Bromley dermatology guidelines final edition february 201
BromleyClinical
Commissioning
February 2011
Bromley PBC Dermatology Introduction Welcome to the Bromley PBC Dermatology Project. We would like to intro-duce you to some easy to follow, evidence based and locally referenced care pathways that have been designed to help GPs deliver a first class ser-vice to their patients. These guidelines follow on from the development of similar locally produced guidance for Gynaecology, ENT and Musculoskeletal Services and as such follow a similar format. Dermatology was chosen as the attendance rates in Bromley from GP referrals to dermatology outpatient services are well above the national average and there is a wide range between practices. Conse-quently, a recent peer review pilot (January to June 2010) was completed which confirmed that peer review and discussion of differential diagnoses could lead to a reduction in inappropriate referrals and improve our confi-dence levels and diagnostic skills with regards to skin conditions. To make the most of these guidelines, please spend a few minutes looking through them to see what there is and how they work. Pages 4 & 5 summa-rise the key points in a dermatology history, include some useful dermatol-ogy terminology and a guide for 2 week wait referrals. Thereafter there is a common format of one page algorithm and one page notes. All the algo-rithms read from top to bottom (with the exception of leg ulcer management) with as few boxes as possible. You will also find key messages and re-sources, these will help you find the guidance on which these pathways are based, patient information and images to help you. Please remember that these are only guidelines which have been developed for use by GPs with the necessary knowledge to interpret them and, unless otherwise indicated, are to assist you in the management of adult patients. They may be controversial in places and, whilst we hope accurate at the time of going to print, recognise that service guidelines may change. Your clinical instinct must always come first. Please also note that practices with Scriptswitch will need to consider alternative products recommended at the point of prescribing e.g. emollients and antihistamines. If you have any cor-rections, questions or ideas for improvement please let us know by emailing [email protected] Thank you Drs Andrew Parson, Jon Doyle, Jackie Tavabie, Stephanie Munn, Sandy Flann, Chandima Sriwardhana, Geoffrey Barker, Abigail Barry & Janet Edmonds Dermatology history and terminology 2 and 4 week wait criteria/Urgent Assessment of a pigmented lesion Malignant melanoma Squamous cell carcinoma Basal cell carcinoma NICE Skin Tumours (IOG): Update May 2010 Actinic/Solar keratoses Efudix patient information Urticaria/angioedema Tinea/fungal infections Benign skin conditions Exceptional treatments Useful management tips Patient information Dermatology history and terminology History
Sun exposure: episodes of blistering sunburn, sunbed use
Do you burn, burn then tan or just tan? Sun protection used (health promotion) Immunosuppression Personal Hx skin Ca Family Hx skin Ca Change in size, shape, colour, sensation (See 7 point checklist) Treatments (OTC, prescribed, complementary therapies) Distal portions of limbs (hand, foot) and head (ears, nose) Dermatomal Corresponding with nerve root distribution
Extensor vs Flexural (also known as intertriginous)
Follicular Individual lesions arise from hair follicles
Generalised, Symmetrical, Unilateral
Herpetiform Grouped umbilicated vesicles, as arise in Herpes simplex/zoster.
Koebnerised Arising in a wound or scar
Photosensitive Does not affect skin that is always covered by clothing.
Seborrhoeic Areas generally affected by seborrhoeic dermatitis: scalp, behind
ears, eyebrows, nasolabial folds, sternum and interscapular Truncal Favours trunk and rarely affects limbs
Morphology
Macule Smooth area of colour change less than 1.5cm diameter
Papule Small palpable lesion less than 0.5cm diameter
Nodule Larger solid papule greater than 0.5cm diameter
Plaque Palpable flat lesion greater than 0.5cm diameter
Vesicle Small fluid filled blister, less than 0.5cm diameter
Pustule Purulent vesicle
Bulla Large fluid-filled blister
Weal Oedematous papule/plaque caused by swelling in dermis, often indicates
2 and 4 Week Wait Criteria & Urgent 2 week Outpatient Appointment
Refer as 2 week wait (fax proforma) for: Lesion strongly suspicious of malignant melanoma Lesion strongly suspicious of SCC Urgent Outpatient Appointment
Fax referral form or Choose & Book for: Widespread blistering disorder Severe cases of inflammatory skin disease e.g. Psoriasis involv- ing widespread areas of body with systemic upset 4 week Outpatient Appointment
Letter to pigmented lesion clinic/Choose & book for: Changing atypical mole, not high suspicion of melanoma Severe inflammatory disease Routine (6-8 week) Outpatient Appointment
Letter to general dermatology clinic/Choose & book for: All other dermatological conditions including mole checks and BCC not involving face Nb: there is a separate paediatric dermatology clinic Assessment of a pigmented lesion Glasgow 7 point weighted checklist
Major features of lesions (2 points
Irregular colour Minor features of lesions (1 point
each):
Largest diameter 7mm or more Change in sensation Lesions scoring 3 points or more are suspicious
If you strongly suspect cancer any one feature is adequate to prompt
urgent referral
For low suspicion lesions, undertake careful monitoring for change
using the 7 point checklist for 8 weeks. NICE recommends photo-
graphing with marker scale/ruler and date (patient may take own
photo)
The ABCDE system is a useful method of explaining to patients what to look out for:
Asymmetry shape of a melanoma is often uneven and asymmetrical;
Border or edges of a melanoma are often ragged, notched or blurred;
Colour of a melanoma is often not uniform. There may be 2-3 shades of brown or
black;
Diameter of a melanoma is usually larger than 6 mm and it continues to grow. How-
ever, they can sometimes be smaller than this;
Evolving any change in size, shape, colour, elevation or any new symptom such as
bleeding, itching or crusting may be due to a melanoma.
