCC & Keratoacanthoma
What should be sent as a 2WW
referral?
Rare skin cancers*
*Cutaneous sarcomas, DFSP,
angiosarcoma, KS, Merckle Cell,
Cutaneous mets of internal
malignancy
What should be sent as a 2WW
referral?
BCC
What should be sent as a 2WW
referral?
Bowen’s & AK’s
What should be sent as a 2WW
referral?
Cutaneous Lymphoma
Improving 2WW Referrals
• Avoid referring BCC’s
• Mole checks, dysplastic naevi
• Children
• Multiple naevi
• Inflammatory referrals
Referrals to Secondary Care
What not to refer
• Cosmetic removal of benign skin
lesions – moles, SK’s, cysts etc.
• Laser hair removal
• Treatment of acne scarring
• Molluscum Contagiosum
• ‘Simple’, low grade or minor
rashes
What to refer
• All suspected skin cancers:
–
–
–
–
Melanoma, SCC, BCC, rare skin cancers
Cutaneous lymphomas
Cutaneous deposits of internal malignancy
Pre-malignant skin disease
• simple AK’s can be treated in primary care
– Paraneoplastic rashes
What to refer
• Surgical referrals:
– All skin cancers and pre-malignant disease requiring a
biopsy or excision
– Lesions that are to large to remove in primary care
– All inflammatory rashes which require a biopsy
– Paediatric biopsies
– Patients on Warfarin, with pacemakers or other CI’s
eg. Myasthenia Gravis
What to Refer
• Moderate or severe
inflammatory rashes that:
– require systemic therapy, patch
testing, phototherapy etc.
– Have not responded to topical
therapies
– Are having a significant impact of
patients quality of life
• All bullous disorders except
insect bites
What to Refer
• Acne that:
– Is scarring
– Failed on standard therapies
– Significant psychological impact
• Hyperhidrosis that:
– Has failed antiperspirants
– Significant psychological impact
What to Refer
• Rare skin disorders:
–
–
–
–
–
Genetic skin disease
Tropical skin disease
Photodermatoses
Psychiatric skin disease
HIV & immunosuppression related skin
disease
– Pregnancy related rashes
– Cutaneous manifestations of connective
tissue disease and vasculitis
– Genital skin disease
• Disorders of the hair and nails
Urgency of Referrals
• 2WW – Cancer only
• Routine / C&B – 12 Weeks:
• BCC
• Inflammatory referrals eg. eczema, psoriasis
• Very Urgent / Life Threatening referrals:
• We do not offer a same-day / urgent / On-call / Advice referral service
• If you have a life or limb threatening skin problem eg. TEN
– Within working hours call dermatology secretaries
– OOH send to A&E / MAU
– 24/7 on-call dermatologist at Birmingham Skin Centre (City Hospital)
• Please Note – A&E if only for those with life threatening skin
disease associated with systemic upset. A&E does not have access
to dermatologists and can not expedite dermatology appointments
Semi-Urgent referrals
•
The most challenging group of patients to know what to do with:
– Not sick enough to justify admission to hospital or same day referral
– Can not wait 12 weeks to be seen
•
From my perspective:
– Very difficult to ‘ring-fence’ slots for
– Great variability in number and quality of referrals
– Causes a lot of frustration for GPs and us!
•
Good examples: New diagnosis bullous pemphigoid, stable suberythrodermic rashes,
vasculitic rashes
•
Bad examples: Patients with stable skin disease who keep consulting yourself / A&E,
‘unknown’ rashes in systemically stable well patients
•
Send urgent fax and we will triage – we will try our best!
Example of a Good
Referral
• Concise
• Relevant
• Appropriate
Allergy Testing
When do you Allergy Test?
