1. Referral Guidelines for Dermatological Conditions
East Berkshire PCT

2. Contents Acne/rosacea Allergy testing Eczema Fungal nail infections
Hair disorders
Scabies
Seborrhoeic keratoses
Skin Cancer
Solar Keratoses
Pigmentary disorders
Psoriasis
Urticaria
Viral Warts
Others

3. Acne
Mild to moderate acne can be managed in primary care. Different agents may need to be used alone or in combination e.g. oral antibiotic with topical retinoid. It is important to explain that the response may be slow. Allow at least 12 weeks before review unless specific problems with the treatment
Mild acne (non-inflammatory lesions – open and closed comedones)
Benzoyl peroxide NB. Can bleach clothes and towels
Topical retinoids
Mild/moderate acne (comedones and some papules/pustules)
Topical retinoids +/- topical antibiotic
Erythromycin and zinc acetate
Erythromycin and benzoyl peroxide

4. Acne Moderate acne (more extensive inflamed lesions)
Treatment with a systemic antibiotic should continue for a minimum of 6 months and repeat if necessary.
Lymecycline 408mg od
Doxycycline 100mg od compliance better
Erythromycin 500mg bd
Minocycline 100mg od
NB. All the tetracyclines must be avoided in pregnancy
Moderate/severe acne ( deeper inflammation and scarring)
Consider additional hormone therapy in women eg. Dianette

5. Acne Severe acne (nodular lesions with significant scarring)
Start oral antibiotics and refer for consideration of isotretinoin therapy
CRITERIA FOR REFERRAL
For isotretinoin treatment:
Severe acne
Scarring
Poor response to antibiotics
Rapid relapse after antibiotics
Severe psychological problems
Possible underlying endocrinological cause for acne eg. polycystic ovary syndrome
Uncertain diagnosis or unusual features

6. Rosacea Clinical features:
Flushing, telangiectasia, papules, pustules, rhinophyma in advanced disease.
TOPICAL TREATMENT
Metronidazole gel/cream can be used in mild cases.
SYSTEMIC TREATMENT
NB. All tetracyclines are contra-indicated in pregnancy, lactation and renal disease
Oxytetracycline 500mg bd for 6-12 weeks
Doxycycline mg od for 6-12 weeks
Minocycline 100mg od
Lymecycline 408mg od
Erythromycin 500mg bd – can be used in pregnancy
Intermittent therapy may be required for those with occasional flare-ups but some patients will need maintenance treatment for control.
CRITERIA FOR REFERRAL:
Uncertain diagnosis
Severe disease/pyoderma faciale
Ocular rosacea

7. Allergy testing
Allergy testing for chronic urticaria is not relevant, do not refer.
Allergy testing for type I reactions – refer to allergy clinic at Amersham or St Thomas’. If anaphylactic reactions, refer St Thomas’
Extensive patch testing (type IV reactions) is available locally. Refer to secondary care.

8. Eczema PRINCIPLES OF MANAGEMENT emollients topical steroids
topical steroid/antibiotic combination if infected
antihistamines
education
REFER IF:
failure of first line treatments
children requiring moderately potent steroids for prolonged periods
erythrodermic exacerbations
NB. URGENT referral for suspected secondary infection with herpes simplex (eczema herpeticum)
1. EMOLLIENTS
The regular, intensive use of emollients is fundamentally important in the treatment of eczema. Emollients restore the water content of the skin and prevent scaling, cracking and itching.
a. Moisturisers Diprobase
Aqueous cream
Epaderm
Emulsifying ointment
b. Soap Substitute Aqueous cream
c. Bath additives Oilatum
Bath E45
Diprobath
Oilatum Plus and Emulsiderm have antiseptic properties
If the patient soaks in the bath for at least 15 minutes, a lipid layer is left on the skin preventing further water loss.

