1. Dermatology GP Education & Networking Event 24 th 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

5. What should be sent as a 2WW referral? Melanoma & Lentigo Maligna

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

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

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

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

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

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

13. Referrals to Secondary Care

14. 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

15. 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

16. 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

17. 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

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

19. 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

20. 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

21. 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!

22. Example of a Good Referral Concise Relevant Appropriate

23. Allergy Testing

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

25. 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

26. 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’

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

28. 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

29. 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

30. Dermoscopy

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

32. 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

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

34. Reticular Pattern Most common pattern in melanocytic naevi Also seen in melanoma, lentigo simplex & dermatofibroma  Typical regular reticular network seen in a benign naevus

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

36. 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

37. 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

38. 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

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

40. 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

41. Parallel Pattern Seen with naevi on acral skin  Typical parallel pattern seen in a benign acral naevus

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

43. 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

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

45. 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

46. Questions?