DermDesk — Dermatology Clinician Handbook

🩺 Clinic

Your working page — how to run the clinic, what to know for the clinic you're in, how to refer on, and how to close each consultation.

📖Generic Clinic Guide

📚Clinic-Specific Guides

📋Referrals

🏁Outcomes & Follow-Ups

Other Sessions

💉Minor Ops & Procedures

🗂️Admin, Pathology & MDT

✅New Starter Checklist

🏥Hospital Sites

📖Protocols

📘Junior Guide

📞Contacts

💻IT & Systems

⚠️ For Clinical Staff Only This handbook is intended for use by dermatology medical and nursing staff. Content reflects local pathways and should be used alongside current NICE guidelines and departmental SOPs. Contact your consultant if in doubt.

Department Overview

The Dermatology department runs outpatient clinics across four sites: Royal Berkshire Hospital (RBH) — the main site — plus Townlands Hospital (Henley), West Berkshire Community Hospital (Thatcham) and Bracknell Healthspace — see Hospital Sites. Services include general dermatology, urgent suspected cancer (2WW), acne, biologics, rheum/derm, vulval, paediatric, nail, hair, phototherapy, PDT, and minor ops.

Inpatient consults are managed via the on-call team. All acute referrals from A&E and inpatient wards are made as EPR referrals — there is no derm bleep.

Referral Pathways

All internal referrals should be made via [EPR system]. External GP referrals arrive via e-RS. Select a service below for specific referral criteria and process.

🔴 Patch Testing Service

Indications

Suspected allergic contact dermatitis (ACD)
Occupational dermatitis — nickel, rubber, fragrance, preservatives
Periorbital or facial eczema not responding to topicals
Eczema in unusual distribution
Suspected cosmetic allergy
Hand eczema with possible contact component

Exclusions / Contraindications

Active widespread eczema (risk of false positives / excited skin)
Systemic immunosuppressants within 4 weeks (discuss with consultant)
Pregnancy (defer unless urgent)
Unable to attend x3 appointments over 4–5 days

How to Refer

Check inclusion/exclusion criteria above
Open MModal FLEX and dictate a letter with "Referral for patch testing" as the first heading
In the recipient field, type a name and click Add New Contact. Address the letter to:

Catriona Wootton OR Patch Testing Consultant
Patch Testing
Dermatology Department
Churchill Hospital
Oxford
OX3 7LE

Include in the letter: clinical indication, current medications, suspected allergen(s), occupation, and prior patch test history
Advise patient: must attend 3 appointments (Day 0, Day 2, Day 4) — cannot attend if back/upper arm skin is broken or actively inflamed

⚠️ Stop topical steroids to test site 1 week before. Systemic steroids (>10mg prednisolone) can suppress reactions — discuss with patch test team before referring.

🔪 Mohs Micrographic Surgery

Appropriate Indications (BAD guidance)

High-risk BCC: H-zone face, recurrent, morphoeic/infiltrative, large (>2cm face, >3cm trunk)
High-risk SCC: >2cm, poorly differentiated, perineural invasion, recurrent, immunosuppressed
Lentigo maligna (melanoma in situ) — where tissue conservation critical
Dermatofibrosarcoma protuberans (DFSP)
Sebaceous carcinoma (periocular)
Selected Merkel cell carcinoma

Not Appropriate For

Standard low-risk BCCs on trunk/limbs
Melanoma (except LM/LMM — discuss with MDT)
Patient unfit for prolonged local anaesthetic procedure
Patient on anticoagulants not able to pause (assess risk)

How to Refer

Arrange a scoop biopsy first to confirm the diagnosis before referring
Once histology confirmed, refer via MModal FLEX — include background, clinical details, and timing clearly in the letter
Choose one of the two referral options below:

Option 1 — Oxford

Mohs Consultant
Dermatology Department
Churchill Hospital
Oxford
OX3 7LE

Option 2 — Guy's Hospital, London

Mohs Team
01 Outpatient Village
Cancer Centre, Guy's Hospital
Great Maze Pond
London
SE1 9RT

⚠️ Timing: Mohs for 2WW pathway tumours must be booked within the cancer waiting time target. Flag urgency clearly in the referral letter.

☀️ Phototherapy (NB-UVB / PUVA)

Indications — NB-UVB

Psoriasis (moderate–severe, or topical-refractory)
Atopic eczema (topical-refractory)
Vitiligo
Mycosis fungoides (early stage)
Pruritus (uraemic, cholestatic)
Polymorphic light eruption (desensitisation)

Indications — PUVA

Palmoplantar psoriasis / eczema
CTCL (mycosis fungoides)
Lichenoid conditions

Contraindications

Xeroderma pigmentosum or photosensitivity disorder
History of melanoma or multiple BCCs
Active SLE / photosensitive drug use (for UVB)
Pregnancy or breastfeeding (for PUVA — psoralen)
Cataracts or inability to wear eye protection (PUVA)
Unable to attend 2–3× weekly for 6–8 weeks

How to Refer

Confirm patient meets indications and has no contraindications
Document prior treatments (topicals, systemics) in referral
Refer via [EPR] to "Dermatology – Phototherapy" — specify NB-UVB or PUVA
State skin type (Fitzpatrick I–VI) and any photosensitising medications
Phototherapy nurse will contact patient to arrange scheduling and baseline assessment

✅ Concurrent biologics NB-UVB can be combined with certain biologics (e.g. dupilumab) — discuss with phototherapy team.

Phototherapy Unit: [Location] | Contact: Ext. XXXXX

🔗 Other Referral Pathways

Service	Referral Route	Notes
Skin Cancer MDT	Via MDT coordinator — Ext. XXXXX	Melanoma, high-risk SCC, MCC, DFSP. Meets [Day, time].
Rheumatology – Connective Tissue	e-RS / internal [EPR]	Lupus, dermatomyositis, scleroderma. Joint clinic available [Day].
Ophthalmology	Internal [EPR] referral	Ocular rosacea, orbital involvement, uveitis. Urgent if vision at risk — same day via A&E.
Gynaecology	Internal [EPR] referral	Lichen sclerosus with malignant change, vulval cancer MDT. Joint vulval clinic available.
Plastic Surgery	Internal [EPR] referral	Reconstruction post-Mohs, complex excisions, fasciocutaneous flaps.
Immunology / Allergy	Internal [EPR] referral	Drug allergy, urticaria MDT, complex angioedema.
Wound Care Nursing	Direct contact — Ext. XXXXX	Chronic wounds, leg ulcers, complex dressings.

📖 Generic Clinic Guide

How to run any clinic — EPR check-in and checkout, DNA process, MModal letter writing, and hospital pharmacy prescriptions. For condition-specific guidance see the Clinic-Specific Guides.

💻 EPR Workflow

Patient Lists & Check-In

Patient lists are displayed under Schedule. When the patient has been checked in at reception, their name will turn green.

Checkout — OP Outcome

It is the clinician's responsibility to check out each patient under the OP Outcome tab.
Tick everything you have done — most commonly Dermoscopy and Cryotherapy — then click Checkout (green box at the top).
After saving and refreshing, the patient banner should turn grey.
Only one outcome can be selected — see Outcomes & Follow-Ups for the full list of outcome codes and when to use each.