NB: Both the 7 point checklist and ABCDE criteria are useful, but it is vital to take
account of the dermatology history (e.g. history of trauma to lesion).
Skin cancer: Malignant melanoma Key messages • Refer lesions strongly suspicious of MM under 2 week wait as per Glasgow 7 point list or ABCDE The major risk factor is sun exposure (including sun-beds), particularly in the first 20 years of life. Other risk factors include: ∗ Fair skin that burns easily (Type I or II skin) ∗ Blistering sunburn, especially when young ∗ Previous melanoma ∗ Previous non-melanoma skin cancer ∗ Family history of melanoma ∗ Large numbers of moles (especially if there are more than 100) ∗ Abnormal moles (atypical or dysplastic naevi) ∗ Immunosupression Biopsy of suspected MM should NOT be performed in primary care
Melanoma is caused by the uncontrolled growth of melanocytes. It occurs in adults of any age but is very rare in children. Melanomas can arise from otherwise normal appearing skin (50% of melanomas) or from within a mole. Precursor lesions include: Congenital melanocytic naevi , atypical/dysplastic naevi and benign melanocytic naevi. Melanomas can occur anywhere on the body, the commonest site in men is the back (around 40%), and the most common site in women is the leg (also around 40%). Although melanoma usually starts as a skin lesion, it can also grow on mucous membranes such as the lips or genitals. Resources On-line pictures for GPs: http://www.dermnetnz.org/lesions/melanoma.html Patient leaflets http://www.patient.co.uk/health/Cancer-of-the-Skin-Melanoma.htm http://www.bad.org.uk/site/842/Default.aspx Skin cancer: Squamous cell carcinoma Key messages Refer lesions strongly suspicious of SCC under 2 week wait: Non-healing keratinising or crusted tumour larger than 1cm with signifi- cant induration on palpation. Commonly found on face, scalp or back of hand (sun exposed sites). Expansion over 8 weeks. Those who have had an organ transplant and develop new/growing cuta- neous lesions (SCC is common with immunosuppression but may be atypical and aggressive). Biopsy of suspected SCC should NOT be performed in primary care.
SCC is a malignant tumour of the keratinising cells of the epidermis. Locally invasive and has potential to metastasise. Invasive SCCs are usually slow growing, tender, scaly or crusted lumps. High risk areas are lower lip (smoking is a risk factor), pinna, periauricular forehead and scalp. May develop in areas of chronic inflammation e.g. leg ulcers (Marjolin's Resources On-line pictures for GPs: http://dermnetnz.org/lesions/squamous-cell-carcinoma.html Patient leaflets http://www.patient.co.uk/doctor/Squamous-Cell-Carcinoma-of-Skin.htm http://www.bad.org.uk/site/876/Default.aspx Skin cancer: Basal cell carcinoma Key messages Refer lesions suspicious of BCC routinely. See updated NICE guidance for management of low risk BCCs in primary care. http://www.nice.org.uk/nicemedia/live/10901/48878/48878.pdf Early lesions are often small, translucent or pearly and have raised areas with telangiectasia. The classic rodent ulcer has an indurated edge and ulcerated centre. It is slow growing but can spread deeply to cause con- siderable destruction. BCCs are slow growing, locally invasive malignant epidermal skin tu- mours, thought to arise from hair follicles. The commonest skin cancer in Sun-exposed areas of the head and neck (80%) are the most commonly involved sites, with the rest mainly on the trunk and lower limbs Multiple BCCs are a feature of basal cell naevus (Gorlin's) syndrome Surgical excision is the preferred treatment but the choice of treatment depends on the site and size of the BCC, the condition of the surrounding skin and number of BCCs to be treated. Other treatments include: Curettage and cautery Topical fluorouracil 5% cream (Efudix) is useful in the management of
multiple superficial BCCs on the trunk and limbs. The lesions must be
proven by biopsy OR if treated empirically they must be closely followed-
up and referred if not improved by treatment
Resources On-line pictures for GPs: http://www.dermnetnz.org/lesions/basal-cell-carcinoma.html Patient leaflets http://www.patient.co.uk/doctor/Basal-Cell-Carcinoma-(Rodent-Ulcer)http://www.bad.org.uk/site/800/Default.aspx NICE Skin Tumours (IOG) Improving Outcomes Guidance: Updated May 2010 Key messages Pre-cancerous lesions (e.g. Bowen's, AKs) can be treated by GP or re- Low risk BCCs may be managed in the community by: GPs performing skin surgery within LES/DES framework; GPwSI (None currently in Bromley, although this may change); Model 2 practitioners (Outreach community skin cancer services). Lesions suspicious of SCC/MM should be referred to dermatology.
