Skin Health Service Referral Form

(Please complete the relevant pages in full. Failure to do so may delay the application)

(Please refer suspected Squamous Cell Carcinoma or Malignant Melanoma and other non BCC suspected skin cancers as a two week wait. Refer to attached guidelines.)

Patient Details: / GP Details:
NHS No: / Name:
Date of Birth: / GP Practice:
Male / Female: / Address:
Mr / Mrs / Miss / Other (please state):
Surname: / Post Code:
First Name: / Tel No.
Address: / Fax No.
Post Code: / Mental Capacity:
Tel No. / Does this patient have capacity / Yes / No
Mobile No.
Details of skin condition/ lesion (not including suspected cancers - for suspected BCC instead complete box below and for suspected SCC or malignant melanoma please refer as two week wait on 2 week wait form)
Description:
Site:
Size (mm):
Further information (including why lesion cannot be managed in GP surgery, how patient meets referral criteria or exceptionality):
Suspected BCC:
Size (mm):
Site - in particular if on face describe if close to eyes, nose lips or ears (diagram if possible).
Is patient immunosuppressed or has Gorlin’s Syndrome? Yes/No. If yes, please give details. ……..
Is the BCC/ suspected BCC overlying an important underlying structure (artery or vein)? Yes/No If yes, please give details:
Is this a recurrent BCC? Yes/No
Relevant Medical History:
Relevant Investigations / Results / Blood Tests etc.
Current Medication Including Anticoagulants
Send UBRN notification via e-mail to :
OR /
Send via Fax No. / 01438 712381
Telephone No. for queries only / 01438 841848

Please note that inappropriate referrals which do not meet the referral guidelines and/or the Beds and Herts priorities forum guidance or do not state sufficient exceptional circumstances will be sent back to the referring GP.

HCT Skin Health Referral Guidelines for Adults (16 years and above)


Whilst referral guidance is given for each condition, where diagnostic uncertainty exists, the patient should be referred to a skin specialist. Central triage is managed by Skin Health Service.

Please use the Skin Health Service Referral Form or ensure that a detailed clinical referral is made which includes the size (mm) and site of the skin condition.