DNA (Did Not Attend)

First DNA: Right-click the patient on Schedule and select Did Not Attend. Click Communicate on the patient record and send a message to the CAT 8 Dermatology team to re-book.
Second DNA: Discharge the patient. Write to the GP explaining, and ask them to re-refer if the problem persists.

🎙️ MModal — Letter Writing

All letters are written via MModal FLEX — you can type, dictate with voice recognition, or use a mixture.

Finding the Patient

Type the patient's MRN to find their encounter, or select No Encounter
Select Letter to GP

Required Letter Structure

Diagnosis
Management plan — in alphabetical format (A / B / C …)
Advice to GP — include only if asking GP to prescribe on your behalf (e.g. Efudix). Omit this heading if not applicable.
Follow-up plan — e.g. discharged, pending histology, or follow-up in X months
Main body of the letter — full appropriate history including PMH, drug history, allergies, presence/absence of pacemaker or implantable device

Document any discussions around treatment options offered and how the outcome was reached, including balance of risks and benefits.

GP Prescriptions

If you want the patient to have a prescription, ask the GP to prescribe it (unless very urgent)
Tell the patient it may take up to 2 weeks for the GP to issue the prescription
A standard footnote at the bottom of letters explains this — delete it if you are not requesting a prescription

🏥 Rowlands Hospital Pharmacy — Outpatient Prescriptions

ℹ️ Terminology change on the prescription form — when prescribing for collection from Rowlands Hospital Pharmacy, the form now reads:

Option	When to Use
Collect Now	Patient will collect their medication immediately from the Outpatient Pharmacy — i.e. straight from clinic.
Collect Later	All other outpatient prescriptions — e.g. prescribing over the phone, or the patient is coming at a different time / later that day.

📚 Clinic-Specific Guides

Select the clinic you're in for expectations, common presentations, and how to run it efficiently. Generic how-to-run-clinic guidance is in the Generic Clinic Guide.

💊 Acne Clinic

Clinic purpose: To initiate or escalate acne therapy beyond primary care, including oral antibiotics, combined oral contraceptives, and isotretinoin. Assessment and monitoring for isotretinoin prescribing.

Common Presentations

Moderate–severe inflammatory acne (papulopustular, nodular)
Scarring or pigmentary change
Failed primary care (topical retinoid + antibiotic × 3 months)
Acne in females (consider hormonal workup — PCOS, late-onset CAH)
Psychological impact / acne excoriée

Initial Assessment

Grading: Global Acne Grading Scale / Leeds score
Distribution: face, chest, back
DLQI (psychological impact)
Prior treatments and duration
Female patients: LMP, contraception, menstrual irregularity
Family history of severe acne

Isotretinoin Prescribing — Key Points

⛔ Pregnancy Prevention Programme (PPP) — MANDATORY for all females of childbearing potential Two forms of contraception required. Monthly pregnancy tests. Dispense monthly only. Register on Pregnancy Prevention Programme. No prescription without negative pregnancy test in preceding 3 days.

Standard dose: 0.5–1 mg/kg/day. Cumulative target: 120–150 mg/kg
Bloods before starting: LFTs, fasting lipids, FBC — repeat at 4–6 weeks, then every 3 months
Advise: avoid waxing/laser for 6 months, use SPF daily, lip care (e.g. Vaseline)
Mood monitoring: document baseline mood/PHQ; advise to report changes
Contact sports / gym: can continue but advise on fragile skin

Follow-up Interval

4–6 weeks initially (bloods); 3-monthly once stable on isotretinoin. Post-treatment review at 3 months after completing course.

⏱️ Urgent Suspected Cancer Referrals

Urgent suspected cancer referrals (formerly known as two week wait / 2WW) make up a large proportion of the dermatology workload. The majority of these referrals will be to exclude melanoma, SCC and high-risk BCCs.

When seeing these patients, a thorough history should include: history of the lesion, UV exposure, skin type, prior/family history of skin cancer, relevant PMHx and immunosuppression.

Rely on clinical and dermoscopic assessment to decide on the management options outlined below.

Cancer Waiting Time Target: First appointment within 14 days of GP referral. Definitive treatment (or clear cancer diagnosis ruling out) within 62 days.

🏥 Services Available

Surgery — What We Do In House

Excisions, shave C&C ×3, punch biopsy, incisional biopsy on the body
Shave C&C ×3, incisional biopsy, punch biopsy on the face
Small facial excisions (<1cm) can be kept in house
Where possible, do not book everything as biopsy first — if the lesion needs removing, book for excision/removal unless there is real diagnostic uncertainty that will impact treatment
How to list: forms, booking times, surgeon level and photos — see Minor Op Listing

Surgery — When to Refer Out

Lesion >1cm on the face (excluding scalp/neck) → ENT (ears/nose) or Plastic Surgery (anywhere else)
ENT do NOT accept pigmented lesions — only BCC and SCC. Send pigmented lesions to Plastics.
Cases requiring flaps or grafts → Plastics or ENT (we do not do these in house)
Recurrent BCC / clearly morphoeic BCC in a cosmetically sensitive site → consider pre-Mohs scoop biopsy. Local Mohs centres: Oxford and London (GSTT). Discuss in MDT once result back.
To refer out: write a referral letter via MModal specifying urgency — 2WW, urgent (within 6 weeks), or routine

PDT (Photodynamic Therapy)

We offer standard and artificial daylight PDT (e.g. suitable for large superficial BCC)
Arrange a diagnostic biopsy first, give the patient a PDT leaflet, and complete the PDT referral form (paper)
Hand the form to the nurse at the end of clinic

Cryotherapy

Available in clinics — ask the nurse in charge where the cryotherapy is kept
Document in your letter: number of freeze/thaw cycles and duration
Give a cryotherapy leaflet to every patient treated

📸 Clinical Photographs

⛔ Surgery will not go ahead without a pre-op photograph confirming the correct lesion.

Photographs should be taken for all patients and lesions
Use the Alertive app (download onto your trust phone)
Mark the correct lesion with a surgical marker — circle it or draw two pointed arrows to indicate it
Take three images: (1) overview of the area to orientate the surgeon (e.g. 'back'), (2) close-up of the lesion, (3) dermoscopic image where possible

📝 General Notes

Benign Lesions

We do not treat (and are not funded to treat) benign lesions — including irritated seborrhoeic keratoses. If you determine the lesion is benign, discharge back to the GP. They can refer to Loddon Vale GP Practice for removal of symptomatic benign skin lesions, or suggest private providers.

Leaflets

Give patients written information wherever possible — it improves understanding and communication. Folders with the most commonly needed leaflets will be available in clinic. If you need one that isn't there, ask the nurse to print it.

Consent for Surgery

Consent is obtained on the day of the procedure, not at the consultation appointment. You do not need to complete a consent form during clinic.

📅 Follow-Up & PIFU

Follow-up slots are limited — only order if genuinely needed.

For PIFU: select PIFU on the OP Outcome in EPR, then also add a Derm PIFU order separately
For all other follow-up order types, see the Follow-Up Ordering section

🔵 Vulval Clinic

This is a specialist clinic — run jointly with gynaecology where possible. Sensitivity and a trauma-informed approach are essential.

