Dermatology GP Education & Networking Event 24 th September 2014 Dr James Halpern Consultant...
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Transcript of Dermatology GP Education & Networking Event 24 th September 2014 Dr James Halpern Consultant...
Dermatology
GP Education & Networking Event
24th September 2014
Dr James HalpernConsultant 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
What should be sent as a 2WW referral?
Rare skin cancers*
*Cutaneous sarcomas, DFSP, angiosarcoma, KS, Merckle Cell, Cutaneous mets of internal malignancy
Improving 2WW Referrals
• Avoid referring BCC’s
• Mole checks, dysplastic naevi
• Children
• Multiple naevi
• Inflammatory referrals
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!
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
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
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:AsymmetryVariable thickness of
networkVariability 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
Homogenous pattern with reddish halo seen in a melanoma metastasis
Dark red/black homogenous seen in subcutaneous haemorrhage
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