Dermatology Toolkit

Introduction to Dermatology Toolkit

Skin conditions are the most common reason for patients to present in primary care. Around 1 in 4 patients visit their GP with skin problems each year. Many skin conditions are chronic, 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 confidence in 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.

Resources marked with * are supported by pharmaceutical industry or the commercial sector

Clinical resources for practitioners

Dermatoscopy Overview 

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 a 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 recognizable 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 should become uniform practice in primary care to aid with skin lesion diagnosis.

Dermatoscope Top Tips 

Getting started with using a Dermatoscope TOP TIPS

Which dermatoscope to use?

There are 3 types of dermatoscope. Deciding which instrument to use is personal preference, and it may be helpful to try out different devices. All devices contain rechargeable batteries.

1. Contact non-polarised light (classic dermoscopy)

Pros

  • Long established devices
  • Good image quality 
  • Stable device for camera attachment

Cons

  • Requires use of contact fluid on the skin which can be time consuming and messy
  • Risk of cross infection

2. Non-contact polarised light

Pros

  • Smaller pocket size
  • Can be used quickly to examine multiple lesions on the skin
  • No contact fluid needed on the skin
  • Low risk of cross infection

Cons

  • Inferior image quality

3. Hybrid (has both contact and non-contact ability, and non-polarised and polarised light options) 

Pros

  • Combines ability to screen multiple lesions quickly using polarised mode and better image quality of contact devices.Very practical device in primary care setting

Cons

Primary Healthcare professionals considering purchasing a Dermatoscope may wish to approach their Clinical Commissioning Group (CCG), who may be able to advise and support.

Other Equipment

1. Contact fluid 

  • Alcohol Hand Gel or sterets recommended except around eyes and nails (reduces risk of cross infection, and can be used to clean device between patients)
  • KY Jelly (viscous gel) for examining lesions on nail folds

2. Disposable endplates  are the gold standard when examining bleeding lesions. An alternative option to consider if your device doesn't have this option is Clingfilm which is  applied over the endplate. 

3. Camera and Camera attachments (to enable photography of lesions examined)

  • Either Digital camera with adaptor kit to attach to dermatoscope or
  • Smartphone adaptor kit to attach dermatoscope directly to a smartphone/mobile device*

4. Software
Any photos taken will need to be attached to the patient record in the clinical system. Software can be used to resize files of images taken with digital cameras so that they can readily be uploaded/viewed within the electronic medical record. File sizes of images taken on mobile devices can be resized during the process of secure image transfer using an NHS.net account.*

*Refer to Using personal mobile devices to take photos TOP TIPSs for guidance on using personal mobile devices in Dermatology.

 

Using personal mobile devices to take photos TOP TIPs

Use of a mobile device is a pragmatic tool to take clinical dermatology images in primary care and community settings. If they are used, clinicians must follow clear guidelines to ensure that images are captured and transferred in a confidential and secure manner, meeting the requirements of the Data Protection Act 2018,(1) and EU General Data Protection Regulation (GDPR).(2) UK guidance has been produced on the use of mobile devices in Dermatology.(3)

Every practice should have a policy on ‘bring your own device’ (BYOD). The practice may consider buying a device or using an old one purely for medical use i.e. no SIM or account, to act solely as Wi-fi device with no further connectivity or backup storage.

If you are going to use your OWN device the following steps should be taken:

1. Securely configure your mobile device:

  • Passcode protection  (6+ characters) and auto locks after 5 minutes
  • Check data encryption is enabled in the security settings of the device
  • Check operating systems are fully updated
  • Turn off any default settings including global positioning satellite (GPS) location services which are linked to photographs, and any setting that automatically uploads or backs up photos to cloud storage

2. Add NHS.net account onto mobile device

3. Obtain Consent 

  • Informed consent is good clinical practice and should be obtained before capturing any images
  • Written consent is recommended whenever possible, with completion of a standardised consent form which must then be uploaded to the patient record. Individual clinicians are advised to ensure that they are acting in accordance with any local information governance policy.
  • An example consent form can be found as Appendix A (p30) of the British Association of Dermatology UK Guidance on the use of mobile photographic devices in Dermatology

4. Take a Photo

Always take a Macro (distant) image as well as a Dermoscopic image*

Either use: 

  • Camera on mobile device with Bluetooth, cloud-based backup system, location settings and social media switched off

OR

  • Dedicated GDPR compliant APP on your mobile device.  Several APPs are in existence and more are likely to be developed.
  • If the patient has a mobile device, consider TAKING PHOTOS ON THEIR DEVICE AS WELL so they have a record.

