TNRF2: Dermatology

Overview

Keloid scars can result after injury to the skin such as that from surgery, burns or piercings.

Keloids are excessive scars which grow beyond the boundaries of the original wound, do not spontaneously regress and frequently recur after being excised. They can be painful, sore and/or itch. People with a history of keloids are advised to avoid skin piercings, tattoos, and unnecessary surgeries.

Most keloid scars do not require treatment of any kind.

Thresholds and eligibility 

NHS Surrey Heartlands will only consider keloid scar refashioning when the following criteria below have been met:

Initial keloid scar diagnosis:

Avoid sun exposure. Treat keloid with silicone-based therapy (gel or sheeting) and compression plus moisturising if compatible for the patient. These treatments can be purchased over the counter.

4 weeks to 6 months – growing keloids:

In combination use silicone gel sheeting, intralesional injections of corticosteroids.

After 12 months – if there is no response:

Consider onward referral for specialist opinion for surgical treatment.

For keloid scars that have not resolved after at least 6 months of silicone-based therapy OR are unsuitable for silicone-based therapy due to duration or continued growth of the lesion; onward referral may be considered if:

• The lesion is above the collar bone and cannot be easily covered up 

AND

• Is large (e.g. greater than 1cm keloids on ears) 

AND

• There is no history of previous piercings requiring keloid treatment

Advice and guidance from a dermatologist or plastic surgeon should be sought initially with photographic evidence and full case details, in order for the specialist to decide whether any treatment is appropriate for those who fit the above criteria.

Treatments that could be considered for use by dermatology or plastic surgery departments include intralesional corticosteroid injections, surgical excision, radiotherapy and/or laser treatment.

In all other cases treatment is considered to be low priority and therefore not normally funded.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

The IFR route can be used to consider exceptional cases not fitting the above criteria if required.

Exceptional circumstances may be considered where there is evidence of significant health impairment and there is also evidence of the intervention improving health status.

Patients should be encouraged to stop smoking prior to treatment, if applicable.

 

Overview

Lipomas are soft, fatty lumps that grow under your skin. They're harmless and do not usually need any treatment.

Thresholds and eligibility 

Soft tissue subcutaneous lesions, particularly over 5 cm, which are rapidly enlarging and not clearly longstanding and asymptomatic may be a soft tissue sarcoma. These patients should be referred to the appropriate service under the two-week rule. 

Removal of lipomatous lesions is permitted where the lesion is associated with at least one of the following criteria: 

• The lesion is an obvious or proven lipoma that is large (> 5cm). 

OR 

• The lesion causes serious functional limitation of movement resulting in documented impairment of activities of daily living (details of the impact on daily activities to be included in the application).

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

In severe and chronic cases, in people with lymphoedema that does not respond to conservative treatment, liposuction can be used. This involves the use of suction to remove fluid and fat through punctures in the skin, and these treatments are not the same techniques as those used for cosmetic liposuction.

Thresholds and eligibility 

NHS Surrey Heartlands will not routinely fund cosmetic liposuction.

Liposuction may be funded:

• As part of other surgical procedures when indicated for other conditions, e.g., thinning of a transplanted flap.

In lymphoedema patients: 

• With moderate to severe lymphoedema (International Society of Lymphology stage II/III respectively).

AND

• Where all conservative methods (such as MLD and DLT) for treatment have been attempted and have failed.   
  • Note: Manual lymphatic drainage (MLD) for lymphoedema is currently routinely funded. However, if clinicians wish to provide Complex Decongestive Therapy of which MLD is usually a component, then pre-authorisation will need to be sought.

AND

• Patient selection should only be done by a multidisciplinary team as part of a lymphoedema service.

AND 

• Standard arrangements are in place for clinical governance, consent, and audit.
   

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

The removal of a benign skin lesion is the surgical procedure of removing non-malignant (not cancerous) skin lesions or abnormal growths from different parts of the body including the trunk, arms, and legs.

Thresholds and eligibility 

Where malignancy is suspected, the patient should be referred to an appropriate service under the two-week rule.  Benign lesions (excluding lipomas and viral warts; please refer to the separate policy for these lesions).  Clinically benign lesions should not be removed for cosmetic reasons and such procedures will not be funded. Details should be provided as to the nature of the lesion, the size and how it is affecting the patient.  Removal of benign skin lesions is only available as a treatment option for patients where: 

• The lesions size or position causes serious functional limitations which severely impair activities of daily living (see note below), as documented by the applicant.

OR

• There is documented evidence that the lesion is causing recurrent symptoms such as bleeding, infection, or discharge over at least three months and has not responded to appropriate conservative treatment over this period. All clinicians must be prepared to justify to NHS Surrey Heartlands the criteria applicable for the treatment of any benign skin lesions. Any treatment of skin lesions outside of the criteria will not be funded.

Note: Daily living means dressing, personal hygiene (washing and toileting), functional mobility (moving from one place to another to perform activities required in the home or at work) and meeting nutritional needs (shopping, preparing, and eating food). 

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Viral warts are viral infections of the skin that are most common on the hands and feet.

Thresholds and eligibility 

Viral warts are usually of aesthetic significance only and surgical removal and / or laser treatment is not routinely funded by NHS Surrey Heartlands.

NHS Surrey Heartlands will fund removal of viral warts in patients who are immunocompromised. There are no restrictions of genital or anal warts.

• The patient is immunocompromised

OR

• Does the patient have genital or anal warts?

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.