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Right Decision Service newsletter: May 2024

Welcome to the Right Decision Service (RDS) newsletter for May 2024.

Issues with RDS and Umbraco access

A fix was deployed on Thursday 30th May to address the stability issues experienced with the Right Decision Service over recent weeks. These arose principally when multiple toolkits were built simultaneously or successively to the mobile app  We are hopeful that the stability issues are now resolved. If you encounter any problems with this newly deployed site, please email ann.wales3@nhs.scot and onivarova@tactuum.com immediately as well as raising an Urgent support ticket.

Thank you again for your patience while we have been resolving these issues.

New editor request form

A form to request creation of new editors, or updates to existing editor details, is available in the Standard Operating Procedures toolkit  .

Redesign and improvements to RDS

The timeline for this work has been slightly delayed because effort has been diverted to addressing the recent stability issues.  However, the redesign of search, browse, archiving and version control have now been through a second round of testing and Tactuum is beginning to work on amendments.  We now plan to go out to user acceptance testing in July 2024 and will let you know when we are ready to do this.

Deep linking direct to individual toolkits on the mobile app

We are awaiting clarification from Tactuum on the time and effort required for this development. We should hear this week and I will let you know as soon as information is available.

New feature requests

Once we have completed the current redesign and deep linking we will be able to take stock of outstanding new feature requests and update you on what can be achieved within available resource.

Training

Introductory webinars for new RDS editors will be held on the following dates:

  • Thursday 27 June 11 am – 12 pm
  • Wednesday 3rd July 3.15 pm – 4.15 pm

To book to attend one of these webinars, please contact Olivia.graham@nhs.scot , stating your name, job title, health board and preferred date for training.

The RDS Learning working group is also progressing work on “train the trainer” resources for RDS editors and toolkit leads. These resources include:

  • A module on clinical and care governance for RDS content
  • A step by step introduction to the toolkit development process.
  • Video learning bytes to introduce key editorial features and functions.

We aim to have initial content available on the RDS Learning area by end of June/early July.

Evaluation

Thanks to Fergus Donachie in NHS Dumfries and Galloway and Sheila Grecian in NHS Lothian, who have shared the results of user surveys for their referral management and diabetes & endocrinology toolkits. The results provide excellent insights into how RDS is improving practice and saving time for clinicians. And there are also helpful suggestions for improving the service.

This all provides valuable material to support the business case to Scottish Government for the next stages of RDS development. If you have carried out local evaluation we would be very pleased to hear from you.

New toolkits

The following RDS toolkits are now live:

The Right Decisions toolkit for SIGN 171: Management of diabetes in pregnancy.

SIGN 168: Assessment, diagnosis, care and support for people with dementia and their carers. This toolkit is live and just awaiting final editorial review to remove the “in development” status.

Living well with dementia - for everyone. We recommend that you use the mobile version of this toolkit, as the web version contains only informational resources. The mobile app provides access to the Dementia wellbeing diary, which enables people in early post-diagnostic stages and their carers to keep track of their wellbeing outcomes. Each wellbeing outcome is linked to resources and services supporting that outcome. The mobile toolkit also provides a digital version of the “Getting to know me” form, and a range of resources and tools for people living with dementia and their carers. Four HSCPs have localised this app to include directories of local support services, but this generic app is available for anyone in any location to use.

The following toolkits are due to go live imminently:

  • SARCS (Sexual Assault Response Coordination Service)
  • Child protection procedures (North Lanarkshire)
  • NHS Lothian neonatal guidelines

Toolkits in development

Some of the toolkits the RDS team is currently working on:

Waiting Well – national toolkit for healthcare professionals. This toolkit is being developed for the Scottish Government Waiting Well team in collaboration with NHS GGC knowledge services staff. It provides healthcare teams in NHS Boards and HSCPs with guidance and tools to develop and implement their action plans to support people on waiting lists with access to information, signposting to local community assets and services, and to professional support and services.

