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Dermatology toolkit

Site: Royal College of General Practitioners - Online Learning Environment
Course: Clinical toolkits
Book: Dermatology toolkit
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Date: Monday, 29 April 2024, 9:28 AM

Description

Skin conditions are the most common reason for patients to present in primary care.

Table of contents

Introduction

Skin conditions are the most common reason for patients to present in primary care. Around one in four patients visit their GP with skin problems each year. Many skin conditions are long term, with significant morbidity and requiring high levels of self-care. Skin cancer incidence and dermatology referrals are rising with high demands on secondary care services and increasingly long delays for dermatology specialist review.

Who is the Dermatology Toolkit for?

This evidenced-based resource aims to be easy to use for primary healthcare teams in the UK to support them with their learning and help them build confidence when caring for patients suffering from skin conditions. People affected by skin conditions and their carers can directly access or be signposted by healthcare professionals to sources of information and support, and it is suitable for commissioners of services for people suffering from skin conditions.

This Dermatology Toolkit was developed in partnership with a stakeholder group comprising of 13 members including; GPs, GPs with extended roles in Dermatology, Dermatology consultants, a Dermatology Nurse, a patient representative, committee members of the Primary Care Dermatology Society and representatives of a commissioning organisation.

Clinical resources for practitioners – dermoscopy and teledermatology

What is a dermatoscope?

A dermatoscope is a handheld device that combines 10x magnification with light and a polarising filter to eliminate surface reflection. This enables the colour and structures in the skin that are not visible with the naked eye or ordinary magnification to be seen. It aids the diagnosis of skin lesions, together with taking good history and full examination.

Why is dermoscopy useful in primary care?

With training it is most useful in excluding the common benign lesions which can mimic skin cancers including seborrhoeic keratoses, haemangiomas, sebaceous hyperplasia, dermatofibromas, comedones and benign moles.

It also has a role in detecting the most recognisable pre-cancerous lesions including Bowen’s disease and actinic keratoses, as well as cancerous lesions including basal cell carcinomas (BCCs), squamous cell carcinomas (SCCs) and malignant melanoma.

With a burgeoning rise in referrals to dermatology services, there is a need to improve the ability of primary healthcare professionals to triage skin lesions suspicious for skin cancer more accurately. This could reduce both referrals and unnecessary skin surgery for obviously benign lesions, and increase timely access for patients suffering from skin lesions and conditions which need specialist care.

Mission statement

In the same way that GPs use stethoscopes, auroscopes and ophthalmoscopes to aid diagnosis, dermatoscopes and dermoscopy training can become uniform practice in primary care to improve skin lesion recognition skills.

Dermoscopy Top Tips

  1. Top Tips: Getting started with using a dermatoscope (PDF)
  2. Using personal mobile devices to take photos TOP TIPs (PDF)
  3. Top Tips: How to take good dermatology photos (PDF)

Teledermatology and Advice and Guidance

Clinical resources for practitioners

The following tools may be used in diagnosing and managing patients suffering from a skin condition.

1. Websites

2. Primary Care Treatment Pathways developed by the PCDS

3. Royal College of General Practitioners (RCGP)

4. Clinical Knowledge Summaries (CKS)

CKS from National Institute for Health and Care Excellence (NICE) for dermatology conditions.

Specifically, for common dermatology conditions seen in primary care:

5. Guidelines and best practice

Guidelines in Practice and BMJ Best Practice includes summaries of guidelines and implementation of best practice. 

6. Dermatology in Practice

A review-based journal which is free to subscribe to. Quarterly bulletins are produced with an array of clinical articles, practical guides and case studies.

7. Skin of Colour resource

The Centre for Evidence Based Dermatology (CEBD) provides evidence based information of relevance to skin colour.

8. Assessment of disease severity and quality of life

The following tools can be used in clinic to guide treatments and need for specialist referral. 

  • Psoriasis Area and Severity Index (PASI)

i. Worksheet from British Association of Dermatologists (BAD)

ii. An easy and useful Psoriasis 360 APP can aid with psoriasis assessment in clinic and includes a PASI calculator (available on android)

  • Psoriasis Epidemiology Screening Tool (PEST) for Psoriatic Arthritis. It is recommended that patients with psoriasis who do not have a diagnosis of psoriatic arthritis have an annual screening for arthritis using this validated questionnaire.
  • Dermatology Quality of Life Index (DLQI) is a dermatology specific quality of life questionnaire which can be translated to different languages for:

i. Adults

ii. Children

  • Urticaria Activity Score (UAS7) is a patient-reported measure over 7 days of the number of wheals and intensity of itching, in those suffering from Chronic Idiopathic Urticaria. It is also available as an APP, SYM TRAC HIVES (android and iOS) 
  • Patient Orientated Eczema Measure (POEM) is an eczema severity assessment tool which is available to adults and children to self-complete their eczema symptoms.It is also available as an APP, My Eczema Tracker on android and iOS to enable eczema severity to be assessed over weeks or months.
  • Eczema Area and Severity Index (EASI) is a validated scoring system for recording the physical signs of eczema

9. Topical Corticosteroids potency ladder and quantity of application using the Finger Tip Unit (FTU) measure

There are a wide variety of topical corticosteroids available. The BNF has a useful topical corticosteroid potency page to support clinicians with identifying which potency a particular corticosteroid is.