Common Diagnoses

Lichen sclerosus (LS)
Lichen planus (LP) — erosive
Lichen simplex chronicus
Contact/irritant dermatitis
Vulval intraepithelial neoplasia (VIN)
Psoriasis, eczema
Plasma cell vulvitis (Zoon's)

Clinic Tips

Always offer chaperone — document in notes
Vulvoscopy / magnification aids diagnosis
Consider biopsy if: VIN suspected, diagnosis unclear, poor response to treatment
Review all topical products used (soaps, wipes, lubricants)
Lichen sclerosus — lifelong follow-up due to SCC risk (~4%)

Lichen Sclerosus — Management

First line: Clobetasol propionate 0.05% — maintenance regimen (e.g. reducing from nightly to 2× weekly)
Provide written treatment plan — "The British Society for Vulval Diseases" patient leaflet
Annual review — assess for architectural changes, malignant change, and adherence
Refer to gynaecology if: scarring affecting function, VIN, or any suspicious area

⛔ Suspected VIN / vulval cancer → urgent gynaecology referral + skin cancer MDT

👶 Paediatric Dermatology

Consent: For children under 16 — parent/guardian must be present unless Gillick competency established and documented. For procedures, written consent from parent required.

Common Presentations

Atopic eczema (most common)
Viral warts, molluscum
Psoriasis (guttate, plaque)
Vascular anomalies (haemangiomas)
Alopecia areata
Genodermatoses
Tinea capitis

Clinic Tips

Use POEM / CDLQI for eczema severity (child-reported and parent-reported)
Consider safeguarding: unusual distribution, delay in presentation, inconsistent history
EMLA cream should be applied 45–60 min before any procedure
Oral antihistamines: chlorphenamine (under 1 yr avoid), loratadine from 2 yrs
Topical steroids: use least potent effective — avoid potent steroids on face/flexures

Atopic Eczema Escalation Pathway

Mild → emollients + mild topical steroid (hydrocortisone 1%). Moderate → moderate steroid (Eumovate), consider topical calcineurin inhibitor. Severe → potent steroid with close monitoring, refer for wet wrap training with specialist nurse, consider systemic (ciclosporin, dupilumab from age 6+).

⚠️ Tinea capitis: Requires oral antifungal (oral griseofulvin or terbinafine) — topical alone is ineffective. Confirm with skin scrapings / hair samples for mycology.

🩺 General Dermatology Clinic

General derm clinics cover the breadth of dermatological conditions not managed by specialist sub-clinics.

Common Conditions Seen

Chronic urticaria / angioedema
Psoriasis — topical and systemic
Lichen planus
Rosacea
Bullous pemphigoid / pemphigus
Drug reactions (DRESS, SJS/TEN)
Skin infections (cellulitis, HSV, VZV)

Clinic Running Tips

New patients typically 20 min; follow-ups 10 min — adjust for complex cases
Photograph lesions on EPR (see IT section)
For biologic prescribing — confirm bloods up to date and MDT documented
Any diagnosis of bullous disease → admit or urgent consultant review same day

Biologics — Pre-prescribing Checklist

Hepatitis B, C and HIV serology
Tuberculosis screening (IGRA / CXR) — prior to IL-17, IL-23, TNF inhibitors
Varicella immunity (offer VZV vaccine if non-immune prior to biologic)
Pregnancy test if applicable
Confirm PASI / DLQI documented for audit

💉 Biologics Clinic

Clinic purpose: initiation, monitoring, and switching of biologic therapy — mainly psoriasis (IL-17, IL-23, TNF inhibitors), atopic dermatitis (dupilumab, JAK inhibitors), and urticaria (omalizumab).

Before Initiation

Confirm eligibility per NICE criteria (e.g. PASI ≥10 + DLQI >10 and failed standard systemics for psoriasis)
Pre-screen bloods: Hep B/C, HIV, FBC, U&E, LFTs
TB screening (IGRA ± CXR) before IL-17, IL-23, TNF inhibitors
Varicella immunity — offer VZV vaccine if non-immune, before starting
Pregnancy test if applicable; discuss family planning
Document baseline PASI / EASI + DLQI (needed for audit and continuation decisions)
MDT / funding approval documented where required

At Each Review

Score response: PASI/EASI + DLQI — compare against continuation criteria (e.g. PASI75 or PASI50+DLQI improvement at 16 weeks)
Screen for infection, malignancy red flags, injection-site issues
Check adherence and supply (homecare delivery issues are common)
Annual review: vaccinations up to date (no live vaccines on biologics), skin cancer surveillance in high-risk patients
Order follow-up as Derm Biologics F/U — 3-monthly first year, then 6-monthly

Inadequate Response / Switching

Primary failure (no response by week 16) vs secondary failure (loss of response) — document which
Check adherence and weight-based dosing before declaring failure
Switching within/between classes: discuss at biologics MDT / with consultant; re-baseline PASI/DLQI

⚠️ Serious infection: withhold biologic during significant active infection and advise patients to report fevers. Peri-operative pausing per agent half-life — discuss with consultant.

🦴 Rheum/Derm Combined Clinic

Joint clinic with rheumatology for connective tissue disease and psoriatic arthritis — patients are seen by both specialties in one visit. Runs [Day / frequency].

Common Presentations

Cutaneous lupus (discoid, subacute, systemic overlap)
Dermatomyositis (heliotrope rash, Gottron's papules)
Systemic sclerosis / morphoea
Psoriasis with psoriatic arthritis
Vasculitis with systemic features
Overlap syndromes / undifferentiated CTD

Clinic Tips

Screen every psoriasis patient for PsA (PEST questionnaire) — early arthritis referral prevents joint damage
Lupus workup: ANA, ENA, dsDNA, complement, urinalysis at every visit
Dermatomyositis: check CK, consider malignancy screen (age-appropriate) and myositis antibody panel
Skin biopsy ± DIF often helpful for lupus — discuss protocol before biopsy
Shared-care DMARDs (methotrexate, hydroxychloroquine): agree who monitors — document clearly in the letter
Hydroxychloroquine: baseline + annual ophthalmology screening after 5 years

How Patients Get Into This Clinic

Internal referral from general derm or rheumatology when both specialties needed
Book follow-up into the combined clinic slot; add clinical context in the comments field

⛔ Red flags: rapidly progressive weakness (dermatomyositis), renal involvement in lupus/vasculitis, digital ischaemia in scleroderma → same-day rheumatology/medical escalation.

💅 Nail Clinic

Specialist nail clinic — manages inflammatory, infective, and structural nail disorders that require specialist assessment or treatment beyond primary care.

