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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

Vitiligo

Vitiligo: Is an acquired autoimmune disorder of pigmentation of the skin and mucous membranes where progressive dysfunction and destruction of melanocytes results in loss of skin pigmentation. Incidence: 1% of world population, 50% appearing before the age of 20 years. A family history may be present in up to 30% of cases. Associated with other autoimmune conditions, particularly thyroid disease occurring in 20% of patients over the age of 20 years. Also associated with Type 1 diabetes, pernicious anaemia, alopecia areata, Addison’s disease, systemic lupus erythematosus, rheumatoid arthritis and psoriasis. There is currently no definitive treatment, but spontaneous improvement may occur. Irrespective of clinical severity Vitiligo may cause significant psycho-social distress and referral for psychological support should always be considered. 

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

 

Treatment/ therapy

Severity 

Depends on proportions of physical appearance and psychological impact. 

Mild:  Localised segmental Vitiligo. Non segmental Vitiligo sparing face and hands. Minimal psychological impact. 

  • In absence of definitive treatment, for minimal disease with low psychological impact patients may not seek further treatment. 
  • Recommend a high-factor (SPF50+) sunscreen with protection against ultraviolet A and B. 
  • Check TSH and thyroid antibodies. 
  • For adults with limited areas on trunk and limbs a potent topical steroid may be applied once daily (off licence) for up to 2 months 
  • Not suitable for face and flexures. 
  • Topical calcineurin inhibitor may be useful such as Tacrolimus 0.1% applied BD for face and flexures 
  • Avoid use of sunbeds. 
  • Provide contact details for Changing Faces for advice on skin camouflage and the Vitiligo Society for further information and support.

Moderate: More widespread.  Acrofacial.  Significant psychological impact. 

  • Check TSH and thyroid antibodies. 
  • For adults with limited areas on trunk and limbs a potent topical steroid may be applied once daily (off licence) for up to 2 months or daily for one week on one week off for longer periods of time. Not suitable for face and flexures. 
  • Topical calcineurin inhibitor may be useful such as Tacrolimus 0.1% applied BD for face or flexures. Consider referral to secondary care if failing to respond to simple measures for further assessment  

Expert recommendations: camouflage 

  • Self-tanning agents in gel, cream, lotion or spray: These give the skin a brown colour that resembles a natural tan and normally lasts from 3 to 5 days. 
  • Highly pigmented cover creams: May require guidance on selection and application 

Severe:  Generalised / Universal / Active Progressive spread, Rapidly progressive spread and/or Major psychological impact 

For all patients for whom the condition is progressing rapidly; or where there is diagnostic uncertainty; or if the condition has a significant psychosocial impact; or the condition is not responding to topical treatment 

Refer to secondary care services for consideration of treatment with: 

  • Topical steroids 
  • Topical calcineurin inhibitor 
  • Narrowband – UVB 
  • Emerging treatments

NB. treatments may help but none are curative at present.

 

 

Referral Management

Severity 

Depends on proportions of physical appearance and psychological impact. 

Mild: Localised segmental Vitiligo. Non segmental Vitiligo sparing face and hands. Minimal psychological impact. 

Refer to secondary care: 

  • If the condition is progressing rapidly 
  • there is diagnostic uncertainty 
  • the condition has a significant psychosocial impact, or 
  • the condition is not responding to topical treatment. 

Moderate: More widespread.  Acrofacial.  Significant psychological impact. 

Refer to secondary care: 

  • If the condition is progressing rapidly 
  • there is diagnostic uncertainty 
  • the condition has a significant psychosocial impact, or 
  • the condition is not responding to topical treatment. 

Severe:  Generalised / Universal / Active Progressive spread, Rapidly progressive spread and/or Major psychological impact 

Refer to secondary care: 

  • If the condition is progressing rapidly 
  • there is diagnostic uncertainty 
  • the condition has a significant psychosocial impact, or 
  • the condition is not responding to topical treatment. 

Clinical resources

NICE CKS – Vitiligo   

BAD Guidelines – Vitiligo (2021)

European Dermatology Forum vitiligo guidelines 2012 

PCDS- Vitiligo

DermNet NZ- Vitiligo 

Clinical tips

  • Be aware of possible association with other autoimmune disorders. 
  • Post-inflammatory hypopigmentation can be common in skin of colour and should be clinically distinguishable from depigmentation seen in vitiligo, which may often be symmetrical. 
  • Psychological effects are important. Vitiligo is often immediately visible to others and those with the condition may suffer social and emotional consequences including low self-esteem, social anxiety, depression, stigmatization and, in extreme cases, rejection by those around them. This can be accentuated in darker skin types, where loss of pigment is more visible. 

Patient information resources

BAD patient information leaflet – Vitiligo:  

BAD patient information leaflet – Skin camouflage:   

Patient.info leaflet – Vitiligo:   

NHS Conditions- Vitiligo:  

ICD search categories

Epidermal/ 

Appendageal 

ICD11 code - ED63.0 

Editorial Information

Last reviewed: 30/05/2023

Next review date: 30/05/2025

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