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Announcements and latest updates

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

  1. Contingency planning for RDS outages

Following the recent RDS outages, Tactuum and the RDS team have been reviewing the learning from these incidents. We are committed to doing all we can to ensure a positive outcome by strengthening the RDS to make it fully robust and clinically resilient for the future.

We would like to invite you to a webinar on 26th September 3-4 pm on national and local contingency planning for future RDS outages.  Tactuum and the RDS team will speak about our business continuity plans and the national contingency arrangements we are putting in place. This will also be a space to share local contingency plans, ideas and existing good practice. We would also like to gather your views on who we should send communications to in the event of future outages.

I have sent a meeting request for this date to all editors – please accept or decline to indicate attendance, and please forward on to relevant contacts. You can also contact Olivia.graham@nhs.scot directly to register your interest in participating.

 

2.National  IV fluid prescribing  calculator

This UK CA marked calculator is now live at https://righdecisions.scot.nhs.uk/ivfluids  . It has been developed by a multiprofessional steering group of leads in IV fluids management, as part of the wider Modernising Patient Pathways Programme within the Centre for Sustainable Delivery.  It aims to address a known cause of clinical error in hospital settings, and we hope it will be especially useful to the new junior doctors who started in August.

Please do spread the word about this new calculator and get in touch with any questions.

 

  1. New toolkits

The following toolkits are now live;

  1. Updated guidance on current and future Medical Device Regulations

We have updated and simplified this guidance within our standard operating procedures. We have clarified the guidance on how to determine whether an RDS tool is a medical device, and have provided an interactive powerpoint slideset to steer you through the process.

 

  1. Guide to six stages of RDS toolkit development

We have developed a guide to support editors and toolkit leads through the process of scoping, designing, delivering, quality assuring and implementing a new RDS toolkit.  We hope this will help in project planning and in building shared understanding of responsibilities throughout the full development process.  The guide emphasises that the project does not end with launch of the new toolkit. Implementation, communication and evaluation are ongoing activities throughout the lifetime of the toolkit.

 

  1. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:
  • Thursday 5 September 1-2 pm
  • Wednesday 24 September 4-5 pm
  • Friday 27 September 12-1 pm

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

7 Evaluation projects

Dr Stephen Biggart from NHS Lothian has kindly shared with us the results of a recent survey of use of the Edinburgh Royal Infirmary of Edinburgh Anaesthesia toolkit. This shows that the majority of consultants are using it weekly or monthly, mainly to access clinical protocols, with a secondary purpose being education and training purposes. They tend to find information by navigating by specialty rather than keyword searching, and had some useful recommendations for future development, such as access to quick reference guidance.

We’d really appreciate you sharing any other local evaluations of RDS in this way – it all helps to build the evidence base for impact.

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

Basal Cell Carcinoma

Basal cell carcinoma (BCC) is the most common form of skin cancer. It is believed that BCCs arise from pluripotential cells in the basal layer of the epidermis or the infundibulum of the hair follicle. BCCs typically occur in areas of chronic sun exposure and present as slowly enlarging reddish pearly patch, papule, or nodule commonly, but not exclusively, on the head and neck. The low-risk superficial variant is often located on the trunk. BCCs frequently ulcerate and become crusted. BCCs are slow growing, often increasing by 2-3mm a year. Although they rarely metastasise, they can cause significant local destruction and disfigurement if neglected or inadequately treated, particularly if of the sclerosing or infiltrative subtype. 

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

Treatment/ therapy

Low risk BCCs management: Patient (>24 years) has a BCC less than or equal to 1cm below the clavicle, and is of the superficial or nodulocystic histology, and is not overlying important anatomical structures (e.g. major vessels), and the patient is not immunosuppressed, and does not have Gorlin’s syndrome. 

Lesions should be biopsied if there is uncertainty regarding the diagnosis, if not, they must be closely followed-up and referred if not improved by treatment. 

 

For superficial BCCs (sBCC) 

Prescribe: 

  • Topical fluorouracil 5% cream (Efudix) 

1 cm margin around the lesion twice daily, for 4 weeks.   

Alternatively; 

Prescribe: 

  • Imiquimod (Aldara 5% cream) once daily, 5 times a week, for 6 weeks. 

 

Consider surgery for sBCC and some nodular BCCs at low risk sites

Low/ intermediate risk BCCs management: Patient (>24 years) has a BCC less than 1 cm above the clavicle and is of the Superficial or nodulocystic histology; Patient has a BCC greater than or equal to 2cm below the clavicle and is of the Superficial or nodulocystic histology; Patient is not immunosuppressed, does not have Gorlin’s syndrome. 

