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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

Nummular discoid eczema

Nummular eczema/discoid eczema: Cutaneous eruption characterized by coin-shaped plaques of eczema. The plaques usually occur on the extensor surfaces of the extremities, but the face and trunk may also be involved. Plaques are extremely itchy. Each plaque begins as a small group of red spots and tiny bumps (papules) or blisters (vesicles), which cluster together and grow rapidly into a red, swollen, round plaque which often weeps or develops a crusted surface. Plaques may become infected at a later stage. After a while the plaques become dry and scaly. 

The cause is unknown. Prevalence is around 1 in 500 people. There is a peak incidence in both males and females of around 50-65 years of age. It is less commonly seen in children. The condition can respond poorly to treatment compared to other forms of eczema, and typically requires the use of potent topical steroids. 

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

Treatment/ therapy

Mild: ... Slight but definite erythema (pink), slight but definite induration/papulation, and/or slight but definite lichenification. No oozing or crusting. Disease limited in extent.   

  • Advise patient on the avoidance of irritants (e.g. soap). 
  • Prescribe generous amounts of emollients; advise frequent and liberal use. 
  • Moderate potency topical corticosteroids eg.  betamethasone valerate 0.025% or clobetasone butyrate 0.05% 

Moderate: … Clearly perceptible erythema (dull red), clearly perceptible induration/papulation, and/or clearly perceptible lichenification. Oozing and crusting may be present. Disease fairly widespread in extent. 

  • Advise patient on the avoidance of irritants (e.g. soap). 
  • Prescribe generous amounts of emollients; advise frequent and liberal use. 
  • Potent topical corticosteroids eg. betamethasone valerate 0.1% or mometasone 0.1%. If no improvement, may require the use of clobetasol propionate 0.05% (super potent) daily for up to 2 weeks, then review (trunk and limbs, not face and flexures). 
  • Sedating antihistamine at night if sleep disturbed and non-sedating antihistamine for daytime itch if required. 
  • Treatment of secondary infection: antibiotic as appropriate according to swab result. 

Severe: … Marked erythema (deep or bright red), marked induration/papulation, and/or marked lichenification. Oozing or crusting may be present. Disease is widespread in extent. 

  • Advise patient on the avoidance of irritants (e.g. soap). 
  • Prescribe generous amounts of emollients; advise frequent and liberal use. 
  • Refer to dermatologist. Commence treatment in primary care whilst waiting for appointment. 
  • Super potent topical corticosteroids eg. clobetasol propionate 0.05% daily for up to 2 weeks, then review (trunk and limbs, not face and flexures). 
  • Sedating antihistamine at night if sleep disturbed and non-sedating antihistamine for daytime itch if required.. 
  • Treatment of secondary infection: antibiotic as appropriate according to swab result. 
  • Other treatments may be required, such as phototherapy or oral immunosuppressant drugs. 

Referral Management

Mild: ... Slight but definite erythema (pink), slight but definite induration/papulation, and/or slight but definite lichenification. No oozing or crusting. Disease limited in extent.

Manage in primary care; do not refer.  

Seek advice and guidance where there is diagnostic uncertainty. 

Moderate: … Clearly perceptible erythema (dull red), clearly perceptible induration/papulation, and/or clearly perceptible lichenification. Oozing and crusting may be present. Disease fairly widespread in extent. 

Manage in primary care.  

Refer to secondary care service if multiple treatments in primary care have failed. 

 

Severe: … Marked erythema (deep or bright red), marked induration/papulation, and/or marked lichenification. Oozing or crusting may be present. Disease is widespread in extent.

Refer to dermatologist if the patient has not responded to optimum topical therapy (including super potent topical corticosteroids). Could be offered a video consultation. 

Clinical resources

https://cks.nice.org.uk/topics/eczema-atopic/ 

https://cks.nice.org.uk/topics/fungal-skin-infection-body-groin/diagnosis/differential-diagnosis/ 

PCDS guidance – discoid/nummular eczema: http://www.pcds.org.uk/clinical-guidance/eczema-discoid-syn.-nummular-eczema  

Clinical tips

  • Initially, these plaques are often swollen, and ooze fluid. The appearance can be confused with secondary infection. 
  • Antibiotics are rarely indicated for discoid eczema.  
  • Plaques tend to be very itchy, particularly at night. 
  • Over time, the plaques may become dry, crusty, cracked and flaky. The centre of the plaque also sometimes clears, leaving a ring of discoloured skin that can be mistaken for ringworm. Tinea would be suggested by asymmetrical distribution and can be confirmed with skin scrapings for mycology. Tinea corporis is not commonly seen in adults. 
  • Discoid eczema usually requires at least potent topical corticosteroids. 
  • On lighter skin, plaques will be pink or red. On darker skin, plaques can be dark brown or paler than the skin around them. Discolouration can persist for months after the condition has cleared. 
  • Differs from psoriasis in that plaques tend to be a lighter red, the border fades gradually at the periphery and the presence of exudate / crust as opposed to scale. 

Patient information resources

  1. Discoid eczema – BAD Patient info leaflet
  2. Patient.info leaflet – Discoid eczema 
  3. NHS Choices – Discoid eczema- https://www.nhs.uk/conditions/discoid-eczema/  

ICD search categories

Inflammatory 

ICD11 code - EA82 

Editorial Information

Last reviewed: 23/05/2023

Next review date: 23/05/2025

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