|
DATE & VERSION: 26 August 2004, 11:431.35 |
|
NATIONAL GUIDELINE |
|
DISTRICT HEALTH BOARD: Bay of Plenty |
|
Skin lesions in this document refer to skin cancers, pigmented lesions, non-healing ulcers and other individual skin lesions. |
|
|
CLINICAL PROBLEM
(Clinical Determinants) |
|
ACTIONS |
|
LOCAL IMPLEMENTATION REQUIREMENTS |
| PIGMENTED LESIONS |
|
Clinically suspicious of malignancy |
|
Excision biopsy (not incision), full thickness, margins 2mm or greater |
|
Discuss with or refer to Specialist
Excise in 1º care if safe |
|
|
Clinically not malignant |
|
Monitor in 1º care |
|
Annual checks if patient at risk. Photograph lesion beside ruler |
|
| |
Seborrhoeic keratosis |
|
Cryotherapy (or excision) only if symptomatic |
|
Rarely justifies public specialist assistance |
| |
| NON-PIGMENTED LESIONS |
|
Lesion < 5mm |
|
Excision biopsy |
|
| Excise in 1º care if safe. Punch biopsy may be useful in tricky sites. Specialist assistance if beyond GP skill level |
|
|
 |
|
|
|
5mm or greater and clinically typical of SCC or BCC or keratoacanthoma |
|
Excision, full thickness, margins 2mm or greater with careful follow-up to confirm recurrence does not occur |
|
Excise in 1º care if safe. Specialist assistance if beyond GP skill level |
|
|
Clinically suspicious of malignancy or Bowen's disease |
|
Punch biopsy |
|
Biopsy in 1º care if safe. Specialist assistance if beyond GP skill level |
|
|
Solar keratosis |
|
Monitor for development of SCC |
|
GP follow up |
| OR cryotherapy |
Remove in 1º care |
| OR 5-FU if numerous |
5-FU requires "specialist recommendation" |
| |
| HISTOLOGY KNOWN |
|
Melanoma |
|
Discuss with or refer to Specialist |
|
If specialist assistance required, refer head & neck lesions to ORL or dermatology, eye lesions to ophthalmology and limb or body lesions to general surgery or dermatology. Post-excision, follow up patient using appropriate protocols |
|
|
SCC - excised with margin 2mm or greater |
|
Monitor in 1º care |
|
Review at 3 and 6 months then annually. Lesions on lips and ears are high risk tumours with a higher chance of metastatic spread |
|
|
SCC - excised incompletely or with margin < 2mm |
|
Complete adequate excision |
|
Excise in 1º care if safe. Specialist assistance if beyond GP skill level. If large or in any doubt refer for further investigation |
|
|
SCC - with regional nodes |
|
Specialist assistance |
|
Refer to appropriate dept. Mark "Urgent". Telephone specialist |
|
|
Bowen's disease |
|
Complete excision or destruction (cautery, cryotherapy) |
|
Removal in 1º care if safe. Specialist assistance if beyond GP skill level. (Below knee cryotherapy has high risk of ulceration) |
| OR 5-FU |
5-FU requires "specialist recommendation" |
|
|
BCC - completely excised |
|
Monitor in 1º care |
|
Look for other skin cancers annually |
|
|
BCC - incompletely excised |
|
Complete excision OR Destruction (curettage and cautery) |
|
Removal in 1º care if safe. Specialist assistance if beyond GP skill level. Referral for excision depends on patient age and tumour site |
|
|
Local recurrence |
|
Specialist assistance |
|
Refer to secondary care |
|
|
Keratoacanthoma |
|
Complete excision or destruction |
|
| Removal in 1º care if safe. Specialist assistance if beyond GP skill level. Treat as SCC unless pathology confirmed |
|
|
| |
| MISCELLANEOUS |
| |
Non-healing ulcers |
|
If small, excision biopsy
If large, full thickness biopsy of the margin |
|
Review at 4 weeks and biopsy in 1º care if safe at approximately 8 weeks. Specialist assistance if beyond GP skill level |
|
|
Chondrodermatitis nodularis helicis ears |
|
Treat conservatively if small OR Specialist assistance for excision |
|
| Manage in primary care; punch biopsy if suspicious |
| If large refer to ORL or dermatology |
|
|
| |
Pyogenic granuloma |
|
Excision or biopsy, cautery with care to destroy feeding blood vessel |
|
Excision, curette or cautery in 1° care if safe. Specialist assistance if beyond GP skill level |
|
|
Epidermoid cysts
- sebaceous cysts
- pilar (tricholemmal) cysts |
|
Treat conservatively if asymptomatic
OR excise completely |
|
Rarely justifies public specialist assistance |
|
|
Dermatofibroma |
|
Treat conservatively |
|
Rarely justifies public specialist assistance |
|
|
Milia |
|
Treat conservatively
OR (rarely) incise and express intact |
|
Rarely justifies public specialist assistance |