Common Presentations

Psoriatic nail disease (pitting, onycholysis, subungual hyperkeratosis)
Onychomycosis (fungal nail) — confirmed or suspected
Lichen planus of the nail
Nail unit tumours (subungual melanoma, glomus tumour)
Chronic paronychia
Twenty-nail dystrophy
Habit-tic deformity

Clinic Tips

Photograph nails at each visit for monitoring
Nail clippings for mycology before starting oral antifungals — ensure adequate sample from proximal involved nail and subungual debris
Dermoscopy (onychoscopy) useful for pigmented lesions and early diagnosis
Oral terbinafine: check LFTs before starting; avoid in hepatic impairment
Nail biopsy: punch or lateral longitudinal biopsy — discuss with consultant

Onychomycosis Treatment

Confirm with mycology (nail clippings) before systemic treatment
Terbinafine 250mg od: fingernails 6 weeks, toenails 12 weeks
Itraconazole pulse (200mg bd for 1 week/month): fingernails ×2 pulses, toenails ×3 pulses
Topical amorolfine: suitable for distal/lateral disease without matrix involvement — poor cure rate for extensive disease

⛔ Subungual melanoma: Any longitudinal melanonychia with irregular pigmentation, nail dystrophy, or Hutchinson's sign → urgent biopsy. Do not discharge without senior review.

💇 Hair Clinic

Specialist hair clinic — investigates and manages hair loss and scalp disorders referred from primary care or general dermatology.

Common Presentations

Alopecia areata (patchy, totalis, universalis)
Androgenetic alopecia (male and female pattern)
Telogen effluvium (diffuse shedding)
Frontal fibrosing alopecia (FFA)
Lichen planopilaris (LPP)
Scarring alopecias (central centrifugal, discoid lupus)
Trichotillomania

Initial Assessment

Scalp dermoscopy (trichoscopy) — key diagnostic tool
Hair pull test — positive if >6 hairs in telogen phase
Bloods: FBC, ferritin, TFTs, zinc, B12, folate (tailored to history)
Scalp biopsy (4mm punch × 2): one in formalin, one in Michel's for DIF — for suspected scarring alopecia
Document: onset, rate of progression, distribution, family history, medications, recent illness or stress

Key Management Points

Alopecia areata: Intralesional triamcinolone (2.5–10mg/ml) for patchy disease. Topical immunotherapy (DPCP) for extensive. Baricitinib/ritlecitinib for severe — check current NICE criteria
FFA/LPP: Hydroxychloroquine, topical/IL steroids, 5-alpha reductase inhibitors (FFA). Halt progression rather than regrow.
Androgenetic alopecia: Topical minoxidil (male/female), oral finasteride (male), spironolactone (female)
Telogen effluvium: Identify and treat precipitant. Reassure — usually self-limiting at 6–12 months

💊 Ritlecitinib Pathway — Alopecia Areata (SALT ≥50)

ℹ️ Ritlecitinib is available for severe alopecia areata (SALT score 50+). Eligibility criteria have been circulated by Rebecca — refer to these before initiating the pathway.

Patient is seen in general dermatology clinic by any clinician
Assess whether the patient meets the criteria for Ritlecitinib (SALT ≥50 + criteria per Rebecca's guidance)
If the patient meets criteria: book a follow-up appointment and write "Ritlecitinib" in the comments field — this ensures they are booked into Rebecca's specific hair clinic
If the patient does not meet criteria: discharge

⚠️ Do not initiate Ritlecitinib directly. The dedicated hair clinic handles eligibility confirmation, baseline assessments, and prescribing.

🔵 Male Genital Dermatology

Specialist clinic for inflammatory, infective, and neoplastic conditions affecting male genital skin. A trauma-informed, sensitive approach is essential. Always offer a chaperone and document.

Common Presentations

Lichen sclerosus (BXO) — phimosis, white plaques, fissuring
Lichen planus (erosive or papular)
Psoriasis / seborrhoeic dermatitis
Zoon's balanitis (plasma cell balanitis)
Penile intraepithelial neoplasia (PeIN)
Contact/irritant dermatitis
Fixed drug eruption

Clinic Tips

Always offer a chaperone — document acceptance or refusal
Review all topical products used (soaps, lubricants, condoms)
Consider biopsy if: PeIN suspected, diagnosis unclear, poor treatment response, suspicious pigmented lesion
Lichen sclerosus: refer to urology if significant phimosis or urethral involvement
Any suspected penile cancer → urgent urology referral + skin cancer MDT

Lichen Sclerosus (Male) — Management

First line: Clobetasol propionate 0.05% — reducing regimen (nightly × 4 weeks → alternate nights × 4 weeks → 2×/week maintenance)
Circumcision: refer to urology if phimosis not improving or BXO of prepuce
Annual review: examine for SCC change, architectural distortion, urethral meatal stenosis

⛔ Suspected PeIN or penile SCC → urgent urology referral + skin cancer MDT discussion.

Outcomes & Follow-Ups

Everything for closing a consultation: which OP Outcome to select at checkout, which follow-up order to place (via the Outcome Form (Mpage) — not the Orders tab), PIFU, and minor-op listing essentials.

⚠️ Important: Do not discharge a patient without a safety net in place — either a follow-up date, a clear return pathway, or written advice on when to seek review.

Which OP Outcome to Select

At checkout, tick everything done in clinic (dermoscopy, cryotherapy etc.), then select the outcome under the OP Outcome tab. Only one outcome can be chosen — pick the one that reflects the patient's onward disposition.

⚠️ Key rule: if you are discharging the patient at all, select Discharge — even if you've also treated in clinic.

Outcome	Meaning	Local Guidance
Outcome pending investigation OUTCOME PEND	Patient to be sent for outpatient diagnostic investigation	e.g. post-MOPS before results back
Add to waiting list for treatment ADD WL TREAT	Add to waitlist for treatment	Booking a MOP to treat the lesion — even if the specimen is also sent for histo to confirm
Add to waiting list for diagnostic ADD WL DIAG	Add to waitlist for a diagnostic procedure	Diagnostic biopsy only
Discharge DISCHARGE	Discharged back to referring GP	Use if discharging at all — even if you've also treated
Follow up treated previously FOLLOWUP TRE	Requires a post-treatment follow-up appointment	—
Follow up not yet treated FOLLOWUP	Not yet treated, requires a follow-up appointment	Should be rare — we treat ~99% in clinic
Open appointment — no order OPEN APPT	Non-discharged patient without follow-up can contact to request an appointment	Avoid — use PIFU (bottom of the selection) instead
Treatment given in clinic TREATED	Required treatment given during the current appointment	e.g. cryotherapy, topicals started
Active Monitoring Only ACTIVE MONIT	Initiate or continue "Watch & Wait" active monitoring	—
Admitted from clinic ADMITTED	Admitted as an inpatient from the current clinic	—
Internal referral to another team REFER RBH	Referred to another RBH specialty	e.g. Plastics, ENT, Gynae
Refer for diagnostic/opinion at another Trust REFEROUT DIA	Referred to another Trust for diagnostic / opinion	e.g. patch testing
Refer for treatment at another Trust REFEROUT TRE	Referred to another Trust for treatment	e.g. Mohs
PIFU PIFU	Patient-initiated follow-up	Bottom of the selection — this also places the order

Listing for a Minor Op — Essentials

Green form = 2WW · White form = diagnostic / urgent / soon / routine. Complete ALL sections + your initials at the top; hand to the nurse at end of clinic
Booking times: punch/shave biopsy 30 min · shave C&C ×3 30 min · incisional 40 · body excision 40 · facial excision 40 · 2 lesions (≥1 excision) 60 · 2 shaves/biopsies 40 — add 10 min each for capacity form (form 4), mobility issues, or interpreter
Surgeon level: "ANY" (default) · "FACIAL" (any head/neck excision) · "CONSULTANT" (use sparingly)
Pre-op photos via Alertive are mandatory — mark the lesion (circle or two arrows), take overview + close-up + dermoscopic. Surgery will not go ahead without them
Consent is taken on the day of the procedure — no consent form needed in clinic
Full technique guides and margins: Minor Ops & Procedures

Which Follow-Up Order Type to Use

Selecting the correct order type is important for CATs and capacity management.