Low risk BCCs are:
No diagnostic uncertainty Not overlying important anatomical structures (e.g. major vessels) Patient >24 years, is not immunosuppressed, does not have Gorlin's GP with DES/LES: Low risk BCC Model 1 care: Low risk BCC Model 2 care: Provides surgery only (GP or Nurse with appropriate skills) Model 3 care: Dermatology consultant in community Model 2 and 3 care is not yet available in Bromley, although this may Resources http://www.nice.org.uk/nicemedia/live/10901/48878/48878.pdf Actinic/Solar Keratoses & Bowen's Initial assessment Treatment:
Advise all patients on use of sun protection and emollients. Diclofenac sodium (Solaraze) apply BD for 60-90 days. Topical Fluorouracil 5% (Efudix) cream apply OD for 6 weeks OR BD for 4 weeks. Review after treatment to ensure healing has Cryotherapy, freeze for 10-15 Diagnostic uncertainty Suspicion of malignancy Failure of response to one cycle of treatment (requires biopsy) Refer dermatology Actinic/Solar Keratoses Key messages Actinic keratoses are usually multiple, flat, pale or reddish-brown lesions with a dry adherent scale. They are a reflection of abnormal skin cell development due to exposure to UV radiation and are considered pre-cancerous. A keratosis may also develop into a cutaneous horn. They appear as multiple flat or thickened, scaly or warty, skin coloured or reddened lesions. The vast majority do NOT progress to squamous cell carcinoma, evidence suggests the annual incidence of transformation is less than 0.1%. This risk is higher in the immunocompromised. It is not necessary to refer all patients with actinic keratosis. They should be managed in primary care. Diclofenac sodium gel (Solaraze) produces much less inflammation than fluorouracil 5% cream (Efudix) and is better tolerated. It is less effective than Efudix for thicker lesions. Use with caution in those with GI/renal dis- Fluorouracil 5% cream (Efudix) is ideal for multiple, ill-defined AKs. It spares normal skin. It is safe and efficacious with little systemic absorp- tion. Marked inflammation should occur prior to resolution, warn the pa- tient to expect this. Advise patient across the field of lesions (see patient advice leaflet). Optimum effect is seen 1 month post fluorouracil (Efudix) treatment. Resources On-line pictures for GPs: http://dermnetnz.org/lesions/solar-keratoses.html Patient leaflets:
Treatment with
Fluorouracil 5% (Efudix) Cream
Patient Advice Leaflet
You have been prescribed ‘Efudix' or ‘5 fluorouracil' cream, which is used to treat areas of
sun-damaged skin. These may appear as scaly, pink or light brown patches on any part of
the body that has had a lot of exposure to the sun over many years. Sometimes this dam-
age may have occurred without producing any obvious mark on the skin and the cream will
also treat this ‘invisible' sun damage. The cream will not affect normal skin.
The dermatologist will tell you exactly which areas should be treated.
How many times a day the cream should be applied and for how long varies for different
degrees of sun damage and on different parts of the body.
You should apply a thin layer of the cream and rub it into the lesions and to a centimetre
area of skin around the lesions as follows:
Once / Twice a day for weeks to _
Wash your hands after use and avoid getting the cream in your eyes or mouth.
YOUR SKIN MAY SEEM TO GET WORSE BEFORE IT GETS BETTER
After a variable time the treated skin will become red and sore. This is an expected part of
the treatment as the cream gets rid of the visible and invisible sun damage. You may bathe
the area with water or a weak salt solution and cover with a dry dressing if necessary. If the
reaction is uncomfortable this can be eased with paracetamol, aspirin or ibuprofen.