Skin Condition / GP Core Service Treatment / Referral / If Referring
Refer to:
Squamous cell carcinoma
http://dermnetnz.org/lesions/squamous-cell-carcinoma.html / Refer under the two week rule / Secondary Care 2 week rule
Melanoma
http://www.dermnetnz.org/lesions/melanoma.html / Refer under the two week rule / Secondary Care 2 week rule
Lentigo/Lentigo Maligna
http://www.dermnetnz.org/lesions/lentigo-maligna.html / A multi coloured Lentigo could be Lentigo Maligna and these can turn into a melanoma – any concerns refer via 2 week wait as for melanoma / Central Triage
or
2 week wait / Central Triage
or
2 week wait
Atypical Naevi http://dermnetnz.org/lesions/atypical-naevi.html / If concern re melanoma refer under 2 week rule. / Central Triage / Central Triage
Or 2 week wait
Basal Cell Carcinoma (BCC)
http://www.dermnetnz.org/lesions/basal-cell-carcinoma.html / Central Triage – Urgently
*Please clearly state in referral the size/site of possible BCC if the patient is immunosuppressed or has Gorlin’s syndrome, if it is overlaying an artery/vein or if close to eye/nose/lips/ears / Central Triage
Kerato-acanthoma
http://dermnetnz.org/lesions/keratoacanthoma.html / Refer under 2 week rule. / Refer under the two week rule / Secondary Care 2 week wait
Viral Warts
http://dermnetnz.org/viral/viral-warts.html / Leave alone or use cryo therapy or topical paints (sign post to community pharmacy). Use patient info leaflet.
Cryotherapy painful -avoid in small children – Duct Tape worth trying / Do not refer- Part of GMS contract essential services
Exception when florid/severe e.g. in immunosuppressed / Secondary Care
Molluscum Contagiosum
http://dermnetnz.org/viral/molluscum-contagiosum.html / Treatment for molluscum contagiosum (MC) is not routinely recommended because most cases clear up in around 6 to 18 months without the need for treatment
Products available over the counter but no convincing evidence / Do not refer – Part of GMS contract essential services
Skin tags
http://dermnetnz.org/lesions/skin-tags.html / Treat only if problematic. Cosmetic removal not available on the NHS - Use patient info leaflet / Do not refer – Part of GMS contract essential services
Seborrhoeic Warts / Keratoses
http://dermnetnz.org/lesions/seborrhoeic-keratosis.html / Treat using cryotherapy or curettage and cautery only when problematic. Cosmetic surgical removal not available on the NHS. Use patient info leaflet / Do not refer – Part of GMS contract essential services
Spider Naevi /Cambell de Morgan Spots / Vascular Angiomata
http://dermnetnz.org/vascular/angioma.html / Snip &/or cautery with Hyfrecator. Cosmetic surgical treatment not available on the NHS / Do not refer – Part of GMS contract essential services
Benign Naevi
http://dermnetnz.org/lesions/moles.html / Pigmented lesions should not be shaved if there is any chance at all of malignancy. Shave and cautery for intradermal moles only if clinically indicated due to physical impairment. Cosmetic removal not available on the NHS. Always send for histology / Do not refer – Part of GMS contract essential services
Solar Lentigines
http://www.dermnetnz.org/lesions/lentigines.html / Cosmetic. Treatment not indicated & not available on the NHS. / Do not refer
Epidermoid /Pilar (Sebaceous) Cysts
http://www.dermnetnz.org/lesions/cysts.html / If problematic can be excised under the minor surgery directed enhanced service. / Refer to Central Triage only if have documented repeat infection and unable to remove in primary care. Please clearly document how the patient meets criteria in referral / Central Triage
Lipoma
http://dermnetnz.org/lesions/lipoma.html / Cosmetic removal not available on the NHS. If problematic can be excised under the minor surgery Directly Enhanced Service / If beyond the scope of DES/ difficult site or size and causing significant problems refer to Central Triage. Please clearly document how the patient meets criteria in referral / Central Triage
Dermatofibroma / Histiocytoma
http://dermnetnz.org/lesions/dermatofibroma.html / Cosmetic removal not available on the NHS. If problematic can be excised under the minor surgery Directly Enhanced Service. Take care as ugly scars possible. Histology essential. Please seek exceptional panel treatment approval prior to referral
NB there is rare form of sarcoma – dermatofibrosarcoma protuberans (DFSP) which can look similar -they are solitary, and tend to recur after removal / If diagnostic uncertainty refer to Central Triage / Central Triage
Pyogenic Granuloma
http://dermnetnz.org/vascular/pyogenic-granuloma.html / N.b. Occasionally a melanoma gets mistaken for a pyogenic granuloma - the history is key. Pyogenic granulomas have a very short history from a few days up to a month.
Treatment is curettage and cautery (histology essential), treat rapidly as fast growing / If unable to remove in primary care refer to Central Triage urgently because of rapid growth (if concern of malignant melanoma refer under 2 week wait) / Central Triage
(refer under 2 week wait if concern of malignant melanoma)
Actinic/Solar Keratosis
http://dermnetnz.org/lesions/solar-keratoses.html / Treatment with cryotherapy or curettage and cautery or by topical treatment e.g. 3% Diclofenac gel / NICE recommends these are treated in Primary Care / Central Triage, if significant problem managing in primary care