NHS Borders RefHelp – referral guidance for NHS Borders. Work is about to start on a similar toolkit for NHS Tayside.

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit

Thank you to everyone who has completed the retrospective Quality Assurance checklist. I am pleased to say that the latest report was well-received within Healthcare Improvement Scotland, with positive comments on the commitment shown by NHS Boards and other organisations to ensuring the quality and safety of their content on the RDS.

 

Implementation projects

A knowledge exchange session to share learning about implementation of patient and public-facing RDS apps is scheduled for 28th June 11 am – 12 pm.  This will include sharing key points from a recent literature review, and the results of early tests of change of implementing the ‘Being a partner in my care’ app, which aims to help citizens to become active partners in Realistic Medicine. 

If you would like to attend this session and have not yet received an invitation, please contact ann.wales3@nhs.scot .

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

 

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

 

The Right Decision Service:  the national decision support platform for Scotland’s health and care

Website: https://rightdecisions.scot.nhs.uk    Mobile app download:  Apple  Android

 

Acne

Warning

Acne vulgaris: A common chronic inflammatory skin disorder affecting the pilosebaceous unit (i.e., the hair follicle and sebaceous gland) resulting in blockage of the follicle and immune mediated inflammation. Acne affects males and females of all races and ethnicities. All patients with acne should be offered clear information tailored to their needs and concerns. Consider referring to mental health services if a person with acne experiences significant psychological distress or mental health disorder.  

Not all treatment options may be listed in this guidance. Please refer to local formulary for a complete list.

Treatment/ therapy

Severity* 

*A universally accepted definition of acne severity does not exist. Overall severity is a clinical judgement based on multiple factors including previous treatment response, scarring and family history. Lesion counts are commonly used in research and the definitions provided are based on NICE 2021 guidelines purely as a guide. 

Mild - For mild to moderate acne, this includes people who have 1 or more of: any number of non-inflammatory lesions (comedones); up to 34 inflammatory lesions (with or without non-inflammatory lesions); up to 2 nodules. 

Self care- patients should be encouraged to use a non-alkaline synthetic cleansing product daily, avoid comedogenic products and avoid scratching or picking of lesions 

First line treatment options, taking into account severity and patient preference after a discussion of advantages and disadvantages: 

  • Fixed combination topical Adapalene with topical benzoyl peroxide (any acne severity) or; 
  • Fixed combination topical tretinoin with topical clindamycin (any acne severity) 
  • Fixed combination benzoyl peroxide with topical clindamycin (mild/moderate acne) 
  • Topical Azelaic acid (moderate to severe acne). 

 

Consider benzoyl peroxide monotherapy if above options contraindicated or patient wishes to avoid topical retinoids/antibiotics.  

 

Topical retinoids should not be prescribed in pregnant/breastfeeding women.  

 

*Please see key messages box below* 

Moderate - For mild to moderate acne, this includes people who have 1 or more of: any number of non-inflammatory lesions (comedones); up to 34 inflammatory lesions (with or without non-inflammatory lesions); up to 2 nodules.

Fixed combination topical benzoyl peroxide and topical adapalene OR topical azelaic acid twice daily in addition to an oral antibiotic for 12 weeks such as: 

  • Doxycycline 100mg OD   
  • Lymecycline (Tetralysal 300) 408mg OD 

 

If no improvement after 12 weeks then trial another antibiotic. If improvement noted after 12 weeks can continue for another 12 weeks but ideally not beyond a total of 6 months. Stop antibiotics as soon as possible.  

 

Tetracyclines can cause photosensitivity and are teratogenic. They should be avoided in children <12 years. Oral antibiotics may cause systemic side effects and antimicrobial resistance.  

 

Erythromycin or trimethoprim (unlicensed) can be considered if contraindications/ intolerance to tetracyclines. 

Trimethoprim can cause serious but rare side effects including agranulocytosis and severe cutaneous adverse reactions such as Stevens-Johnson syndrome. 