The reaction varies in different people and on different parts of the body. Sometimes the
reaction is very mild and the skin only becomes a little red, but occasionally the reaction can
be quite fierce and cause weeping, scabbing and rarely, bleeding or pain. If the reaction is
this bad please stop the treatment for a few days to allow it to settle and then restart the
treatment until you finish the course. The dermatologist or your GP may prescribe a mild
steroid ointment to settle any reaction if necessary.
However severe the reaction it ALWAYS settles once the Efudix is stopped and this treat-
ment is usually very successful at clearing the sun damage and leaving the skin smooth af-
terwards. The dermatologist may check that the treatment has worked a few weeks or
months after the reaction has settled.
The face usually responds more quickly to treatment than the body, legs or arms. These
areas may need more than one course of the cream although the reaction is usually less on
subsequent courses. If any rough or scaly areas are left after the first course of treatment
then the dermatologist may advise a second course, but you should only use the cream as
instructed by the doctor. If you have any concerns during treatment you can phone the de-
partment for further advice on 01689 865260.
Initial assessment Mild: Open and closed comedo-
nes
Moderate: more frequent
(non inflammatory) lesions with mild scarring Severe: Cystic scarring acne
Papules and pustules Severe psychological disorder as a result of acne True treatment failure Topical therapy with keratolytic/comedolytic: Continue topical therapy, in addition to: Systemic antibiotic for 3 months: Salicylic acid 2% Oxytetracycline 500mg BD Doxycycline 50mg BD Benzoyl peroxide start Lymecycline (Tetralysal 300) 408mg OD with 2.5% can increase Consider Co-cyprindiol (Dianette) in fe- males particularly if needing contracep- Topical Retinoids tion (exclude PCOS before starting). Li- censed for 12 mths can consider acne friendly pill thereafter e.g. Yasmin or Cilest Continue antibiotics for at least 6 Trial alternative antibiotic for 3 months, continue keratolytic months, consider concomitant Dianette in females Consider trimethoprim 200mg BD
for a further 3 months NB point 4
overleaf
Refer dermatology for consideration of oral isotretinoin Acne Key messages Consider the psychological impact of the disease on the patient and their quality of life. Refer those with severe acne with nodules, cysts and scarring or those not responsive to at least 3 months of 2 different antibiotics. Isotretinoin (Roaccutane) is a secondary care only drug for severe,
scarring acne resistant to other therapies, it is teratogenic and females should be on oral contraceptive. Those with PCOS will not respond to Discourage picking, squeezing and encourage application of oil free cos- Always use a topical keratolytic for comedones (salicylic acid/Acnisal
2%, benzoyl peroxide 5%, topical retinoids, Epiduo.)
Use antibiotics for moderate disease (oxytetracycline 500mg BD, doxy-
cycline 50mg BD, lymecycline 408mg OD) combined with topical treat-
ment. Trimethoprim 200mg BD is useful in resistant acne, but is unli- censed for this indication and tends to be initiated by dermatologists who may increase the dosage to 300mg BD. Assess treatment at 2-3 months, continue for a total of 6 months. Stress importance of compliance (aim for 50% improvement at 2 months). Those with severe psychological overlay also require mental health refer- Dermatology can reassure patient, review treatment and prescribe Resources On-line pictures for GPs: http://www.dermnetnz.org/acne http://www.dermatologist.co.uk/acne_img.html Patient leaflets http://www.patient.co.uk/health/Acne.htm http://www.bad.org.uk/site/793/default.aspx Antibiotic Guideliines http://nww.bromleypct.nhs.uk/content.php?page=241 Topical steroids in children
Face & flexures in all ages, mild to Initial assessment moderate eczema: Mild potency
(Hydrocortisone 1%) Moderate & severe eczema on trunk Baseline treatment: & limbs: Moderate potency
(clobetasone - Eumovate) Avoidance of irritants (e.g. soap) Use wet wraps if infection is con- trolled (Refer if failure to respond to Topical steroids 2 weeks clobetasone treatment.) Sedating antihista-mine at night if sleep Topical steroids in adults
Trunk & limbs: Moderate potency
clobetasone (Eumovate, Betnovate
Treatment of secondary infec- Potent betamethasone (Betnovate),
tion: antibiotic as appropriate mometasone (Elocon), fluticasone according to swab result Discoid or hand & foot eczema: Potent (Betnovate, Elocon,
Severe eczema not responding to baseline treatment Inability to return to work Case of diagnostic difficulty For contact allergy patch testing Refer dermatology Eczema Emollients Bath oil and soap substitute (e.g. aqueous cream, Dermol 500 lotion),
encourage daily baths. Liberal and frequent moisturiser e.g. Diprobase cream, E45 cream,
Epaderm, liquid paraffin 1:1 white soft paraffin (be careful as fire
hazard with paraffin-based emollients). Prescribe large quantities,
500g/week if severe. Leave 20 minutes between application of emollient and steroid. Topical steroids Use ointment (more effective) rather than cream if possible. Prescribe appropriate strength for type/size of eczema and age of patient (see guidance on finger-tip units.) Induce improvement with short course of stronger steroid then quickly move to weaker ones. Secondary infection The commonest cause for a flare of atopic eczema in children and the commonest cause of treatment failure. Take swab in any acute eczema but particularly if crusting/weeping (take from most cracked area). Prescribe antibiotic active against Staphylococci (e.g. flucloxacillin or
erythromycin, and Co-amoxiclav should be reserved for severe in-
fection and only following microbiology results).
