“Don’t make a mountain out of Dermatology”

Mole Hill Topics:• Psoriasis & Eczema• Acne & Rosacea• Urticaria, Itch & Itchy

Rashes• Melanoma & it’s mimics• SCC, Bowens, AKs• BCC & Benign skin

lumps & bumps

Dr Paul Farrant, Consultant Dermatologist & Clinical Lead at BSUH

Dermatology During Covid 19

Update on Dermatology

• Challenges• Phase 1 - 3• Learning so far– Photography

• Solutions

Challenges

• Totally outpatient patient facing speciality• One of largest TWW services in trust• Large number of elderly patients with skin

lesions– Lack technology or inability to use– Isolation from family

• Decreased staff (more than ½ of nurses + 2 juniors + 4 pregnant + self-isolation)

Phase 1

• Crisis management• Stop all people coming to hospital other than TWW • Rejig week: Daily TWW and urgents (am only)• Cancelling of all non-urgent surgery• Forward planning of booked clinics from Mid-March to

May• News added to disease specific waiting list –• Follow ups managed virtually, where possible• Contacting all high risk patients with the ever changing

advice!

Phase 1Process changes• Instructions for patients to take own photos• Skin lesion information sheethttp://www.brightondermatology.co.uk• Approval to change TWW & education of TWW team• Consultant Triage of all eRS (300+) “Disease specific

hold letters”• …and clearing admin email! • AccuRx installation to S1 • Verification of mobile numbers• Smart cards and admin training for medical staff

Phase 2

• New TWW with patient submitting own photos for virtual appointment

• Telederm with patient submitting own photos for virtual appointment

• Routine patients told not to attend• Follow ups carried out same day +/- news• New job plans for consultants• Staff trained for redeployment

Phase 2 Observations

• Referrals - marked decrease incl TWW• Lots of patients needing surgery won’t come• Photo quality correlates strongly with being

able to make a definite decision – teledermtaking twice as long as normal!

• Brings out the best and worst in staff and variable skills in adapting to change

Phase 3

• Getting back to “new normal”• Clearing all follow ups for next 2 months• Disease specific pre-consult for new patients• Plan to start new virtual consults next week• Increase surgery to head and neck BCCs and

all SCCs• Continuation of consultant triage and A&G

Learning so far

• Change is good but hard work!• There is a lot that can be done virtually• Lots of people can’t take photos or are totally

incompetent! • Pre-screening of TWW, if done properly, has huge

potential to ease the strain on face to face• Local photography likewise, eg travelling to studio

doesn’t make sense if we can improve quality

Learning so far

• There is benefit of consultant triage– Appropriate referrals– Pre-appointment advice– Rejection with advice or signposting to more

appropriate service

• A&G is under utilized – more A&G coming through with photos which makes for far more meaningful dialogue

Learning so far

• Video is no good for visualizing a skin lesion & can be overly time consuming

• Photographs need to be submitted ahead of time and uploaded to record

• Additional information and information over the phone is helpful

• A surprising number of follow ups can be done over the phone but what are we missing and does it matter?

Solutions

• Advice on how to take imageshttp://www.brightondermatology.co.uk• Advice on all things telederm, photographyhttps://www.bad.org.uk/healthcare-professionals/teledermatology• Use of mobile devices to take photoshttps://www.bad.org.uk/shared/get-file.ashx?itemtype=document&id=5818

Taking photos on your phone

• Securely configure your device (lengthen passcode, encrypt data, turn off GPS tagging)

• Add NHS.net account to mobile• Obtain verbal consent• Take photos – one further away with

something to give scale 10p/measuring strip, one close up

• Transfer (e-mail) the image securely using NHS.net account – In the ‘To’ field type own nhs.net email– In the ‘subject’ field patient data needs to be anonymised – 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

– 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.

• 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.

Extra & better hack!

• Open your nhs email on your phone from the outlook app

• To, Bcc and Subject as before• Click on camera icon and take pictures which

directly adds to email and doesn’t leave on camera roll or folders or cloud

Taking photos on your phone

• Consider using GDPR compliant App– Hospify

• Use well lit space• Beware of flash• Macro mode

Consultant CONNECT

Getting patients to take theirown photos

• Challenging!• Encourage them to get help– Friends– Neighbours– NHS volunteers?

• Read the instructions - far and close• Keep steady• Check the result • Re-size as small or medium

High Risk Skin Lesions

• Most lesions are slow in evolution and change over months

• Pigmented lesions– Pencil eraser size✎– Asymmetrical – usually flat (cf raised & rough usually benign)– Multiple colours– Change! Consider monitoring.

• Other lesions PAIN = SCC, Bleeding = BCC

Other Skin problems

• Acne– Isotretinoin a risk?– Antibiotics + retinoids +/- COCP

• Eczema, Psoriasis – maximise topical therapy– Phototherapy suspended but hoping to restart soon– Social distancing for those on immunosuppressive

therapies

• Urticaria – maximise anti-histamines – Could consider Omalizumab

Itchy Patient(Consider any new drugs)

Without Rash• Soap Substitute to wash eg Doublebase wash• Anti-itch emollient eg Balneum PLUS cream bd• Non-sedating anti-histamines during day• Sedating at nighWith rash• As above +• Trial of potent steroid before bed eg

Mometasone ointment

Other Skin problems

• Symmetrical rashes– Soap substitutes & Emollients– Trial of moderate/potent topical steroids if itching

or flaky

• Asymmetrical rashes– Infection eg tinea until proven otherwise– If weeping – Permitab soaks?

• Not sure what to do? – consider A&G

Covid Skin ChangesSpanish observational study 41% serologically positive for Covid19:• Measles like exanthem

47% Early• “Pseudo-chilblains” 19%

Late• Urticaria 19%• Vesicular chicken pox like

eruption 9%• Livedo 6%• Kawasaki like

Useful Resources

• https://www.skinhealthinfo.org.uk/symptoms-treatments/common-symptoms/

• https://dermnetnz.org/• http://www.acnesupport.org.uk/

The “New Normal”

• Focus on Getting back to work• Lots of day surgery patients to be persuaded

to come in • New patients from waiting list to be seen

virtually where possible• Limited face to face with social distancing• Active management of “surge ” of referrals– Consultant triage– Photos pre-consult (self vs medical photography)

The “New Normal”

• Aim for photos at point of referral for all skin• Lengthen appointments between patients for

theatre, phototherapy, photography = ½ capacity

• More virtual appointments for new and followup

• More use of A&G

For the Future

• Could we have better sharing of quality images between primary & secondary care?

For the Future

• Easy to use• High quality• Secure image storage• Shared access

• Fotofinder with a private hub connecting all your referring GPs to reviewing specialist

For the Future

• GP “skin” specialists• Support and train GPs with an interest to:– Internally see skin patients– Trained in dermatology incl dermoscopy– Provided with dermatoscope/camera/iPad– Provide local services eg cryotherapy, telederm

capture– £$ Who, How much – needs to be separated from

normal general practice and remunerated fairly

Summary

• Dermatology is continuing but largely as virtual but face to face as necessary

• Most new patients needing to submit photos• Gradually re-starting new patient

consultations and extending surgery• Photos, Photos, Photos

Next Topic

Acne & RosaceaTues 19th May

7:30pm