West Hertfordshire HospitalsNHS Trust

Dermatology Services for Patients with Vulval Disease

• Current– Monthly HHGH (VBw)– Monthly WGH(FMT & PM)– Quarterly joint Gynae/Derm (VBw & AH)

• Future– Monthly SACH (VBw)?joint with GUM

West Hertfordshire HospitalsNHS Trust

Vulval Disease

All ages• Lichen sclerosis• Eczema: seborrhoeic, contact/irritant/ atopic• Psoriasis• Vulval pain syndromes• Lichen planus• VIN• Immunobullous disorders• Hidradentis suppuritiva

West Hertfordshire HospitalsNHS Trust

Vulval Disease

• Dedicated clinic

• Increased consultation time

• Access to other specialities

• Teaching opportunity?

West Hertfordshire HospitalsNHS Trust

Please don’t refer!

• Suspected vulval cancer – (unless melanoma)

• STD/warts

West Hertfordshire HospitalsNHS Trust

Patch Testing Service

Dr. Simon Dawe Consultant Dermatologist

West Hertfordshire NHS trust

West Hertfordshire HospitalsNHS Trust

Epidemiology

• Point prevalence of eczema in UK 20%

• Occupational dermatitis 29% of occupational disease

• 4.5 % of population is allergic to nickel

• 1-3% of the pop are allergic to ingredients of cosmetics

West Hertfordshire HospitalsNHS Trust

Patch and Photopatch Testing

• To allow confirmation of allergic contact dermatitis and of photo allergic contact dermatitis

• To differentiate between allergic and irritant contact dermatitis

West Hertfordshire HospitalsNHS Trust

What is Patch testing?

• To illicit an immune response by challenging already sensitized persons to defined amounts of allergen and assessing the degree of response

• Patch testing is not helpful in the assessment of food allergic individuals

West Hertfordshire HospitalsNHS Trust

Patch Testing

West Hertfordshire HospitalsNHS Trust

Patch Testing at West Hertfordshire NHS trust

West Hertfordshire HospitalsNHS Trust

Numbers Tested

• We offer a patch testing service at SACH and HH

• Patch testing is arranged after an initial clinical assessment and appropriate batteries of allergens selected

• Yearly rate 168 patients per year

• We are in the process of setting up a dedicated clinic whose remit may widen

West Hertfordshire HospitalsNHS Trust

Indications for referring for patch testing• Eczematous disorders where contact

allergy is suspected or is to be excluded

• Eczematous disorders failing to respond to treatment as expected

• Chronic hand and foot eczema

• Persistant or intermittent eczema of the face, eyelids, ears and perineum

• Complicated varicose eczema

West Hertfordshire HospitalsNHS Trust

Follow up caseload: HELP!!!

West Hertfordshire HospitalsNHS Trust

Follow up caseload: HELP!!!

• Huge reductions in commissioned follow up activity (40%)

• CATS will increase complexity of secondary care caseload

• Follow up caseload includes skin surgery (good value for you!)

• Nurse activity now being counted

• ALL A MESS!

West Hertfordshire HospitalsNHS Trust

HELP!!!!

West Hertfordshire HospitalsNHS Trust

Dermatology Follow up case load implications of new: follow up 1:1.2 ratioHHGH 31% patients no follow up appointments, SACH 31% patients no follow up appointments, HMH 42% patients no follow up appointmentsTop ten diagnoses of those needing more than one follow up appointment

Diagnosis No of patients

Mean no of FU in 12 months

Total no FU slots in 12 months

Reason

Basal cell carcinoma

328 1.52 499 Most are discharged after first excision, high recurrence sites and those having curettage and cautery are followed up with an extra visit. Many have multiple tumours

Eczemadermatitis

325 1.94 630 Adults with difficult eczema on second line treatments such as azathioprine, ciclosporin, oral steroids, PUVA or day treatment. Prevents hospitalisationSome patients require 3 patch test appointments for investigation of allergic contact dermatitisChildren followed up and supported in nurse led eczema follow up clinic to avoid hospitalisation

Psoriasis 253 2.17 549 Represents those patients with complex disease on second line treatments. Nurse psoriasis clinic and second line drug monitoring clinic in place.

Squamous cell carcinoma

207 1.88 207 National guidance requires specialist follow up. Well differentiated tumours already discharged. Many patients have multiple lesions

Melanocytic naevi

206 1.37 282 Includes patients with multiple atypical naevi. Expert patient programme being developed

Acne 199 1.92 382 Male Isotretinoin patients need a minimum of 3 follow up appointment, Females need 5 visits to meet the EU pregnancy prevention programme

Actinic keratosis 199 1.59 316 Many patients have associated skin cancer. Trying to discharge all these but they commonly are re-referred

Malignant melanoma

95 1.91 181 Melanoma guidance requires 3 monthly follow up for 5 years. NICE indicates should be dermatology specialist

Lichen sclerosis 70 1.84 129 Chronic condition requires follow up in small cohort of patients with difficult disease; cancer risk

Leg ulcers 64 2.25 144 Should improve with development of community leg ulcer services

West Hertfordshire HospitalsNHS Trust

Dermatology Nurses Rule: OK?

Liz Farley Senior Dermatology Nurse Specialist

West Hertfordshire HospitalsNHS Trust

Nurses and the patient pathway

GP Referral

Childrens Eczema

Nurse led clinic

PsoriasisNurse led

clinic

Leg ulcerNurse led

clinic

Primary Care clinic

Nurse support

Treatments:OintmentsPhototherapyBehavioural treatment

Doctors clinicNurse support

Discharge

Nurse skin surgery

Reaccess via Nurse led helpline

Patch testing

Nurse led drug

monitoring clinic

West Hertfordshire HospitalsNHS Trust

It’s all about team work …

… thank you