Combined topical steroid/anti-infective preparations are useful for milder infections (e.g. Fucibet, Fucidin H, Betnovate N or C) for short-term use
Resources On-line pictures for GPs: Patient leaflets http://www.patient.co.uk/showdoc/270/ http://www.bad.org.uk/site/796/default.aspx Initial assessment Generalised erythrodermic or pustular psoriasis Refer as dermatological emergency Chronic plaque psoriasis
Guttate psoriasis
Scalp psoriasis
Assess lifestyle precipitants e.g. Throat swab and ASO titre Combination of keratolytic and anti- alcohol, medications inflammatory agents Vitamin D analogue +/- moderate Calcipotriol scalp application Vitamin D analogue +/- topical ster- potency topical steroid Tar based shampoo Coal tar / topical steroid Potent topical steroid scalp applica- Coal tar / topical steroid Dithranol cream as short contact Severe cases: keratolytic e.g. cononut, tar & salicylic ointment Topical retinoid Consider referral for phototherapy Diagnostic uncertainty Flexural psoriasis
Extensive disease Mild to moderate potency steroids Occupational disability/excessive combined with anti-biotic/fungal work/school absence Involvement of difficult sites (face, palms, genitalia) Failure of appropriate topical Tx af-ter 2-3 months Adverse reaction to topical Tx Facial psoriasis
Severe disease requiring systemic Mild to moderate potency steroids used intermittently Refer dermatology Psoriasis Key messages Instruct all patients in the use of emollients which make the skin more comfortable and reduce the quantity of active agents needed. Appropriate active treatment is dependent on type of psoriasis.
Psoriasis is treatable but not curable. Medications known to precipitate psoriasis: lithium, beta blockers, hy- droxycholoroquine, NSAIDS, stopping corticosteroids. Nail psoriasis responds poorly to topical Tx, consider podiatry for painful toenails, dermatology referral for severe disease. Dermatology will follow-up those with very severe disease and those re- quiring systemic Tx. Topical vitamin D preparations: Calcipotriol (Dovonex) licensed for
long term use, apply liberally BD (not for use on face/flexures). Tacalcitol (Curatoderm) can be used on face, OD preparation. Calitriol (Silkis) can
be used in flexures. Dovobet should be used intermittently and with cau-
tion maximum 4 weeks (can make psoriasis unstable and steroid over use Eumovate with 5% liquor picis carbonis although useful for itchy in-
flamed psoriasis is a "Special" and as such the cost will vary dependent For thick, scaling scalp psoriasis use SebCo ointment. Advise leave on
Psoriasis in children: use emollients and mild steroid/tar combinations such as Alphosyl HC cream. Dovonex can be used in over 12s. Resources On-line pictures for GPs: Patient leaflets http://www.patient.co.uk/health/Psoriasis.htm http://www.bad.org.uk/site/864/Default.aspx Urticaria/angioedema Initial assessment: individual weals < 6 weeks Acute
Take food and drug vanish after a few hours and are (May be allergic) replaced by new weals > 6 weeks Chronic
Trial of non-sedating antihistamine up to 6 weeks Consider addition of H2 blocker Diagnostic difficulty
Failure to respond to treatment with
at least 6 weeks of continuous anti-
histamines of different types
Refer dermatology Urticaria/angioedema Key messages A careful history is key, lesions last for less than 24 hours and don't leave Chronic urticaria often has a diurnal pattern, it is caused by an immu- nological malfunction. All patients should avoid strawberries, shellfish, aspirin, ACEIs, NSAIDs Antihistamines are the mainstay of treatment. Steroids and adrenaline are NOT indicated for the management of simple Check a full blood count in those with urticaria. Weals are a central itchy white papule or plaque due to dermal oedema. This is surrounded by an erythematous flare. The lesions are variable in size and shape and may be associated with angioedema. Angioedema is swelling of the soft tissues of the eyelids, lips and tongue, it is NOT itchy and lasts up to 72 hours. It is occasionally inherited. Trial non sedating antihistamines first (e.g. loratadine 10mg OD, cetirizine Sedating antihistamines (e.g. chlorphenamine 4mg TDS, usual night time dose for hydroxyzine is 25mg at night increasing to TDS if required). Addition of H2 blockers (e.g. cimetidine 400mg BD or ranitidine 150mg BD off licence use for both ) may be helpful in a small number of patients, consider referral. Resources On-line pictures for GPs: http://www.bad.org.uk/site/740/Default.aspx Initial assessment Mild: Topical treatment
Metronidazole 0.75 to 1% cream/gel