Nodulocystic BCCs of greater than 1cm above the clavicle and greater than 2cm below it should be treated with a complete excision by an accredited skin surgeon, with 4mm surgical margins.  

 

Nodulocystic BCCs ≤1 cm at low-risk sites can be treated with curettage and cautery (with sufficient passes).  If the histopathology shows any high-risk features, then a formal excision by an accredited skin surgeon in an approved site is advised.  

High risk BCCs management: Patient (>24 years) has a BCC greater than or equal to 1cm on their facial areas (nose, lips, periorbital) and is of a high-risk (Infiltrative, micronodular, basosquamous) Histological type; Patient is immunocompromised or has a genetic predisposition e.g. Gorlin’s syndrome. 

High risk BCCs as mentioned above regardless of size should be referred as an urgent referral 

 

Note that infiltrative BCCs can be difficult to diagnose. To aid diagnosis, stretching out the lesion or using an alcohol wipe may reveal the typical pearly features. 

 

Dermoscopy can show the sharply focused telangiectasia. Consider a shave biopsy to confirm.   

Referral Management

Low risk BCCs management: Patient (>24 years) has a BCC less than or equal to 1cm below the clavicle, and is of the superficial or nodulocystic histology, and is not overlying important anatomical structures (e.g. major vessels), and the patient is not immunosuppressed, and does not have Gorlin’s syndrome. 

Manage in secondary care. Surgery can be considered by GPs with available skills in some low-risk situations. 

  • A simple guide is ≤1 cm below clavicle [but excluding hands, nail units, genitals, pretibial, ankles and feet] 
  • For further detail on low risk sites see BAD guidelines for management of BCCs 

Low/ intermediate risk BCCs management: Patient (>24 years) has a BCC less than 1 cm above the clavicle and is of the Superficial or nodulocystic histology; Patient has a BCC greater than or equal to 2cm below the clavicle and is of the Superficial or nodulocystic histology; Patient is not immunosuppressed, does not have Gorlin’s syndrome. 

Manage in secondary care. 

  • ≥ 2 cm Below clavicle [but excluding hands, nail units, genitals, pretibia, ankles and feet] 
  • <1 cm on the face, excluding nasolabial sites (central face, eyebrows, periorbital, nose, lips (cutaneous and vermilion), chin, mandible, preauricular, postauricular, temple, ears nose, forehead, ears, neck) 

High risk BCCs management: Patient (>24 years) has a BCC greater than or equal to 1cm on their facial areas (nose, lips, periorbital) and is of a high-risk (Infiltrative, micronodular, basosquamous) Histological type; Patient is immunocompromised or has a genetic predisposition e.g. Gorlin’s syndrome. 

Manage in secondary care.  

  • All basal cell lesions ≥1 cm on face and ≥2 cm below clavicle.  
  • Cases with high-risk histopathology may need discussion within a skin cancer MDT  

Clinical resources

BAD clinical guidelines 

DermnetNZ basal cell carcinoma 

NICE CKS Skin Cancers, see also NICE – Improving Outcomes for People with Skin Tumours including Melanoma 

PCDS - Basal Cell Carcinoma 

Clinical tips

  • Suspect BCC in lesions which have intermittent spontaneous bleeding. 
  • If topical treatment provokes excess inflammation consider moderate potency steroid for up to 10 days. 
  • Patients prescribed Efudix or Imiquimod should be followed up (3-6 months) after completion of treatment.   
  • All non-face to face consultations or requests for advice should have an accompanying photograph and ideally a dermoscopy image if possible. 
  • BCCs occur in all skin types. Patients who have had a BCC are prone to developing further skin cancer (estimated clinical risk of 50% over 5 years)  
  • Incomplete excisions at high-risk sites can lead to complex and high morbidity recurrence.  
  • Once a person develops basal cell carcinoma, they have commenced a chronic disposition to UV-pathology and should consider sun protection and self-examination for potential skin cancers.  

Patient information resources

  1. BAD Patient Information Leaflet – Basal Cell Carcinoma 
  2. Patient.Info Basal Cell Carcinoma 
  3. BAD Patient Information Leaflet – 5-Fluorouracil cream (Efudix) 
  4. BAD Patient Information Leaflet - Imiquimod cream 
  5. Patient.info Skin Cancer Types 

ICD search categories

Malignant 

ICD11 code - 2C32 

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