9. Eczema
KEY POINTS
Emollients are usually not applied frequently or liberally enough
Ointments are more effective than creams
Prescribe large quantities e.g. 500g
2. TOPICAL STEROIDS
* for secondary infection. This is a common cause of flares of atopic eczema. It is important to revert to a pure steroid preparation once the infection is treated (generally after days) to prevent bacterial resistance. Oral antibiotics may be needed for widespread infection.
Tips about topical steroids
The majority of patients do not use topical steroids adequately. Often, they will not use them at all, but are happy to take oral steroids when they are unnecessary! Hydrocortisone is usually too weak but this is the steroid that patients are often most concerned about
if used correctly, they are safe
choose the correct steroid for the body site
a moderate to potent steroid is used to bring the eczema under control before reducing the potency for maintenance
As a guide to quantities that are needed, some patients may find the finger tip unit helpful
Face and flexures
Trunk and limbs
Child
1% hydrocortisone
Fucidin H*
Clobetasol butyrate 0.05%
(Eumovate)
Mometasone fuorate (Elocon)
Adult
Eumovate
Elocon
Mometasone fuorate (Elocon) Betamethasone valerate (Betnovate RD)
Fucibet cream*

10. Eczema 3. ANTIHISTAMINES
Sedative antihistamines can be used if itching prevents sleep eg. trimeprazine, hydroxyzine. The non-sedating antihistamines are not very helpful in eczema.
4. WET WRAPS/BANDAGING TECHNIQUES
These can be helpful in certain situations but require a lot of time, skill and motivation to be used properly. The parents also need expert tuition to make these work.
5. GENERAL POINTS
keep nails short
wear cotton clothing - wool tends to irritate

11. Eczema TREATMENT REFERRAL ACUTE POMPHOLYX
Itchy blisters on palms and soles
Emollients and topical steroid (at least moderately potent)
Potassium permanganate soaks - 1:10000 for 20 mins/day
Treat secondary infection
Treatment failure
Repeated episodes
Severe disease
CRONIC HAND ECZEMA
Fissured or scaly dry skin
Exclude fungal infection
Can be chronic problem
Treatment failure
Patch testing if allergic contact dermatitis suspected
Emollients
Potent topical steroids

12. Eczema TREATMENT REFERRAL VARICOSE ECZEMA Usually elderly, lower legs
Varicose veins
Moderately potent topical steroid with liberal emollients
Remove Keratotic debris
May require e.g. Fucibet around ulcers for infected skin
Use compression bandaging if circulation adequate
Patch testing may be needed for resistant cases
DISCOID ECZEMA
Discrete round patches often starts on lower legs
Usually secondarily infected
Moderately potent topical steroid
Steroid plus antibiotic combination if infected
Warn patient it may recur and require repeated treatment from time to time

13. Eczema TREATMENT REFERRAL CONTACT DERMATITIS
Common sites affected - hands, feet, face
Consider in pruritus ani, pruritus vulvae
Potent topical steroid
Avoid obvious allergens e.g. nickel
Need for patch testing
SEBORRHOEIC ECZEMA
Face, scalp, central chest
Greasy and/or scaly patches
Ketoconazole shampoo
Steroid scalp preparation
Daktacort and tar shampoo
Severe condition may indicate HIV infection

14. Fungal nail infections
Clinical features are hyperkeratosis under the nail with thickening and crumbling often of several nails.
If clinically typical, check cultures, but can treat empirically if symptomatic. Fungal cultures may be unreliable.
Treat for weeks but nail may not look normal then. Wait for it to grow out normally, can take >6 months

15. Hair disorders Refer scarring alopecia eg. Discoid lupus
Most patients with alopecia areata will regrow within 6-9 months.
Physiological hair loss in older women – no need to refer. Check ferritin and thyroid function.
Refer young women <25years to secondary care, may need endocrinological investigation

16. Scabies
SCABIES
The mites are most easily transmitted by close contact eg. children holding hands, sharing a bed. The symptoms may not develop until 4-6 weeks after being infested. Warn patients that the pruritus may take several weeks to settle after the treatment.
CLINICAL CLUES:
Widespread popular eruption
Burrows in web spaces
Inflammatory nodules on the genitalia
There may be a secondary eczematous or urticarial response.
TREATMENT:
Malathion 0.5% aqueous solution (Derbac M) or permethrin 5% (Lyclear dermal cream) applied to all skin below the neck. Malathion should be left on for 24 hours and permethrin for 8-12 hours. Warn patients that it will need to be re-applied after hand washing.
NB. Ensure that all members of the household and close contacts are treated at the same time.
TIPS:
Topical crotamiton cream (Eurax) can be helpful for residual itching
Avoid repeated application of scabicides for residual itching as this exacerbates any eczematous reaction.
Failure of treatment is most likely to be poor compliance with treatment.