Refer ophthalmology Azelaic acid 15% gel (Finacea) BD Moderate: Systemic treatment
Oxytetracycline 500mg BD
Doxycycline (unlicensed use) 50-
100mg OD
Lymecycline 408mg OD
Severe: rosacea not responding to
systemic therapy
Diagnostic difficulty
Refer dermatology Rosacea Key messages Clinical features: papules on an erythematous background, pustules, te- langiectasia, rhinophyma. No comedones. Flushing is made worse by alcohol, spicy foods, hot drinks, temperature changes or emotion. Early treatment is important as each exacerbation leads to further skin damage and increases the risk of more advanced disease. Consider intermittent therapy for those with very occasional flare-ups, con- tinuous therapy needed for frequent recurrences. Continue topical treatment for 6-8 weeks and re-assess. Use cream for dry/sensitive skin, gel for normal/oily skin. Continue systemic treatment for 8-12 weeks, response is usually rapid. Advise those with ocular disease on lid hygiene and managing blepharitis. Pulse dye laser can be used for moderate-severe telangiectasia however this may be regarded as a procedure of limited clinical effectiveness and therefore not available on the NHS. Laser resurfacing may be offered for those with severe rhinophyma how- ever this may be regarded as a procedure of limited clinical effectiveness and therefore not available on the NHS. Patient education: trigger factors, sun protection. Resources On-line pictures for GPs: Skin infections Viral warts Hand warts: use high concen-
Cryotherapy: Freeze times
tration of salicylic acid 3 month treatment after wart has turned white Adults: e.g. Occlusal (26%) Hands 10-20 seconds Children: e.g. Duofilm or Salactol Plantar warts: Ver-
Feet 15 seconds, thaw 1-2 rugon (50% salicylic minutes then repeat 15 sec- Plane warts (face/hands):
Filiform warts (face/
Leave alone or trial of Tretinoin eyelids):
0.025% (unlicensed use) cream Initial assessment: features Use scabicide to treat patient and suggestive of scabies contacts: Malathion 0.5% aqueous solution (Derbac-M) OR Permethrin 5% cream (Lyclear Der- Impetignisation usually due to secondary Staph infection If residual rash/itch use Hydrocortisone 1% clinoquinol 3% Crotamiton/HCT (Eurax) (Vioform HC) cream +/- Flucloxacillin 7-10 days Referral exclusion unless disabling (e.g. florid hand warts in a hairdresser) must have adequate treatment for 6 months prior to referral. Children are an absolute referral exclusion. There is no cure, more than 70% resolve spontaneously in 2 years. Plantar warts are more persistent. All wart treatments are locally destructive and some are painful and cause scar- ring. Choice of Tx depends on age of patient and site of warts (it is unkind to use cryotherapy for warts in children). Topical Tx is as effective as cryotherapy for hand warts. In children you may want to consider using a gel and cover with plaster to prevent spread. Keep warts pared down between treatments (insufficient filing of dead skin can reduce effectiveness of treatment. Treatment with duct tape may help. Scabies is an infestation caused by the mite Sarcoptes scabiei. Mites are most readily transmitted from one person to another by close physical contact (e.g. sharing a bed, caring for children/elderly). An individual who has not had scabies previously, may not develop symptoms until 1 to 3 months after becoming infested. Clinical features: burrows on non hair bearing skin, often a widespread eczema- tous rash (sparing face in older children/adults). Possible inflammatory nodules on genitalia, periareolar areas, axilla/groin (especially if long standing). Malathion should be left on skin for 24 hours and repeated after 7 days. Perme- thrin for 8-12 hours and can be repeated after 7 days if necessary. One treatment usually curative except in crusted (Norwegian) scabies. It is essential that all household and other close social contacts receive treatment at the same time as patient. Mites are killed within 24 hours, but symptoms may take 3-6 weeks to Resources On-line pictures for GPs: Patient leaflets Initial assessment Body (corporis) Scalp (capitis) Nails (unguium) Skin scrapings for Skin scrapings for mycology, Subungual nail scrap- use disposable toothbrush in ings for mycology Use topical treatment Treat unaffected family con- (ketoconazole shampoo) whilst tacts with ketoconazole sham- awaiting microscopy poo twice weekly for 4 weeks Topical treatment usually sufficient: Oral treatment is essential Children: only licensed treatment is
Imidazole cream e.g. clotrimazole or Griseofulvin (15-20mg/kg) OD for 8- miconazole BD for 1-2 weeks after skin healed, agents containing a Adults: Griseofulvin or Terbinafine
