Dermatology Toolkit

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 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 
2. Top Tips: Using personal mobile devices to take photos 
3. Top Tips: How to take good dermatology photos

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

1. Websites

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

Specifically, for common dermatology conditions seen in primary care:

5. 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 iOS  and 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 - the DLQI is also available on the Psoriasis 360 APP (available on iOS and android)  

ii. Children

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. Wrightington, Wigan and Leigh NHS Trust has 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 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) has Maps of Systematic Reviews collated by topic for Acne, Atopic Eczema, Cellulitis, Hidradenitis Suppuritiva, Psoriasis and Vitiligo.

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

B. Patient information for other skin conditions

• Public/patient skin conditions information leaflets (British Association of Dermatologists) A comprehensive resource of patient information leaflets for many common skin conditions and their treatments.
• Patient.Info skin conditions. An online information and forum resource for many skin conditions that can be easily TRANSLATED to different languages.
• British Skin Foundation A-Z skin information. An alphabetical online resource of skin conditions, treatment options and self-care advice.
• Molluscum Contagiosum Diagnostic Tool for Parents. A booklet that helps parents to identify if a spot of lump on their child's skin is Molluscum Contagiosum.

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

D. Patient information on how to use TOPICAL skin treatments

E. Self-management in Eczema 

• Personalised self-management plan for managing eczema in children from the Centre for Academic Primary Care, Bristol University has been developed to support parents and carers in managing their child’s eczema at home with support from their GP.
• EmolliZoo app from the National Eczema Society is a child friendly APP to support children and carers in learning about emollients in eczema as well as a diary to set up treatment reminders, and record photos and notes to discuss with healthcare professionals.
• My Eczema Tracker APP from the Centre for Evidence Based Dermatology, Nottingham University is an eczema severity assessment tool which is available to adults and children to self-complete their eczema symptoms over weeks or months. Available on both iOS and Android. 

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. 

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

• The Primary Care Dermatology Society (PCDS) runs absolute beginners and more advanced dermoscopy courses
• Cardiff University runs a three-month Introduction to Dermoscopy distance learning course

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

• Dermnetnz website has photos, descriptions of dermoscopic features and a free online course
• The International Dermoscopy Society (IDS) has several sources of education for dermoscopy including a forum, Facebook page, and podcasts as well as links to the online dermoscopy equivalent of Wikipedia – Dermascopedia!

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

• The International Atlas of Dermoscopy and Dermatoscopy is produced by the skin cancer college of Australia and New Zealand and includes an online quiz 
• Dermascopedia! 

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.]

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

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

for example, atopic eczema

3. Case history quizzes on Dermnetnz and Derm 101  

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 has launched a new process of accreditation of GPs with Extended Roles in Dermatology, delivered with the support of the British Association of Dermatologists and the Primary Care Dermatology Society. 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. All relevant information regarding the GPwER accreditation can be found on the RCGP website here. 

1. Dermatology high level service reviews

• Schofield J, Grindlay D, Williams H. Skin conditions in the UK: a health care needs assessment. Centre of Evidence Based Dermatology, University of Nottingham, 2010.
• British Association of Dermatologists publication on case reviews in commissioning of Dermatology Services in England 2013
• Kings fund report March 2014. ‘How can dermatology services meet current and future patient needs, while ensuring quality of care is not compromised and access is equitable across the UK? 
• Independent Expert Working Group (EWG) report 2018. ‘Making real our shared vision for the NHS: optimising the treatment and care of people with long-term skin conditions in England’. 

2. Service Guidance and Quality Standards

• Quality standards for Dermatology 2011
• Quality standards for teledermatology 2013 
• Guidance for commissioning Dermatology Services, Clinical Services Unit, British Association of Dermatologists 2014
• UK guidance on the use of mobile photographic devices in Dermatology 2017

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

• Skin cancer (QS130) 2016
• Psoriasis (QS40) 2013
• Atopic Eczema Under 12’s (QS44) 2013
• Pressure Ulcers (QS89) 2015

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 

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 

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

10. Dermatology Structured referral forms 

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

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

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.

Figure 1: QI cycle. RCGP QI Guide, p10.

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.

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
2. Atopic Eczema in Children Example
3. Acne Example

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.