Bowen’s Disease
http://dermnetnz.org/lesions/bowen.html / Refer to Central Triage / Central Triage / Central Triage
Keratin Horn
http://www.dermnetnz.org/lesions/cutaneous-horn.html / Curettage and cautery (histology essential) / If unable to remove in primary care refer to Central Triage. / Central Triage / Secondary Care
Giant Comedones
http://www.pcds.org.uk/clinical-guidance/giant-comedone#images / Can be incised and contents expressed. Lesions over 5mm need excision. As this is cosmetic treatment not available on the NHS / If causing significant problems refer to Central Triage. / Central Triage
Naevus Sebaceous
http://dermnetnz.org/lesions/sebaceous-naevus.html / Probably should be excised in adulthood because of long-term risk of malignancy although this risk is small. / If unable to remove in primary care refer to Central Triage. / Central Triage
Congenital Naevi
http://www.dermnetnz.org/lesions/naevi.html / Cosmetic. Treatment not available on the NHS / Central Triage 20cm in diameter or 2cm in neonate because of possible malignant risk. / Central Triage/Secondary Care
Acne
http://www.dermnetnz.org/acne/index.html
http://dermnetnz.org/acne/rosacea.html / Appropriate topical and systemic treatment (oral antibiotics) or hormonal therapy should be tried
See
http://cks.nice.org.uk/acne-vulgaris#!scenario / If failure to respond, refer to Central Triage
If has had adequate treatment with topical treatments and/or antibiotics and not improved refer to Central Triage
If scarring – send urgently / Central Triage
Rosacea
http://dermnetnz.org/acne/rosacea.html / See
http://cks.nice.org.uk/rosacea#!scenario / If severe refer to Central Triage
Psoriasis
http://www.dermnetnz.org/scaly/psoriasis-general.html / Topical therapy to be tried.
If very widespread, if has lots of previous treatments, if severe or if the patient is very affected by it refer to secondary care.
See HMMC topical treatment algorithm guidance / If failure to control refer to Central Triage. If severe refer to Secondary Care. / Central Triage/Secondary Care
Atopic Eczema/ hand eczema/undifferentiated dermatitis
http://www.dermnetnz.org/dermatitis/dermatitis.html / Needs adequate topical treatment – emollients, topical steroids and treatment of infection. For amounts of topical refer to BNF section 13 / If failure to respond despite adequate treatment trial, refer to Central Triage. / Central Triage
Urticaria http://www.dermnetnz.org/reactions/urticaria.html / For Urticaria that has gone on for 6 weeks or more an allergic cause is VERY UNLIKELY. Patch testing or RAST testing will not help.
Regular antihistamines in increasing doses are the key to treatment / If failure to respond, refer to Central Triage / Central Triage
Undiagnosed lump - cancer not suspected / If no functional problems reassure and manage/ treat in Primary Care.
If GP concerned, refer to Central triage.
N.B. Remember rare forms of skin cancer and cancer elsewhere can spread to skin. Nodules need to be diagnosed urgently – consider 2 week wait. / Central Triage if concern or 2 week wait if cancer suspected / Central Triage (or 2 week wait)
Scabies
http://www.dermnetnz.org/arthropods/scabies.html / Scabies should be diagnosed accurately and not treated until diagnosis confirmed as this will exacerbate other skin conditions. Many cases of itch are not due to scabies. Dermoscopy can be very helpful in diagnosing scabies.
Failure to respond is usually due to inadequate treatment or re -infection / If failure to respond, or Norwegian Scabies refer to Secondary Care.
If failure to respond, or for Crusted Scabies refer to Secondary Care / Secondary Care
Onychodystrophy (fungal nail)
http://www.dermnetnz.org/fungal/onychomycosis.html / Fungal nail is a common and mostly benign condition. Therefore most patients require self- care or pharmacy preparations only, and treatment for fungal nail infection is not routinely funded by the NHS.
Exceptions to this are where the onychomycosis causes significant pain; secondary infection (cellulitis); functional impairment (e.g. inability to use footwear or difficulty walking) or where the patient is at significant risk of complications due to, for example, diabetes, peripheral vascular disease or immunosuppression.
It is essential, in those exceptional cases where treatment is planned, that before treatment is commenced the diagnosis must be first confirmed with nail scrapings or clippings.
(see priorities forum guidance - http://www.enhertsccg.nhs.uk/sites/default/files/guidance_19_-_fungal_nail_infection_mar_12.pdf)
Sometimes it can be difficult to diagnose and very difficult to distinguish from psoriatic nails
Fungal nails can lead to widespread fungal disease of the skin in diabetics, the elderly and those who are immunosuppressed.
Fungal infections in the feet are a significant cause of cellulitis
It is essential, in those cases where treatment is planned, that the diagnosis must be first confirmed with nail scrapings or clippings before treatment is commenced. / Refer to dermatology if child <18 needing oral medication; uncertain diagnosis; unsuccessful treatment; immune-compromised patient.
Consider referral to podiatry for nail surgery if nails are traumatized by footwear, or deformed toenails traumatize adjacent toes