steroid are usually not needed and should be used for 1 week only Oral treatment rarely needed Single nail involvement: Amorolfine 5% nail paint 1-2 x per week for 6/12 mths. Multiple nails: Terbinafine 250mg OD for 12 weeks. Check LFTs be-fore starting treatment 2nd line is Itraconazole: either 200mg OD for 3 months or pulsed 400mg OD one week/month for 2 courses for finger nails and 3 for toe nails Griseofulvin is only licensed treat-ment for children 10mg/kg/day for 6-12 months. Not recommended in adults If signs persist after treatment or diag-nostic difficulty refer dermatology Tinea Key messages Dermatophytosis (tinea) infections are fungal infections caused by dermato- phytes (a group of fungi that invade and grow in dead keratin). They tend to grow outwards on skin producing a ring like pattern, hence the term Tinea infections present with a variety of appearances e.g. annular plaques, diffuse scaling, grey patches, pustules, kerion, patchy hair loss, nail Tinea capitis Usually a disease of children. A child can go back to school once treatment commenced. Schools should be informed and they should alert parents what to look for. Family contacts should avoid sharing combs/hair brushes. Griseofulvin is available as 125mg tablets, which can be halved and crushed. Oral Terbinafine is being used increasingly. Although unlicensed in children, in practice it appears to be safe and very effective (at a daily dose of 250mg for child weighing 40kg, 125mg for 20-40kg, 62.5mg for <20kg for one month.) Topical antifungal treatment alone is insufficient but probably reduces infec- tivity and the chance of relapse e.g. ketaconazole shampoo twice weekly or miconazole ointment twice daily for the first month. Washing the scalp daily with an antiseptic emollient helps remove scale e.g. Dermol 500. Tinea unguium Treatment should not be instituted on clinical grounds always consider other causes of nail dystrophy, psoriasis compression by shoes subungual melanoma. Never prescribe systemic treatment without positive my-
cology culture. Scrape subungual nail debris at most proximal part of in-
fection, which may require clipping the nail back. If culture is negative re-
peat test. It can take 6 to 12 months for damaged nail to grow out. Amorolfine 5% is the topical treatment 1st choice but is only recommended for limited infection (e.g. one nail or very distal disease in a few nails). May be used with systemic treatment to improve cure rates or if systemic treat- ment contraindicated. On-line pictures for GPs: http://dermnetnz.org/fungal/tinea.html
Patient leaflets http://www.patient.co.uk/doctor/Dermatophytosis-(Tinea).htm
http://www.bad.org.uk/site/820Default.aspx
Unable to tolerate Refer to Tissue Viabilit Refer to TV for assessment gement of
for the Man
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‘Skin Le
Leg ulcers Key messages This algorithm is taken from the local comprehensive leg ulcer assessment and management guidelines (Bromley PCT, July 2010). Identify risk factors: smoking, peripheral vascular disease (history of clau-
dication), history of varicose veins, deep vein thrombosis or rheumatoid ar- thritis (associated with inflammatory ulcers). Examine patient to identify vascular disease (venous or arterial).
Look for evidence of varicose eczema: if present treat with moderate-
potent topical steroids and compression hosiery. Varicose ulcer: refer to practice nurse for assessment including Dopplers, ulcer dressings and compression bandaging. If fails to respond refer to community tissue viability team. House-bound patients should be referred to District Nurses. Arterial/mixed vascular disease: refer to practice nurse for Dopplers, and vascular surgeons. Notes Dermatology referral criteria: Diagnostic uncertainty, including concern about malignant change (Non healing ulcer with undermined edges). Evidence of contact dermatitis. Failure to respond to treatment after assessment by tissue viability team. Include info on previous dressings and Doppler assessment in referral let- Resources On-line pictures for GPs: Management of Benign Skin Conditions Key Messages: Cosmetic removal is NOT possible on the NHS Molluscum contagiosum No treatment necessary, can try Crystacide
Skin tags
Treat only if problematic Seborrhoeic warts
Treat only if irritated/inflamed and there is no diag nostic uncertainty. Cryotherapy or curettage and Pyogenic granuloma
Curettage and cautery (histology essential), refer to dermatology if difficult size/site Spider naevi/Campbell
de Morgan spots / Vascular angiomata
