LOW PRIORITY PROCEDURE - Policy T28
Management of Benign skin lesions
Policy author: Ipswich and East and West Suffolk Clinical Commissioning Group
Policy start date: July 2011
Minor amendments: July 2012
Second revision: March 2014
Review date: March 2016
Policy Summary
There are three management options for patients presenting to their GP with a skin lesion:
1. No treatment needed at present – reassurance +/- surveillance only
2. Treatment possible in primary care/community setting, e.g. straight forward excision, cryotherapy etc.
3. Referral to secondary care specialist for investigation/treatment
As only a minority of patients presenting with benign skin lesions will derive benefit from specialist referral, the CCG will only offer funding if one or more of the eligibility criteria has been met.
Referral criteria
1. Diagnostic uncertainty exists and there is suspicion of malignancy. GPs are reminded to refer to the 7 features suspicious of malignancy, as per NICE guidance on skin cancer*.
2. The lesion is painful or impairs function and warrants removal, but it would be unsafe to do so in primary care/community setting, for example because of large size (>10mm), location (e.g. face or breast) or bleeding risk. Removal would not be purely cosmetic.
3. The lesion is on or very near to the eye and is painful/infected/infringes on vision and cannot be safely removed in primary care/community setting. Removal would not be purely cosmetic.
4. The patient is 16 years old or younger and removal would not be purely cosmetic.
5. Viral warts in the immunosuppressed.
6. Patient scores >20 in Dermatology Life Quality Index administered during a consultation with the GP or other healthcare professional.
*NICE recommend1 GPs use the following checklist, with major features scoring 2 and minor features scoring 1. A score of 3 indicated high suspicion of malignancy. If there is a strong clinical suspicion, the patient may be referred on the basis of one feature alone.
Major features:
-change in size
-irregular shape
-irregular colour
Minor features:
-diameter 7mm or more
-inflammation
-oozing
-change in sensation
Background to the condition and treatment
Skin lesions are very common, with around 8.4% of GP consultations being in regard to skin complaints 2. The majority are harmless and self limiting and those which are not self limiting are often easy to treat in a primary care setting 3, 4. Lesions which cause no harm to the patient do not require treatment at all, although people may desire treatment for cosmetic reasons. Given the finite resources available, and lack of clinical need, it is important not to offer treatment for cosmetic problems either in primary or secondary care. This ensures time and resources are allocated to those with clinical need, i.e. possible malignancies.
Rationale behind the policy decision
This policy is designed to ensure that limited healthcare resources are put to the best possible use, benefitting patients in clinical need, which includes streamlining referrals to Dermatology. It is NOT intended to discourage clinicians from using the referral pathway appropriately, for those patients in whom they suspect a malignancy, or those who cannot be safely treated in a primary care setting.
In the past, a variety of conditions have fallen under the heading ‘benign skin lesions’. These include non endocrine hirsuitism (see separate policy), male pattern baldness and hyperhidrosis. It is beyond the scope of this policy to cover on all specific conditions; however it is worth noting that the NHS does not fund hair regrowth treatments, and the CCG does not routinely fund botulinum toxin or surgery for hyperhidrosis.
The primary function of a cosmetic procedure is to improve appearance – it is not undertaken to improve functionality (be that mobility, the senses, pain reduction or psychosocial wellbeing) and is by definition nonessential. It can sometimes be difficult to discern whether there is clinical justification for a procedure as it may be extremely important to the individual patient. In order to be fair and try to standardise the care patients can expect to receive both county wide and across the UK, we can try to use objective measures to decide if a procedure is purely cosmetic.
The Dermatology Life Quality Index (DLQI)6 is a widely validated and easy to implement questionnaire7 consisting of 10 questions with a maximum score of 30. This gives an indication of the impact of a benign skin lesion on the patient’s quality of life. A score of >20 indicates an ‘extremely large effect on a patient’s life’ and could be considered justification that a proposed procedure is not purely cosmetic.
References
1. http://www.nice.org.uk/nicemedia/live/10968/29814/29814.pdf (p35)
2. Kerr OA, Tidman MJ, Walker JJ et al. The profile of dermatological problems in primary care. Clin Exp Dermatol. 2010; (4):380-3
3. http://www.patient.co.uk/doctor/minor-surgery-in-primary-care
4. George S, Pockney P, Primrose J et al. A prospective randomised comparison of minor surgery in primary and secondary care. The MiSTIC trial. Health Technology Assessment 2008;12(23):iii-iv, ix-38.
5. http://www.bad.org.uk/Portals/_Bad/Guidelines/Dermatology%20Life%20Quality%20Iindex%20(DLQI)%20-%2001.10.12.pdf
6. Mazzotti E, Barbaranelli C, Picardi A et al. Psychometric properties of the Dermatology Life Quality Index (DLQI) in 900 Italian patients with psoriasis.Acta Derm Venereol 2005;85(5):409-13
7. http://www.dermatology.org.uk/quality/dlqi/quality-dlqi.html