5. Transfer (e-mail) the image securely using NHS.net account (which is an encrypted platform)

  • In the ‘to’ field type nhs.net account (your own)
  • In the‘from’ field scroll down to select your own nhs.net address
  • Inthe ‘subject’ field patient data needs to be anonymised (no patient identifiers)/pseudo-anonymised e.g. initials of clinician who saw patient together with date and time of appointment that patient was seen.
  • Click ‘send’ and choose a file size of ‘small’ or ‘medium’ so that the image can easily be e-mailed or uploaded for Advice and Guidance/dermatology referrals. Smaller file sizes also facilitate faster viewing of images in the patient record.
  • Login to your nhs.net account on a work PC
  • The image can then be downloaded onto work PC and then attached to the patient’s electronic medical record, with a copy of consent.

6. Delete all patient images from mobile device, e-mail account, and PC once photo has been taken, e-mailed and stored in patient’s electronic medical record.

Note that outside the patient record, images should only be stored under access-controlled conditions e.g. in a folder on an PC shared drive which is access controlled via password protection or encryption. This is acceptable if patient consent has been given for using the images for teaching purposes.

*  Refer to How to take good dermatology/dermoscopy photos TOP TIPS

Summary Flowchart for the use of images for clinical purposes3

How to take good Dermatology/Dermoscopy Photos TOP TIPs

Optimising the quality of the clinical images that are taken is very important to support clinical decision making. Follow these top tips to increase the quality of images taken.

  1. Take a distant image with an anatomical marker to establish the location of the lesion
  2. Take at least one close-up (macro) image of the lesion. Additional images with side lighting e.g. at an oblique angle will supplement and allow the viewer to more accurately assess the shape, size, and edge of the lesion. 
  3.  Use a measuring scale with the close-up image. 
  4. Use a background e.g. disposable tissue roll, neutral wall, which should be placed in contact with the patient to reduce shadows
  5. Remove any surface crust or scale on lesions and use micropore tape or equivalent to remove small surface scales on pigmented lesions or dry skin (tape stripping).
  6. Flash should always be ON except with dermoscopy images as this enables reliable reproducible illumination and sharper images. In SLR cameras ensure the ‘macro’ setting is ON.
  7. Do not go beyond the autofocus of the camera to avoid image blurring. Autofocus on the lesion and then use the zoom to get closer to the lesion of interest rather than moving the camera closer, to enable even lighting from the flash. If the lesion is small the camera may not focus that close. Move back and try to focus again rather than moving the camera closer to the lesion.
  8. There are a variety of smartphone and SLR camera dermoscopic attachments which facilitates taking dermoscopy photos
  9. When taking dermoscopic photos use a liquid interface e.g. alcohol gel, KY jelly, ultrasound Gel to prevent surface reflections. Wipe the skin and dermoscope face plate clean before applying the liquid gel to try and avoid bubbles. 
  10. Do not apply too much pressure with the dermoscope as this can squash the vessels
  11. Take non-polarised and polarised images with dermoscope
  12. Replay the image and if not clear take another image.
  13.  For monitoring photos take an image on the patient’s mobile device so they have a copy too.
  14. Smaller file sizes are needed when uploading images to the patient record.  File sizes of images taken on mobile devices can be resized during the process of secure image transfer using an NHS.net account,* or using specific software programmes if the image is taken with a digital camera.

The Teledermatology service in Bristol and North Somerset have developed a guide to taking better photographs 

* Refer to Using personal mobile devices to take photos TOP TIPS for instructions on how to resize files using NHS.net e-mail transfer of images. 

Resources for Practitioners General Dermatology

      1. Websites

      2. Primary Care Treatment Pathways developed by the PCDS

      3. Royal College of General Practitioners (RCGP)

      4. Clinical Knowledge Summaries (CKS) from National Institute for Health and Care Excellence (NICE) for dermatology conditions

Specifically, for common dermatology conditions seen in primary care:

      5Guidelines in Practice and BMJ Best Practice include summaries of guidelines and implementation of best practice.