 

Macrolides are linked with high antimicrobial resistance and are not first line treatments. 

 

Hormonal Treatment Considerations: 

 

  • Progesterone only contraception may exacerbate acne. 
  • The type of progestin used in different combined contraceptive pills differ, as does their anti-androgenic action. For instance, levonorgestrel used in a number of commonly prescribed combined contraceptives has an increased androgenic potential compared with some other progestins. 
  • Ideally combined contraceptives should be used for females with acne who do also require a contraceptive. 
  • For women with polycystic ovary syndrome, treat as per first line management. If this is ineffective consider adding co-cyprindiol (Dianette®) or an alternative combined oral contraceptive.  
  • Those on co-cyprindiol should be reviewed at 6 months to assess need for continuation/other treatment options.  

Severe - For moderate to severe acne this includes people who have either or both of: 35 or more inflammatory lesions (with or without non-inflammatory lesions); 3 or more nodules

Treatment should be started in primary care as per moderate acne (combination oral antibiotics and topical treatment) whilst awaiting appointment with a consultant-led dermatology team for consideration of isotretinoin. 

Referral management

Severity* 

*A universally accepted definition of acne severity does not exist. Overall severity is a clinical judgement based on multiple factors including previous treatment response, scarring and family history. Lesion counts are commonly used in research and the definitions provided are based on NICE 2021 guidelines purely as a guide. 

Mild - For mild to moderate acne, this includes people who have 1 or more of: any number of non-inflammatory lesions (comedones); up to 34 inflammatory lesions (with or without non-inflammatory lesions); up to 2 nodules. 

Can generally be managed in primary care 

Moderate - For mild to moderate acne, this includes people who have 1 or more of: any number of non-inflammatory lesions (comedones); up to 34 inflammatory lesions (with or without non-inflammatory lesions); up to 2 nodules.

Manage in primary care. Consider referral to consultant-led community or secondary care service if: 

- Mild to moderate acne has not responded to 2 completed courses of treatment (topical and oral) antibiotics.  

- Moderate to severe acne which has not responded to previous treatments containing an oral antibiotic. 

Severe - For moderate to severe acne this includes people who have either or both of: 35 or more inflammatory lesions (with or without non-inflammatory lesions); 3 or more nodules

Refer to consultant-led community or secondary care dermatology service in cases of: 

- diagnostic uncertainty  

- acne conglobata 

- nodulocystic acne 

Urgent same day referral should be made for cases of acne fulminans 

Consider referral in those with any severity who have scarring or persistent pigmentary change 

Clinical tips

  • Topical Benzoyl Peroxide (BPO) containing preparations can reduce resistant C. Acnes developing when used alongside topical/oral antibiotics 
  • BPO and topical retinoids cause skin irritation, so should be introduced slowly (low-strength, low-frequency) and should be used alongside hydrating products. Short contact application initially (e.g. application for 1 hour then wash off) can help build skin tolerance. 
  • Do not use systemic monotherapy with a topical antibiotic, monotherapy with an oral antibiotic or topical and oral antibiotics in combination 
  • Spironolactone is an unlicensed treatment for acne in female patients. Practice differs amongst dermatologists but this can be a useful option in some women in whom advice regarding suitability from a dermatologist-led team may be useful. 
  • Consider referral to mental health services if acne is considerably affecting mental wellbeing including those with current/past history of anxiety/self- harm/suicidal ideation/body dysmorphic disorder. 
  • For all patients, regardless of severity, consideration of underlying causes such as drugs/other disease processes should be made with onward referral to specialists such as endocrinologists if deemed necessary.  

ICD search categories

Inflammatory 

ICD11 code - ED80 

Editorial Information

Last reviewed: 24/05/2023

Next review date: 24/05/2025

Author(s): Adapted from the BAD Referral Guidelines.

Version: BAD 1

Co-Author(s): Publisher: Centre for Sustainable Delivery, Scottish Dermatological Society .

Approved By: Scottish Dermatological Society