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DATE & VERSION: 26 August 2004, 11:431.35 |
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NATIONAL GUIDELINE |
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DISTRICT HEALTH BOARD: Nelson Marlborough |
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Skin lesions in this document refer to skin cancers, pigmented lesions, non-healing ulcers and other individual skin lesions. |
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CLINICAL PROBLEM
(Clinical Determinants) |
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ACTIONS |
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LOCAL IMPLEMENTATION REQUIREMENTS |
| PIGMENTED LESIONS |
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Clinically suspicious of malignancy |
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Excision biopsy (not incision), full thickness, margins 2mm or greater |
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Discuss with or refer to Specialist for excision biopsy 1 |
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Clinically not malignant |
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Monitor in 1º care |
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Refer for Specialist opinion if doubt. Consider cosmetic excision1 |
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Seborrhoeic keratosis |
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Cryotherapy (or excision) only if symptomatic |
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Rarely justifies public specialist assistance |
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| NON-PIGMENTED LESIONS |
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Lesion < 5mm |
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Excision biopsy |
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Histology required if diagnosis uncertain. Excision biopsy or destruction (curette + diathermy)1 |
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5mm or greater and clinically typical of SCC or BCC or keratoacanthoma |
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Excision, full thickness, margins 2mm or greater with careful follow-up to confirm recurrence does not occur |
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Histological confirmation required. Margins 2-5 mm. Discuss with Specialist or consider referral if lesion large 1 |
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Clinically suspicious of malignancy or Bowen's disease |
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Punch biopsy |
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Histological diagnosis required. Biopsy methods include: shave, curette, excision, incision, punch 1 |
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Solar keratosis |
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Monitor for development of SCC |
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Curette and histology if doubt |
| OR cryotherapy |
| OR 5-FU if numerous |
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| HISTOLOGY KNOWN |
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Melanoma |
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Discuss with or refer to Specialist |
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Follow-up recommendations for malignant melanoma lesions, see 'general notes' on reverse |
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SCC - excised with margin 2mm or greater |
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Monitor in 1º care |
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Review at 3 and 6 months then annually |
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SCC - excised incompletely or with margin < 2mm |
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Complete adequate excision |
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Refer if beyond GP skill level1 |
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SCC - with regional nodes |
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Specialist assistance |
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Specialist referral |
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Bowen's disease |
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Complete excision or destruction (cautery, cryotherapy) |
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Destruction (shave excision, curette + diathermy, cryotherapy) 1 |
| OR 5-FU |
Refer if beyond GP skill level1 |
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BCC - completely excised |
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Monitor in 1º care |
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GP review at 2-3 months then annually |
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BCC - incompletely excised |
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Complete excision OR Destruction (curettage and cautery) |
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Destruction (curette + diathermy, cryotherapy). Refer if beyond GP skill level 1 |
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Local recurrence |
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Specialist assistance |
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Treat in 1° care if adequately skilled 1 |
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Keratoacanthoma |
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Complete excision or destruction |
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Destruction (curette + diathermy best) 1 |
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| MISCELLANEOUS |
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Non-healing ulcers |
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If small, excision biopsy
If large, full thickness biopsy of the margin |
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Refer if beyond GP skill level 1 |
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Chondrodermatitis nodularis helicis ears |
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Treat conservatively if small OR Specialist assistance for excision |
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Treat with topical antibiotic (Pimafucort, Soframycin) and relief of pressure at night (corn plaster or similar). Refer to dermatologist if persistent or diagnosis in doubt |
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Pyogenic granuloma |
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Excision or biopsy, cautery with care to destroy feeding blood vessel |
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Refer if beyond GP skill level 1 |
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Epidermoid cysts
- sebaceous cysts
- pilar (tricholemmal) cysts |
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Treat conservatively if asymptomatic
OR excise completely |
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Rarely justifies public specialist assistance |
| Excise completely (elliptical excision, or incision and curettage) if symptomatic or cosmetic reasons 1 |
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Dermatofibroma |
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Treat conservatively |
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Excise if symptomatic or cosmetic reasons (elliptical excision to remove completely, or shave to flatten contour only). 1Rarely justifies public specialist assistance |
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Milia |
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Treat conservatively
OR (rarely) incise and express intact |
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Rarely justifies public specialist assistance |