Situation	Order Type	Notes
VHRFU & HRFU	Derm 2WW F/U	Do not use Derm F/U — CATs-efficient way of capturing in a timely manner.
Vulval follow-up	Derm Vulval F/U	Do not use generic Derm F/U for vulval patients.
Acne initiation & first iso nurse F/U	Derm Roaccutane F/U	Use for initiation and first nurse F/U (4–5 weeks after starting isotretinoin).
Transplant / lesion follow-up	Derm Transplant F/U	Include clinical comments on the order.
Systemics (non-biologic)	Dermatology Pharmacist F/U	Or Biologics F/U — whichever is appropriate for the agent.
Biologics	Derm Biologics F/U	Use for all biologic monitoring reviews.
Paediatric dermatology	Derm Paeds F/U	Do not use generic Derm F/U.
PIFU	Derm PIFU	Ordered via Mpage — see PIFU tab →
General derm (eczema, psoriasis, BP, nail, hair, lesions)	Derm F/U	Only for general derm — not for any specific pathway above.

How to Place a Follow-Up Order

At end of consultation, open the Outcome Form (Mpage)
Select the correct order type from the table above
Enter timeframe and any clinical comments
For PIFU — see the PIFU tab, do not use the Orders tab
Confirm and sign off

PIFU — Patient-Initiated Follow-Up

ℹ️ Change in process: PIFU is no longer ordered through the Orders tab on EPR. It is now ordered directly from the Outcome Form (Mpage) at the end of the consultation.

📋 How to Order PIFU via Mpage

Complete the consultation and open the Outcome Form (Mpage)
Select the bottom option: "PIFU"
Choose patient type: Paediatric or Adult (Standard)
Tick "12 months"
Click "OK" to sign off

⚠️ Note: Currently only a 12-month option is available. 3, 6, and 9-month options are being requested — check back for updates.

Follow-Up Intervals by Condition

Clinic / Condition	Recommended Interval	Notes
Acne — Initiation of oral antibiotics	8–12 weeks	Review response, compliance, side effects. Switch if no improvement at 3 months.
Acne — On isotretinoin	4–6 weeks initially, then 3-monthly	Monthly dispensing. Bloods with each appointment (first 3 months). Order as Derm Roaccutane F/U.
2WW — No cancer found	Discharge with safety net or PIFU	Provide return pathway information. Document dermoscopy findings.
Melanoma / SCC & VHRFU / HRFU	As per Skin Cancer MDT	Order as Derm 2WW F/U. Frequency directed by MDT outcome.
Psoriasis — On topicals	3–6 months	Earlier if severe flare. Shared care possible with GP. Order as Derm F/U.
Psoriasis — On biologics	3-monthly (first year), then 6-monthly	Bloods per biologic protocol. Annual PASI/DLQI. Order as Derm Biologics F/U.
Lichen sclerosus / Vulval	Annual	Lifelong due to SCC risk. Order as Derm Vulval F/U.
Atopic eczema — Child on systemic	4–6 weeks initially, then 3-monthly	POEM/CDLQI at each visit. Bloods per agent. Order as Derm Paeds F/U.
Bullous pemphigoid	2–4 weeks initially	Monitor BP, glucose, osteoporosis risk if on steroids. Anti-BP180 titre monitoring.
Phototherapy — Course	Review at 15–20 treatments, end of course	Phototherapy nurse monitors each session. Consultant review at intervals.
Chronic urticaria	8–12 weeks on new treatment	UAS7 at each review. Step up if inadequate (antihistamine → omalizumab).
Transplant patients / lesion surveillance	Annual	Order as Derm Transplant F/U. Include comments on the order.

Minor Ops & Procedures

Guidance for minor operations (MOPS) and common dermatological procedures performed in clinic and on the day surgery list.

⚠️ Consent: Written consent required for all surgical procedures. Verbal consent documented for minor procedures (e.g. cryotherapy for warts). Always explain: indication, procedure, risks (bleeding, infection, scarring, recurrence), alternatives, and what happens if untreated.

Minor Operations (MOPS)

📋 Ordering a Minor Op ▼

Use paper surgical proformas — handed in to the nurse at the end of clinic. Green = 2WW, White = urgent / routine / diagnostic.

⚠️ Complete ALL sections on the form. Write your initials/name at the top where it asks who completed it.

Medical photographs should be taken in advance of the procedure where possible — surgery will not go ahead without a pre-op photograph confirming the lesion. See the Photographs section in the 2WW guide.
Use the Green form for all 2WW / highest priority cases (suspected SCC, melanoma, high-risk malignancy). Use the White form for urgent, routine, or diagnostic cases.

Booking Times

Procedure	Time
Punch or shave biopsy	30 min
Shave C&C ×3	30 min
Incisional biopsy	40 min
Body excision	40 min
Facial excision	40 min
2 lesions (at least 1 excision, e.g. shave + excision or 2 body excisions)	60 min
2 shaves / biopsies	40 min

Add 10 minutes if patient requires a capacity consent form (form 4), has significant mobility issues, or needs an interpreter. Add further time if multiple apply.

Surgeon Level

Punches, shaves, shave C&C ×3, body excisions → write "ANY"
Any excision on the head or neck → write "FACIAL"
Particularly complex cases → write "CONSULTANT" (use sparingly — most facial surgeons can handle most things)

✂️ Excisions ▼

Excision Margins

Lesion Type	Margin	Notes
Pigmented lesions (diagnostic excision)	2mm	Narrow margin for diagnosis. WLE margins are specified by MDT following histology — do not use 2mm for WLE.
Non-pigmented lesions (e.g. BCC, SCC, benign)	4mm	Standard margin for non-pigmented lesions.
Non-pigmented lesion ≥2cm	6mm	Larger margin for bigger lesions to account for lateral spread.
Wide local excision (WLE)	As per MDT / skin cancer team	Margin determined by tumour type, Breslow thickness (melanoma), and site. Always follow MDT outcome.

Technique

Mark lesion + margin with surgical marker; photograph before and after marking
Inject 1% lidocaine ± adrenaline (avoid adrenaline on digits, nose tip, ear tip, penis)
Design ellipse along relaxed skin tension lines — aim for 3:1 length:width ratio to allow flat closure
Incise to subcutaneous fat; undermine broadly at the same plane
Close in layers: deep dermal absorbable sutures (e.g. 3-0 Vicryl) then surface interrupted sutures
Send specimen in formalin — clearly label site, orientation (mark superior pole with suture or ink), and mark 2WW / urgent if applicable

Suture Removal

Face: 5–7 days
Scalp, neck, trunk, limbs: 10–14 days
Back / lower leg: 14 days (slower healing)

⚠️ Advise patient: keep wound dry for 48h, avoid strenuous exercise for 1 week. Wound check if complex closure or at-risk patient (anticoagulants, diabetes, PVD).