17. Seborrhoeic keratoses
Stuck on waxy/warty appearance
Often multiple
Can become irritated and inflamed
No malignant potential

18. Seborrhoeic keratoses
Do not need treatment – patient can be reassured
If symptomatic, cryotherapy or curettage most useful
Referral guidance
Do not send under 2 week rule
If diagnostic difficulty, refer to Pigmented Lesion Clinic. This is held monthly at King Edward VII
For multiple symptomatic lesions, approval of Low Priority Committee required before referral for any treatment

19. Skin Cancer SKIN CANCER
All suspicious and changing pigmented lesions should be referred via the 2 week wait system. Basal cell carcinomata are excluded from this system, and can be referred via the normal route, as routine referrals.
Basal cell carcinoma
Slow growing, locally invasive tumours. Pearly edge is a common feature.
Squamous cell carcinoma
Often rapidly growing and can metastasise. It is reasonable to refer keratoacanthomas via the 2 week wait system, especially if they have been present for more than 2 months as these are more likely to be SCCs.
Malignant melanoma
Most serious skin malignancy. Early detection and treatment is vital to improve the prognosis

20. Pigmented Lesions
CRITERIA FOR REFERRAL OF PIGMENTED LESIONS – those TRULY SUSPICIOUS of a melanoma can be referred via the 2 week wait rule.
Change in size
Change in colour (variability of pigmentation)
Change in shape (irregularity of edge)
Size >6mm
Inflammation
Bleeding/crusting
Itch
Lesions suspicious of lentigo maligna in young patients should be referred via the 2 week wait system.

21. Solar Keratoses (Actinic Keratoses)
Usually flat red, scaly lesions on face, scalp, backs of hands. Often multiple.
TREATMENT:
Cryotherapy – 10 seconds freezing time
Topical 5-fluorouracil (Efudix ) cream – can be helpful for diffuse areas of damage. Use once daily for days. It may need to be used for longer (up to 4 weeks) at non-facial sites. Warn patient to expect a brisk inflammatory response.
Topical imiquimod 5% (Aldara) can also be used. This needs to be used 5 days a week for about 6 weeks. A marked inflammatory reaction can result.
CRITERIA FOR REFERRAL
Any suspicion of malignancy
Failure to respond to treatment
Immunosuppressed patient

22. Pigment disorders
Chloasma/melasma – no need to refer if mild. Only treatment available on NHS is Pigmanorm (contains hydroquinone )which is only available via hospital pharmacy. Can ask advice by letter to dermatology consultant. Consider referral for cosmetic camouflage Vitiligo – refer extensive vitiligo if phototherapy to be considered. This may not have long term benefit. Check auto-antibody screen as may be associated with auto-immune disease.

23. Psoriasis HISTORY Duration Triggers Medical History
Drug HIstory e.g. beta blockers, lithium, chloroquine
ASSESSMENT FOR TREATMENT
Extent
Plaque size/thickness
Inflammation
Practicalities of treatment
Compliance
Adequate prescribing quantities

24. Psoriasis TYPE TREATMENT All forms Emollients
Limited disease or thin plaques
Tar preparations eg. Alphosyl cream bd
Calcipotriol bd
Limited thick plaques
Salicylic acid to break down scale
Calcipotriol bd
Dovobet® ointment
Short contact dithranol (with patient education)