The Finger Tip Unit (FTU) is commonly used to explain the quantity of topical corticosteroid that is to be applied to the skin and guides the clinician around quantities to prescribe. Patient.info have a useful information sheet on the FTU which can be translated into different languages.

10. Emollients (Moisturisers)

These are very important in the treatment of inflammatory and dry skin conditions such as eczema and psoriasis, in which their frequent and liberal use will act to restore the skin’s protective barrier and relieve dryness and itching. They can also be used as a wash (soap substitute). The National Eczema Society has a helpful Emollient Factsheet* which can support the patient and clinician to choose the best emollient for them.

*There are many emollient formularies around the U.K. and clinicians should refer to their local guidance.

The MIMS Emollient Sensitiser table lists emollient brands according to the presence of potential sensitising agents within each preparation.

11. Evidence Based Reviews on skin conditions and their treatments

 The Centre for Evidence Based Dermatology (CEBD) produces free tools and resources of relevance to those who have or research skin conditions.

Information and support for patients and carers

Many skin conditions are long term and require high levels of self-care and monitoring. The following resources can be used to support patients in understanding their skin condition, as well as signposting them to peer support groups.

A. Skin cancer detection and protecting skin damage (sunburn) from the sun’s Ultraviolet (UV) light (PDF)

B. Patient information for other skin conditions

C. Patient support groups, personal experience videos and support programmes for skin conditions (PDF)

D. Patient information on how to use TOPICAL skin treatments (PDF)

E. Self-management in Eczema and Psoriasis 

F. Prescription Prepayment Certificates

Prescription prepayment certificates can be applied for online, through pharmacies or by telephone, and can enable savings on prescriptions when regular prescriptions are being charged. 

Learning resources for dermoscopy

There are several accredited courses for dermoscopy training, as well as an array of online learning opportunities, dermoscopy blogs, apps, and books. Once started the fastest way to improve is by looking at ALL skin lesions using a dermatoscope daily in your practice and refer to pictures online or in books.

Dermoscopy should be an aid to diagnosis in combination with a good history and clinical examination.

Courses

Websites

  • The PCDS website has:

  i. A-Z clinical chapters, where both clinical and dermoscopic images can be viewed

  ii. A Diagnostic Algorithm to support clinical decision making

  iii. Interpretation of dermoscopic features

Blogs

  • Dr. Tim Cunliffe is a GP with an Extended Role (GPwER) in Dermatology and Skin Surgery and the lead author for the PCDS website. His Dermoscopy blog includes clinical cases with dermoscopic images that can be worked through using a dermoscopic algorithm.
  • Dr. Stephen Hayes is a GPwER in Southampton and has produced a Dermoscopy blog which includes many clinical examples of different dermoscopic features.
  • Dermoscopy Made Simple is a teaching blog from the Australian Institute of Dermatology, which includes YouTube presentations. 
  • Dr. Eric Ehrsam is a French Dermatology Specialist who has a Dermoscopy Blog, with examples of different dermoscopic features.

Apps

These provide the ability to practice dermoscopy skills at any time and are freely available:

  • YOU Dermoscopy Training provides lots of dermoscopic images and is divided into different training levels (available on iOS and Android)
  • Dermoscopy two step algorithm includes a series of cases with questions to support with making a diagnosis (available on iOS and  Android)

Online Atlas Dermoscopy Images

Books

The International Dermoscopy Society (IDS) has produced a list of books to support Dermoscopy learning. Useful books for beginners include:

  • Dermoscopy The Essentials [Johr RH, Soyer HP, Argenziano G, Hofman-Wellenhof R, Scalvenzi M. Dermoscopy: the essentials: Mosby; 2004.]
  • Diagnostic Dermoscopy: the illustrated guide [Bowling J. Diagnostic dermoscopy: the illustrated guide: John Wiley & Sons; 2011.]
  • Dermatoscopy: An algorithmic method based on pattern analysis [Kittler H. Dermatoscopy: An algorithmic method based on pattern analysis: facultas. wuv/maudrich; 2011.]

Learning resources for general dermatology

The following resources can be accessed by clinicians to further their understanding and confidence in supporting patients with dermatological conditions.