🔬 Biopsies ▼

Incisional Biopsy

Partial removal of a lesion where complete excision is not indicated or feasible. Used for large lesions, to establish diagnosis before definitive treatment, or where excision would be disfiguring.

Select the most representative area — typically active edge for inflammatory, centre for tumour
Inject LA; make a small ellipse or wedge incision through the lesion into dermis/subcutis
Close primarily or leave to heal by secondary intention depending on size/site
Send in formalin with full clinical details

Punch Biopsy

Most commonly used biopsy technique in derm. Provides full-thickness skin core.

Select site — active edge for inflammatory, centre for tumour
Infiltrate with 1% lidocaine ± adrenaline; stretch skin perpendicular to tension lines
Insert punch (3–6mm; 4mm most common) with firm rotating pressure to full depth
Lift core with fine-toothed forceps; cut base flush with iris scissors
Suture: 1–2 interrupted nylon 4-0 or 5-0; or leave to heal by secondary intention on trunk
Send in formalin — or see specific protocols below for special requests

Shave / Scoop Biopsy

Best for exophytic lesions — seborrhoeic keratoses, dermal naevi, skin tags, molluscum. Avoids sutures.

Infiltrate with LA to elevate the lesion proud of the skin surface
Use a No.15 blade or DermaBlade in a tangential plane — shave flush with skin or scoop beneath the lesion
Haemostasis with aluminium chloride or Monsel's solution; avoid diathermy if sending to histology
Apply Vaseline + non-adhesive dressing; heals by secondary intention
Send in formalin; label as urgent/2WW if clinically indicated

🧫 Special Biopsy Protocols

Immunofluorescence (DIF)

Required for suspected autoimmune blistering conditions: bullous pemphigoid, pemphigus, dermatitis herpetiformis, linear IgA, epidermolysis bullosa acquisita.

Site: perilesional normal skin (adjacent to blister, not within it) — except for DH where buttock or normal skin is preferred
Medium: Michel's transport medium — NOT formalin. Request from lab in advance.
Take a separate punch (3–4mm) in addition to routine histology punch
Label clearly: "DIF — Michel's medium" on the form and pot
Transport to lab promptly; do not freeze

Alopecia Biopsy Protocol

Scalp biopsy for alopecia requires specific technique to maximise diagnostic yield.

Take two 4mm punch biopsies from the affected area (active zone, e.g. advancing hairline for FFA)
One biopsy processed as vertical sections (routine H&E); one as horizontal/transverse sections — label each pot separately and specify on the form
Select area of active disease: erythema, scale, or follicular loss — avoid completely bald areas
For scarring alopecias (FFA, LPP): target the advancing margin
For non-scarring (AA, AGA, telogen effluvium): mid-scalp, clinically involved area
Send both in formalin; clearly annotate "alopecia protocol — horizontal and vertical sections required"

Inflammatory Dermatoses

For unclear inflammatory rashes, biopsy selection and timing matters.

Biopsy an active, established lesion — avoid early lesions (<24–48h old) and very chronic lesions where histology may be non-specific
Punch biopsy (4mm) to full depth is standard; incisional biopsy for annular/morphoeic lesions where edge is important
Avoid biopsying leg lesions in patients with venous disease unless essential (poor healing)
If vasculitis suspected: biopsy within 24–48h of lesion onset for best yield of vessel changes
Include on form: clinical diagnosis, differential, any treatment given, lesion age, systemic symptoms
If lupus or LE overlap suspected — discuss DIF with consultant

🪒 Shave + Curettage & Cautery ×3 ▼

Shave followed by three cycles of curettage and cautery (C&C ×3). Used for superficial BCCs and selected low-risk skin tumours where excision would be disproportionate or site-unsuitable.

Indications

Superficial or nodular BCC — low risk site (trunk, limbs, scalp)
Pyogenic granuloma
Seborrhoeic keratoses (symptomatic)
Not suitable for: H-zone BCC, morphoeic/infiltrative BCC, recurrent tumours, or sites with poor healing (lower leg, PVD)

Technique

Infiltrate with 1% lidocaine + adrenaline; allow full vasoconstriction (2–3 min)
Initial shave: use a No.15 blade to debulk the visible lesion flush with skin surface. Send shave specimen in formalin.
Cycle 1: Curette the base and margins firmly — BCC feels soft and grainy vs firm surrounding dermis. Use a medium curette (3–4mm). Cauterise thoroughly with hyfrecator.
Cycle 2: Re-curette the same area. Cauterise again.
Cycle 3: Final curette pass. Final cauterisation of base and 3–5mm margin.
Apply Vaseline + non-adhesive dressing. Heals by secondary intention over 3–8 weeks.

ℹ️ Aftercare: Wound will look raw and weep initially — reassure patient. Daily Vaseline + dressing. Review at 4–6 weeks to confirm healing. Arrange follow-up for scar review and surveillance as per protocol.

🧵 Sutures ▼

Suture Selection Guide

Layer / Site	Suture Type	Size
Deep dermal (subcutaneous) — all sites	Absorbable (Vicryl / Monocryl)	3-0 or 4-0
Surface — face, neck	Non-absorbable monofilament (Prolene / Ethilon) or Monocryl (buried)	5-0 or 6-0
Surface — scalp	Staples or Nylon	3-0
Surface — trunk, limbs	Nylon (Ethilon) or Prolene	3-0 or 4-0
Surface — back / lower leg	Nylon (Ethilon)	3-0
Punch biopsy defect	Nylon (Ethilon)	4-0 or 5-0

Suture Removal

Site	Removal timing
Face / eyelids	5–7 days
Scalp, neck	7–10 days
Trunk, upper limbs	10–14 days
Back, lower limbs	14 days

ℹ️ Tips: Always close deep dermal layer first to reduce surface tension. For face, consider subcuticular (intradermal) Monocryl to avoid suture marks. Alternate suture removal (remove every other one first) if wound is under tension.

Other Clinic Procedures

🧊 Cryotherapy ▼

Indications

Viral warts (verrucae, hand warts)
Seborrhoeic keratoses (symptomatic or cosmetically troubling)
Actinic keratoses (AK) — field treatment in combination with other methods
Superficial BCC (small, low-risk) — confirm with consultant

Technique — Liquid Nitrogen (LN₂)

Clean area with alcohol wipe and allow to dry
Apply liquid nitrogen with spray gun or cotton-tipped applicator — maintain 1–2 cm distance for spray
Freeze–thaw cycle: freeze until 2mm ice ball forms around lesion; allow to thaw; repeat ×1–2 for resistant lesions
Document: site, size, number of freeze-thaw cycles, any adverse events
Advise patient: expect redness, blistering within 24–48h; blister may be burst with clean needle; healing over 1–2 weeks

ℹ️ Avoid cryotherapy to digital tips, lower legs in PVD/poor circulation, or overlying tendons/nerves without senior guidance.