      6.  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)

      Dermatology Quality of Life Index (DLQI) is a dermatology specific quality of life questionnaire which can be translated to different languages for:

  • Adults
  • Children
  • App: The DLQI is also available on the Psoriasis 360 APP (available on iOS and android)  

  • 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) 

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

There are a wide variety of topical corticosteroids available. Bridgewater Community Healthcare NHS Trust Dermatology Servicehas produced a useful topical corticosteroid potency ladder chart 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 prescribePatient.info have a useful information sheet on the FTU which can be translated into different languages.

8. 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.

9. Evidence Based Reviews on skin conditions and their treatments

The Centre for Evidence Based Dermatology (CEBD)  has Maps of Systematic Reviews collated by topic for Acne, Atopic Eczema, Cellulitis, Hidradenitis Suppuritiva, Psoriasis and Vitiligo.

 

 

Information and support for patients and carers

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.

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

 

Understanding your risk of developing skin cancer

Understanding your skin type and risk of damage from UV light

It is important to self-examine your skin so that any skin changes can be detected early . The following information is how to examine your own skin. This includes how to detect an UGLY DUCKLING amongst your moles. In Hans Christian Anderson’s classic fairy tale, the ugly duckling stood out from the flock because he was destined to become a swan. In Dermatology, the ‘UGLY DUCKLING’ is a mole that does not look like the rest of the moles on a person’s skin and may be suspicious for a melanoma. 

APPs to support patients with tracking changes in their moles 

Facts and signs of melanoma skin cancer

 Facts and signs of common non-melanoma skin cancers

 How to prevent skin cancer using clothing, shade and sunscreen

 Sunscreen factsheet

2. Patient information for other skin conditions

 

3. Patient support groups

 

For those suffering from skin cancer

For  those suffering from Eczema

For those suffering from Psoriasis

For those suffering from Acne

For  those suffering from other skin conditions

Patient experience videos and programmes

4. Patient information on how to use TOPICAL skin treatments

 

Factsheets for Emollients (Moisturisers)

Factsheets for Topical Corticosteroids

Factsheets for application of topical treatments to treat pre-cancerous and cancerous skin conditions

Videos

The British Association of Dermatologists has informative videos on:

  • How to apply moisturisers (emollients)
  • How to apply Topical Corticosteroids
  • How to treat Scalp psoriasis

Videos on eczema treatments in children including topical steroids and emollients (moisturisers)

5. Self-management in Eczema

 

 

 

 

Training and appraisal resources

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.

1. Courses

2. Websites

 The PCDS website has:

3. Blogs

  • Dr. Tim Cunliffe Dermoscopy Blog - Dr. Cunliffe is a GP with an Extended Role (GPwER) in Dermatology and Skin Surgery and the lead author for the PCDS website. His blog includes
    clinical cases  with dermoscopic images that can be worked through using a dermoscopic algorithm
  • Dr. Stephen Hayes Demoscopy Blog - Dr.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 You tube presentations. 
  • Dr. Eric Ehrsam Dermoscopy Blog -  Dr. Eric Ehrsam is a French Dermatology Specialist who has a Dermoscopy Blog, with examples of different dermoscopic features.

4. Apps

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

  • Your Dermoscopy Training provides lots of dermoscopic images and is divided into different training levels. (available on iOS and android)
  • Dermoscopy 2 step algorithm includes a series of cases with questions to support with making a diagnosis. (available on iOS and android)

5. Online Atlas Dermoscopy Images

6. Books
The IDS has produced a list of books to support dermoscopy learning. Useful books for beginners include:

  • Dermoscopy The Essentials(1)
  • Diagnostic Dermoscopy: the illustrated guide(2)
  • Dermatoscopy: An algorithmic method based on pattern analysis(3)
Book references
  1. Johr RH, Soyer HP, Argenziano G, Hofman-Wellenhof R, Scalvenzi M. Dermoscopy: the essentials: Mosby; 2004.
  2.  Bowling J. Diagnostic dermoscopy: the illustrated guide: John Wiley & Sons; 2011.
  3. Kittler H. Dermatoscopy: An algorithmic method based on pattern analysis: facultas. wuv/maudrich; 2011.

 

National reports and information for commissioners

National Reports and Information for Commissioners

Dermatology high level service reviews

Service Guidance and Quality Standards

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

 

 

Resources for quality improvement

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