• Type 1 (immediate reactions)
• Suspected allergic contact dermatitis
•Atopic eczema
•Urticarias
•Generalised itching
•Unknown rashes
Atopic Eczema and Allergy
• 99% of atopic eczema in not
due to allergy
• Serum specific IgE’s (RAST) and
prick testing is of no use in
atopic eczema
• Dermatology does not offer
allergy testing for children with
eczema – Do NOT refer for this
Atopic Eczema and Food Allergy
• Very rare
• Presents at weaning
• ‘All over’ eczema, not confined to flexural areas
• Best test is an exclusion diet and food diary +/dietician input
• No role for allergy ‘testing’
Urticaria and Allergy
• 99% of urticaria is idiopathic
in nature
• There is no role for allergy
testing in the investigation of
urticarial rashes
Type 1 Allergic Reactions - Anaphylaxis
• Immediate (within 2 hours)
• Often due to food
• May be life threatening
• Investigated with Prick Testing
• NOT Dermatology
• Refer children to Dr Ferdinand &
adults to clinical immunology
Type IV – Allergic Contact Dermatitis
• Occurs 72 hours after
exposure of a substance on
the skin and presents as an
eczematous reaction
• Commonly Nickel, Hair Dye
(PPD) or Occupational
• Investigated by
Dermatology with patch
testing
Dermoscopy
What is Dermoscopy?
• The use of a
dermatoscope to
diagnose skin lesions
• A dermatoscope
gives 10x
magnification and
polarised light
What is Dermoscopy?
• Used to diagnose melanoma
• Can distinguish naevi from dysplastic
naevi and melanoma
• Used to diagnose benign skin lesions
• Can distinguish naevi from seb
keratosis and vascular lesions
Diagnosing skin lesions
90%
History
5%
Examination
5%
Dermoscopy
Reticular Pattern
• Most common pattern
in melanocytic naevi
• Also seen in melanoma,
lentigo simplex &
dermatofibroma
 Typical regular reticular
network seen in a
benign naevus
Reticular Pattern
 Atypical reticular
network seen in a
melanoma-in-situ
 Note:
 Asymmetry
 Variable thickness of
network
 Variability of colour
Globular Pattern
• Numerous, variously sized,
round/oval structures with
brown/gray/black colour
• Seen in benign naevi,
atypical naevi, congenital
naevi and seborrhoeic
keratosis
 Note variation in size and
colour of globules in this
atypical compound naevus
Cobblestone Pattern
• Similar to the globular
pattern, numerous closely
aggregated, larger, angular
globules resembling a
cobblestone
• Often seen in papillomatous
naevi
 Typical cobblestone pattern
in this very benign looking
compound naevus
Homogenous Pattern
• Diffuse
brown/gray/blue/black
colour with an absent
network
• Seen in blue naevi, benign
naevi, atypical naevi,
melanoma, haemangiomas,
tattoos and pigmented BCC
 A very typical pattern seen
in a benign blue naevus
Homogenous Pattern
 Dark red/black homogenous
seen in subcutaneous
haemorrhage
 Homogenous pattern with
reddish halo seen in a
melanoma metastasis
Starburst Pattern
• Pigmented streaks in a
radial pattern at the edge
of the lesion
• Classical of Spitz naevi,
occasionally melanomas
can present with this
pattern
 Starburst pattern seen in
a spitz naevus
Parallel Pattern
• Seen with naevi on acral
skin
 Typical parallel pattern
seen in a benign acral
naevus
Parallel Pattern
 Parallel-ridge pattern
seen in acral melanoma
in situ
 Note the pigmentation
crossing the ridges and
variability within the
pigmented ridges
Multicomponent Pattern
• Combination of 3 or more
other patterns previously
described
• Suggestive of melanoma but
also seen in benign naevi,
BCC and non-melanocytic
lesions
 Highly atypical network with
multiple colours, asymmetry,
central white halo and
multiple network types seen
in a melanoma
Lacunar pattern
• Several to numerous
smooth bordered,
round red structures
• Seen in
haemangiomas and
angiokeratomas
 Typical haemangioma
Should you buy a dermatoscope?
• Useful in diagnosing benign skin lesions
• May reduce unnecessary referrals to
secondary care
• Good ones cost ~£1000
• Difficult learning curve and easy to
become deskilled
• Overconfidence/reliance can be
dangerous
Questions?