🔬 Skin Scrapings / Nail Clippings (Mycology) ▼

Label mycology pot with patient details and clinical details (site, clinical diagnosis, prior antifungal treatment)
Scrape the active edge of the lesion (not the centre) using a blunt scalpel or edge of microscope slide
For nails: clip the most proximal involved nail and scrape subungual debris
Collect onto black card (included in mycology kit) — enough material is key
Send to microbiology / mycology lab — results take 3–6 weeks for culture

ℹ️ If urgent (e.g. tinea capitis in child), request KOH microscopy for same-day result (not all labs offer this — check with lab).

Protocols & Guidelines

Local treatment protocols, prescribing guidance, and monitoring frameworks. Always cross-reference with current NICE guidelines and British Association of Dermatologists (BAD) guidelines.

Topical Therapy Potency Guide

Potency	Examples	Typical Use
Mild	Hydrocortisone 1%, 0.5%	Face, flexures, children <1yr, mild eczema
Moderate	Clobetasone butyrate (Eumovate), Betamethasone valerate 0.025%	Eczema on body, mild psoriasis
Potent	Betamethasone valerate 0.1%, Mometasone, Fluocinolone	Chronic eczema/psoriasis on trunk/limbs
Very potent	Clobetasol propionate 0.05% (Dermovate)	Palms/soles, lichen sclerosus, discoid LE — short courses only

Systemic Treatment Monitoring

Methotrexate

Bloods before starting: FBC, LFTs, U&E, CXR
Folic acid 5mg once weekly (not same day as MTX)
Bloods: 2-weekly for 6 weeks → monthly once stable
Stop if: WBC <3.5, neutrophils <2, plts <100, LFT >3× ULN
Avoid alcohol, live vaccines, NSAIDs, trimethoprim
Alert card to patient

Ciclosporin

Dose: 2.5–5 mg/kg/day in 2 divided doses
Baseline: BP (×2), U&E, LFTs, Mg, urate, FBC, fasting lipids
Monitor: BP + U&E fortnightly for 3 months, then monthly
Stop if: creatinine rises >30% above baseline (on ×2 readings), uncontrolled BP, malignancy
Interactions: grapefruit juice, NSAIDs, potassium-sparing diuretics, statins
Max continuous use: 2 years

Dupilumab

Dose: 300mg SC every 2 weeks (after loading dose)
Indication: moderate–severe AD, severe asthma, CRSwNP, EoE, PND
Baseline: EASI / SCORAD / IGA, DLQI, pregnancy test if applicable
No routine blood monitoring required
Common: conjunctivitis (refer to ophthalmology if persistent), injection site reactions
Review at 16 weeks for EASI75 response

Isotretinoin

Dose: 0.5–1 mg/kg/day; cumulative 120–150 mg/kg
Bloods: LFTs, fasting lipids, FBC — at baseline, 4 weeks, 3-monthly
Females: Pregnancy Prevention Programme (see Acne clinic)
Mood monitoring at each visit
Avoid: waxing, laser, blood donation (for 1 month after), high-dose vitamin A

Useful Formulary Links

Local Formulary: [Link to trust formulary / intranet page]
BAD Patient Information Leaflets: www.bad.org.uk/pils
NICE Dermatology Guidance: www.nice.org.uk/guidance/conditions-and-diseases/skin-conditions
DermNet NZ: www.dermnetnz.org — excellent clinical reference

🏥 Hospital Sites

Dermatology runs across several sites. What happens where, how to get there, and who to contact at each. Detailed info to follow.

🏥 Royal Berkshire Hospital (RBH) — Reading

What runs here: [Main site — clinics, minor ops, phototherapy, MDT…]
Location & parking: [Address, travel and parking tips]
Key contacts: Front desk 6954 · Back desk 8701 · CAT 8: 1888
Notes: [Info to follow]

🏥 Townlands Hospital — Henley

What runs here: [Clinics held, frequency]
Location & parking: [Address, travel and parking tips]
Key contacts: CAT 13 (Townlands): 40157 · CAT13@royalberkshire.nhs.uk
Notes: [Info to follow]

🏥 West Berkshire Community Hospital — Thatcham

What runs here: [Clinics held, frequency]
Location & parking: [Address, travel and parking tips]
Key contacts: CAT 12: patient line 40139 · CAT12@royalberkshire.nhs.uk
Notes: [Info to follow]

🏥 Bracknell Healthspace

What runs here: [Clinics held, frequency]
Location & parking: [Address, travel and parking tips]
Key contacts: CAT 13 (Bracknell): 2900 · CAT13@royalberkshire.nhs.uk
Notes: [Info to follow]

ℹ️ Info to follow. Send site details (clinic schedules, parking, door codes, kit available) to keep this page current.

Contact Directory

All key numbers and contacts for the Dermatology department in one place. Update via the department admin team when details change.

📞 Quick Numbers

CAT 8 (Derm) 1888

OP 2 Reception —

Front Desk 6954

Back Desk 8701

Dhru 8702

Big MOPS Room 7590

Jo 3344

Grace 3439

Susan 6845

Iuliana 3937

Kempton Day Unit —

SDEC —

👩‍⚕️ Consultant Directory

Consultant	Specialty Interest	Clinic Day
Dr [Name]	General / skin cancer / Mohs	[Day]
Dr [Name]	Paediatric dermatology	[Day]
Dr [Name]	Vulval / immunobullous	[Day]
Dr [Name]	Acne / biologics / phototherapy	[Day]
Dr [Name]	Contact dermatitis / patch testing	[Day]

🗂️ Clinical Administration Teams (CATs)

Royal Berkshire NHS Foundation Trust — internal use only. CAT 8 (Dermatology & Haematology) internal line is 1888.

CAT	Specialties	Internal No.	Email
CAT 1	ENT, Oral & Max Fax, Orthodontics & Plastics	1881	CAT1@royalberkshire.nhs.uk
CAT 2	Ophthalmology – RBH	1882	CAT2@royalberkshire.nhs.uk
CAT 2A	Ophthalmology – PCEU Windsor	3302	—
CAT 3	General Surgery, Breast Surgery & Colorectal	1883	CAT3@royalberkshire.nhs.uk
CAT 3A	Urology	1891	CAT3A@royalberkshire.nhs.uk
CAT 4	Gastroenterology	1884	CAT4@royalberkshire.nhs.uk
CAT 5	Orthopaedics	1885	CAT5@royalberkshire.nhs.uk
CAT 6	Maternity & Gynaecology	1886	CAT6@royalberkshire.nhs.uk
CAT 7	Paediatrics	1887	CAT7@royalberkshire.nhs.uk
CAT 8 ⭐	Dermatology & Haematology	1888	CAT8@royalberkshire.nhs.uk
CAT 8A	Audiology	1897	—
CAT 9	Diabetes, Endocrinology, Renal & Rheumatology	1889	CAT9@royalberkshire.nhs.uk
CAT 10	Elderly Care, Neurology, Stroke & Neuro Rehab	1893	CAT10@royalberkshire.nhs.uk
CAT 11	Cardiology & Respiratory	1894	CAT11@royalberkshire.nhs.uk
CAT 12	West Berkshire Community Hospital	Patient: 40139	CAT12@royalberkshire.nhs.uk
CAT 13	Townlands & Bracknell	Townlands: 40157 / Bracknell: 2900	CAT13@royalberkshire.nhs.uk

Useful External Contacts

Service	Contact	Notes
Histopathology (urgent results)	Ext. XXXXX	For urgent derm histology queries
Mycology Lab	Ext. XXXXX	Fungal culture results, advice on samples
Pharmacy (specialist)	Ext. XXXXX	Biologic prescribing, unlicensed drugs
Plastic Surgery	Ext. XXXXX	Reconstructive surgery referrals
Rheumatology	Ext. XXXXX	Shared care — psoriatic arthritis, CTD
Gynaecology (vulval)	Ext. XXXXX	Vulval cancer MDT, joint clinic

IT & Systems

Practical guides for IT systems used daily in the Dermatology department — clinical photography, EPR navigation, and dictation with MModal.