25. Psoriasis TYPE TREATMENT Inflamed sore plaques Emollients
Moderately potent topical steroid
Avoid calcipotriol and dithranol
Scalp psoriasis
Tar/salicylic acid shampoo
Steroid scalp application
Xamiol® gel
Ung cocois for thick plaques, and then steroid scalp application

26. Psoriasis OTHER TYPES TREATMENT Guttate Emollients Tar preparations
UVB
Avoid dithranol - can burn
Guttate psoriasis typically self resolves within 6-8 weeks. Do not refer unless recurrent episodes or evolving into more extensive chronic disease.
Facial
Emollients
Mild topical steroids

27. Psoriasis OTHER TYPES TREATMENT Flexural
Moderately potent topical steroid and anti-yeast e.g. trimovate
Arthropathy
Refer to Rheumatology

28. Psoriasis OTHER TYPES TREATMENT Nail dystrophy
Mild changes often resolve spontaneously
A potent topical steroid rubbed into the nail may help
Pustular psoriasis of palms and soles
Diprosalic ointment bd under occlusion

29. Criteria for referral CRITERIA FOR REFERRAL Erythrodermic
Unstable/generalised pustular psoriasis
Extensive/severe disease
Failure to respond or relapse post topical therapies
Recurrent attacks
DIfficulty with diagnosis

30. Urticaria
Chronic idiopathic urticaria is common. Explain to the patient that it is benign and self-limiting. Antihistamines are the mainstay of treatment.
Tests are generally unhelpful. Patch tests are of no use in urticaria
Tips:
Avoid aspirin and NSAIDs - these can exacerbate the problem.
ACE inhibitors can cause angioedema
Exclude C1 esterase deficiency if angioedema is the only sign
Steroids should NOT be used in chronic urticaria
ANTIHISTAMINES
Patients can vary in their response to different antihistamine agents and several may need to be tried.
Cetirizine or Loratidine 10mg od or bd
Fexofenadine 180mg od
Add sedating antihistamine at night eg. doxepin 25 mg or hydroxyzine 25mg if no response
Ketotifen (1mg bd) is sometimes helpful as a mast cell stabiliser
NB. Do not give terfenadine or astemizole with doxepin, imidazole antifungals or macrolide antibiotics to avoid cardiac arrythmias.
CRITERIA FOR REFERRAL
Suspicion of urticarial vasculitis ie. persistence of weals >24 hours, systemic illness
Urticaria associated with systemic features
Urticaria poorly responsive to antihistamines
Hereditary angioedema

31. Viral Warts VIRAL WARTS
Viral warts are self-limiting and are very common. There is no cure until host immunity develops and they are usually best left to resolve spontaneously.
Topical salicylic acid
Use a high concentration eg Occlusal. The patient will need to apply this for many months. It is best applied after bathing and the area rubbed down with a pumice stone or sandpaper.
Cryotherapy
May be helpful but if no sign of improvement after 4-5 treatments, it is unlikely to work and should be stopped. It is best performed at 3-4 weekly intervals. It is uncomfortable and best avoided in children under 6 years of age.

32. Viral Warts - criteria for referral
Referral letters can be accepted where any one of the following are true:
Diagnosis of viral warts is not clearly stated (eg. 'warty lesion' is not stating the diagnosis)
Patient is immunosuppressed
Periocular warts associated with recurrent conjunctivitis
There is any suspicion of malignancy
There is obstruction of an orifice or vision
There is functional limitation on movement or activity
There is an attached agreement from the Low Priorities Committee
The following may be funded but the GP will have to apply through the Low Priorities Committee:
Moderate to large facial lesions which cause disfigurement
Removal for other indications such as itching, bleeding, pain, recurrent trauma.

33. Others....
Refer patients with genital disease (other than infections which can be referred to Garden Clinic at Upton) to secondary care. The vulval clinic is held at King Edward VII.
Patients with generalised pruritus may need referral for diagnosis and investigation
Photosensitivity needs specialist investigation, refer secondary care
Patients with cutaneous lichen planus only do not need referral as this is self limiting. Any patient with mucosal involvement should be referred to secondary care – oral involvement only to Oral Medicine, those with genital involvement to dermatology.