1. E-Learning for Healthcare (eLfH -free resource for NHS professionals)

In particular:

  • e-Derm 03 - Atopic Eczema, covers exacerbating factors in atopic eczema, emollient therapy, topical steroids and topical calcineurin inhibitors
  • e-Derm 02 - Psoriasis
  • e-Derm 28 - Topical Therapy  - covers  Topical Corticosteroids and Appropriate Use in Dermatology, Vit D analogues, Topical antifungals, cytotoxics and Imiquimod
  • e-Derm 26 – Psychodermatology
  • e-Derm 23 – Melanoma (covers clinical variants of melanoma)
  • e-Derm 24 - Non-melanoma Skin Cancer (covers Basal Cell Carcinoma, Squamous Cell Carcinoma)
  • e-Derm 17 - Dermatological Surgery 

2. RCGP Dermatology Library

This resource includes relevant pages from the Primary Care Dermatology Society (PCDS) website, British Association of Dermatologists (BAD), and contains links to e-learning, national guidelines and podcasts.

i. Freely accessible

ii. RCGP e-learning (RCGP membership required to access),

3. Case history quizzes on Dermnetnz 

4. BMJ learning (BMA membership required to access)  has a variety of quizzes, quick tips, 10 minute conversation, and clinical updates on common dermatology conditions.

5. MIMS learning

6. Pulse learning

7. The British Society for Dermatological Surgery has freely available Surgical Logbooks. Dr Cooper’s Logbook is user-friendly and supports minor surgery audits in primary care. 

8. The RCGP and the Primary Care Dermatology Society are supporting the British Association of Dermatologists to provide an accreditation programme for dermatology GPwERs. A GPwER is a GP who undertakes, in addition to their core general practice, a role that is beyond the scope of GP training and the MRCGP, and requires further training. Further information about GPwERs can be found on the RCGP website.

National reports and information for commissioners

1. Dermatology high level service reviews

2. Service Guidance and Quality Standards

3. National Institute for Health and Care Excellence (NICE) Quality Standards

4. National Dermatology Audit standards and reports from the British Association of Dermatologists

5. Cochrane special collection on skin cancer diagnosis

A collection of the evidence for the accuracy of diagnostic tests for all types of skin cancer. 

6. NHS England Elective Care Transformation Programme: Transforming Dermatology elective care services, a handbook for local health and care systems 2019 (PDF) 

7. Stockport Clinical Commissioning Group Dermoscopy project 2016

8. Evaluation of a Community Dermatology Pilot (Solihull pilot at GPS Healthcare) and NHS Savings 2017-18 (PDF)

9. Gloucestershire Clinical Commissioning Group (CCG) case study: Transformation of the routine management of dermatology cases (PDF)

10. Dermatology Structured referral forms (PDF)

may be used subject to local evaluation and adaptation to support secondary care referrals/e-mail advice (designed by Dr Emma Le Roux).

Resources for quality improvement

Quality Improvement (QI) is an evidence-based approach to continuously improve the quality of healthcare by embedding new approaches more effectively and efficiently into practice.

The RCGP have produced a pragmatic Quality Improvement Guideline for General Practice (PDF)

The West of England Academic Health Science Network have a range of downloadable QI tools for us in QI projects.

QI is undertaken using the QI cycle.

  • Step 1: Diagnose
  • Step 2: Plan and test
  • Step 3: Implement and embed
  • Step 4: Sustain and spread

QI cycle. RCGP QI Guide, p10 (PDF).

For the plan and test stage (step 2) of the QI cycle, it can be helpful to use the Model for Improvement approach to clarify the aim and measure of success(1). One approach to identify which changes result in an improvement or not is to undertake the Plan- Do-Study-Act (PDSA) cycle of change The advantage of the PDSA cycle is that it allows us to test out ideas for change in a controlled way, on a small scale. The RCGP has developed practical guidance to this methodology (PDF).

  1. What are we trying to accomplish?
  2. How will we know that a change is an improvement?
  3. What changes can we make that will result in improvement?
  • Plan
  • Do
  • Study
  • Act

Model for Improvement Diagram p1 of RCGP A practical guide to Model for Improvement and PDSA (PDF)

There is plenty of QI activity that can be undertaken within primary care for patients affected by skin conditions. Many of the chronic inflammatory skin conditions, which require high levels of self-management and have associated co-morbidities, could benefit from a QI approach to healthcare.

  1. Psoriasis Example (PDF)
  2. Atopic Eczema in Children Example (PDF)
  3. Acne Example (PDF)
References

1. Langley GJ, Moen RD, Nolan KM, Nolan TW, Norman CL, Provost LP. The improvement guide: a practical approach to enhancing organizational performance: John Wiley & Sons. 2009

Other resources and media



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While the content of this toolkit is reviewed and updated on a regular basis, we do not control or accept any responsibility for any linked resources on third-party websites or for any liability arising from their use. Any inclusion in this toolkit does not necessarily imply RCGP endorsement. Access to and use of content including clinical guidelines on any third-party website is carried out solely at your own risk.

An educational grant was received from Johnson & Johnson, Leo Pharma and Dermal for the production of this toolkit. All editorial and content decisions were made solely by the RCGP.