Bowen's disease
Cryotherapy or curettage and cautery, must be Benign naevi
Atypical naevi
If genuine concern Re: melanoma refer 2 week wait Sebaceous cysts
If problematic can be excised under minor surgery Cosmetic, treatment not possible on NHS Cosmetic removal not possible on NHS Dermatofibroma
Cosmetic removal not possible on NHS, take care as may leave ugly scar, refer if diagnostic Keratin horn
Curettage and cautery (histology essential) Solar/giant comedones Can be incised and contents expressed, lesions
over 5mm need excision (cosmetic, treatment not possible on NHS) Solar lentigines
Cosmetic, treatment not possible on NHS Congenital naevi
Cosmetic, treatment not possible on NHS Exceptional Treatments Policy Dermabrasion (chemical peel) Birthmark removal Excision of benign skin lesions Tunable dye laser Referral Exclusions • Viral warts and verrucae in children Molluscum contagiosum in children Epidermoid (sebaceous) cysts Useful Management Tips Equipment Good light source Surgical instruments Fungal scrapings kit Disposable toothbrush (fungal scrapings in children) Topical Steroids: finger tip units One fingertip unit (FTU) is the amount of topical steroid that is squeezed out from a standard tube along an adult's fingertip. 1 FTU = 0.5g, apply Face & neck (2.5 FTU, 15-30g/week) Trunk (7 FTU, 100g/week) Both arms (6 FTU, 30-60g/week) Both legs (12 FTU, 100g/week) Groin & genitalia (2.5 FTU, 15-30g/week) BNF recommended quantities to be given to adults for twice daily application Face (15-30g cream, 100ml lotion) Both hands (25-50g cream, 200ml lotion) Scalp (50-100g cream, 200ml lotion) Both arms/legs (100-200g cream, 200ml lotion) Trunk (400g cream, 500ml lotion) Groin & genitalia (15-25g cream, 100ml lotion) Scabies permethrin cream 30g generally sufficient although 60g for larger peo- ple. Maximum 60g per application. Lotion 100ml for whole body application Sun Protection Tips Protect skin with clothing, including a hat, T shirt and UV protective sun- Seek shade between 11am and 3pm when it's sunny. Use a sunscreen of at least SPF 30 which also has high UVA protection. Keep babies and young children out of direct sunlight. Investigations in Primary Care Skin scrapings: Suspected fungal infection, use the blunt edge of a scal-
pel blade/disposable toothbrush in children to collect scale from leading edge of rash. Transport in a sterile container on black card. Skin swabs: Suspected bacterial infection, particulary in crusted/weeping
Patient information www.patient.co.uk Conditions
Lichen sclerosus Insect bites and stings Epidermolysis bullosa Erythema ab igne Malignant skin ulcers Erythema multiforme Erythema nodosum Pityriasis rosea Epidermoid and pilar cysts Pityriasis versicolor Fungal infections Acute, chronic and physical urticaria Genital skin problems Seborrhoeic dermatitis Molluscum contagiosum Granuloma annulare Seborrhoeic warts Henoch Schoenlein purpura Squamous cell carcinoma Contact dermatitis Urticaria and angioedema Erythema nodosum Hidradenitis suppurativa Seborrhoeic dermatitis Hypertrophic scars www.dermnetnz.org Management
Acne in pregnancy Actinic keratosis Topical steroids, fingertip units Adverse reaction to drugs Emollients (moisturisers) Cancer of the skin – Prevention Allergic contact dermatitis Leg vein therapies Lichen sclerosus Atopic dermatitis/eczema Malignant melanoma Bacterial skin infections Basal cell carcinoma Papillomas, skin tags Actinic keratosis Parasites & infestations Basal cell carcinoma Pityriasis rosea Pityriasis versicolor Contact dermatitis Bullous pemphigoid Campbell de Morgan spots Candidiasis of skin folds Senile comedones Congenital naevi Contact allergic dermatitis
Source: http://www.bromleyhealthcare.org.uk/wp-content/uploads/2014/12/Dermatology-guidelines.pdf
Am_2004.frm.fm
Årsmelding / Annual Report 2004 Bildet på omslaget illustrerer det katastro-fale jordkskjelvet ved Sumatra den 26. desember 2004. Skjelvet forårsaket en gigantisk flodbølge (tsunami) i det Indiske hav, og førte til tap av nær 300.000 men-neskeliv. The picture on the cover illustrates the catastrophic earthquake near Sumatra on 26 December 2004. This earthquake gen-erated a huge tsunami in the Indian Ocean, claiming nearly 300,000 human lives.
uenma.edu.ec
Guía del docente Evaluación diagnóstica Planificación Bloque 1 Planificación Bloque 2 Planificación Bloque 3 Evaluación formativa Bloque 1 Evaluación sumativa Bloque 1 Evaluación formativa Bloque 2 Evaluación sumativa Bloque 2 Evaluación formativa Bloque 3 Evaluación sumativa Bloque 3 Evaluación del primer quimestre Planificación Bloque 4