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  1. DermatologyGP Education & Networking Event 24th September 2014 Dr James Halpern Consultant Dermatologist

  2. 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

  3. 2WW Referrals

  4. What should be sent as a 2WW referral? Melanoma & LentigoMaligna

  5. What should be sent as a 2WW referral? SCC & Keratoacanthoma

  6. What should be sent as a 2WW referral? Rare skin cancers* *Cutaneous sarcomas, DFSP, angiosarcoma, KS, Merckle Cell, Cutaneousmets of internal malignancy

  7. What should be sent as a 2WW referral? BCC

  8. What should be sent as a 2WW referral? Bowen’s & AK’s

  9. What should be sent as a 2WW referral? Cutaneous Lymphoma

  10. Improving 2WW Referrals • Avoid referring BCC’s • Mole checks, dysplastic naevi • Children • Multiple naevi • Inflammatory referrals

  11. Referrals to Secondary Care

  12. What not to refer • Cosmetic removal of benign skin lesions – moles, SK’s, cysts etc. • Laser hair removal • Treatment of acne scarring • MolluscumContagiosum • ‘Simple’, low grade or minor rashes

  13. 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

  14. 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

  15. 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

  16. What to Refer • Acne that: • Is scarring • Failed on standard therapies • Significant psychological impact • Hyperhidrosis that: • Has failed antiperspirants • Significant psychological impact

  17. 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

  18. 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

  19. 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 suberythrodermicrashes, 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!

  20. Example of a Good Referral • Concise • Relevant • Appropriate

  21. Allergy Testing

  22. When do you Allergy Test? • Type 1 (immediate reactions) • Suspected allergic contact dermatitis • Atopic eczema • Urticarias • Generalised itching • Unknown rashes

  23. 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

  24. 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’

  25. Urticaria and Allergy • 99% of urticaria is idiopathic in nature • There is no role for allergy testing in the investigation of urticarial rashes

  26. 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

  27. 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

  28. Dermoscopy

  29. What is Dermoscopy? • The use of a dermatoscope to diagnose skin lesions • A dermatoscope gives 10x magnification and polarised light

  30. 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 sebkeratosis and vascular lesions

  31. Diagnosing skin lesions 90% History 5% Examination 5% Dermoscopy

  32. Reticular Pattern • Most common pattern in melanocyticnaevi • Also seen in melanoma, lentigo simplex & dermatofibroma • Typical regular reticular network seen in a benign naevus

  33. Reticular Pattern • Atypical reticular network seen in a melanoma-in-situ • Note: • Asymmetry • Variable thickness of network • Variability of colour

  34. Globular Pattern • Numerous, variously sized, round/oval structures with brown/gray/black colour • Seen in benign naevi, atypical naevi, congenital naeviand seborrhoeic keratosis • Note variation in size and colour of globules in this atypical compound naevus

  35. Cobblestone Pattern • Similar to the globular pattern, numerous closely aggregated, larger, angular globules resembling a cobblestone • Often seen in papillomatousnaevi • Typical cobblestone pattern in this very benign looking compound naevus

  36. 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

  37. Homogenous Pattern • Homogenous pattern with reddish halo seen in a melanoma metastasis • Dark red/black homogenous seen in subcutaneous haemorrhage

  38. 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 spitznaevus

  39. Parallel Pattern • Seen with naevi on acral skin • Typical parallel pattern seen in a benign acralnaevus

  40. Parallel Pattern • Parallel-ridge pattern seen in acral melanoma in situ • Note the pigmentation crossing the ridges and variability within the pigmented ridges

  41. 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

  42. Lacunar pattern • Several to numerous smooth bordered, round red structures • Seen in haemangiomas and angiokeratomas • Typical haemangioma

  43. 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

  44. Questions?