EPR — Key Tasks

📋 Writing & Signing Clinic Letters ▼

Open patient encounter on [EPR]
Navigate to Outpatient Letter or use the letter template from the derm letter library
Dictate using MModal (see below) or type directly
Review draft — check: diagnosis, management plan, follow-up, GP actions
Sign the letter electronically — letters should be signed within 5 working days of the appointment
Letters are sent automatically to GP once signed. Print copy if patient requests.

⚠️ Do not save a letter as "Draft" and forget to sign. Unsigned letters cause significant admin burden and can affect patient safety.

🗣️ MModal Dictation — Getting Started ▼

MModal Fluency (formerly Nuance) is the voice dictation system integrated with EPR for creating clinic letters.

Log in to EPR and open the clinic letter for the patient
Click the MModal icon (microphone) in the letter toolbar
Wait for the green light — then speak clearly at a normal pace
Say punctuation aloud: "full stop", "new paragraph", "comma"
Review the transcribed text — MModal learns your voice over time but check carefully
Correct errors: highlight and re-dictate, or type correction
Say "sign off" or click Stop when done

MModal Tips

Speak in complete sentences — avoid pausing mid-word
Use the headset microphone for best accuracy (available from clinic room)
Dictate in a quiet space — background noise reduces accuracy
For drug names / complex terms: spell out if recognition is poor
Training sessions available via IT — contact Ext. XXXXX

🔎 Requesting & Viewing Histology Results ▼

Navigate to patient record on [EPR]
Go to Results → Histopathology
Results are usually available within 7–10 working days (mark urgent for faster turnaround)
For urgent cancer results — call histopathology directly: Ext. XXXXX
Acknowledge and action the result in EPR — document management plan in notes or letter

⛔ Never discharge a patient without confirming all histology results are reviewed and actioned. Use the EPR task list to flag pending results.

📝 Ordering Blood Tests via EPR ▼

Open patient record → Orders → Laboratory
Search for required test or use pre-built derm order sets
Derm order sets available: Methotrexate Monitoring, Ciclosporin Monitoring, Isotretinoin Bloods, Biologics Pre-Screen, Bullous Disease Screen
Set frequency and clinic collection date if applicable
Add a clinical indication — required for some tests (e.g. IGRA)
Sign and submit

💻 System Logins & Access Issues ▼

EPR login issues: IT helpdesk — Ext. XXXXX or [helpdesk@nhs.net]
Smart card reader issues: Check physical connection first; re-insert card; if persists — IT helpdesk
MModal account setup: Arrange via IT on arrival — allow 1–2 days for provisioning
New starter access: Request via [line manager / departmental admin] minimum 5 working days before start
After-hours IT support: Ext. XXXXX (24/7)

Clinical Photography

⚠️ Consent Required: Written consent for clinical photography must be obtained and documented before taking any photograph. Use the trust clinical photography consent form. Photographs taken on personal mobile phones are NOT permitted.

📷 Taking Clinical Photos — Approved Methods

Using the Clinic iPad / Camera

Obtain and document written patient consent
Use [trust-approved camera / iPad] — available from clinic reception
Ensure consistent lighting — use natural light where possible, avoid harsh flash
Include a ruler/scale for lesions where relevant
Take: overview, medium-distance, close-up views
Upload to [EPR / clinical image system] on same day

Dermoscopy Images

Attach phone adapter to dermoscope
Use [approved dermoscopy app] on trust device
Apply gel or use non-contact technique
Capture image and upload directly to patient record via app
Document dermoscopy findings in clinical notes

ℹ️ Uploading to EPR: Go to patient record → Clinical Documents → Images → Upload. Tag with: date, site, clinical indication. Images become part of the permanent medical record.

Useful System Links (Intranet)

Trust Intranet: [intranet URL]
EPR Login: [EPR URL]
e-RS (Choose & Book): [e-RS URL]
Incident Reporting (Datix): [Datix URL]
Local Formulary: [Formulary URL]
Patient leaflets (BAD): www.bad.org.uk/pils

✅ New Starter Checklist

Tick each item as you complete it — progress is saved on this device, so you can come back to it any time. Use this to make sure you're set up and ready before your first clinic.

⚠️ If in doubt, ask. No question is too basic in your first week. Your consultant, registrar, and the nursing team are all there to help you settle in.

Junior Doctor Guide

Practical guidance for junior doctors (FY1/FY2/IMT/CMT/CT) rotating through Dermatology — referral management, CPC, advice & guidance, ward cover, and study leave.

📋 Managing Incoming Referrals

Referrals arrive into the department from GPs and other specialties via e-RS (NHS e-Referral Service). They land in the CAT 8 worklist and are triaged before being allocated to a clinic slot. As a junior, you may be asked to assist with triage or to action specific referrals.

Referral Triage — Priority Categories

Priority	Target	Examples
2-Week Wait	Seen within 14 days	Suspected melanoma, non-healing SCC, dermoscopy concern. Must be booked as 2WW — track on the cancer pathway.
Urgent	Within 2–4 weeks	Rapidly changing lesion (non-melanoma), suspected pemphigus/pemphigoid, severe drug reaction, significant diagnostic uncertainty.
Soon	Within 6 weeks	Moderate–severe eczema or psoriasis uncontrolled on primary care treatment, suspected autoimmune condition.
Routine	Within 18 weeks	Established conditions for specialist input, mild conditions not responding to GP treatment, stable monitoring.

How to Triage a Referral

Log in to e-RS and open the CAT 8 worklist
Open the referral letter — read in full. Note: clinical diagnosis, key examination findings, treatments tried, any photographs
Apply the triage criteria above — if uncertain, discuss with your registrar or consultant before making a decision
Book the appointment into the correct clinic and priority slot in EPR
If referral is inappropriate or incomplete: return via e-RS with a clear, courteous explanation of what is needed
If referral should be a 2WW but was sent as routine: escalate immediately to your registrar

⛔ Never downgrade a 2WW referral without consultant approval. If in any doubt about a potentially malignant lesion, err on the side of 2WW booking and discuss with your supervisor.

Inpatient & A&E Referrals

All acute referrals from A&E or inpatient wards arrive as EPR referrals — there is no derm bleep. Check the referral worklist regularly.
Do not accept verbal referrals without a written entry in the patient's EPR record
For ward consults: review the patient personally and document your assessment and plan in EPR — do not rely on phone advice alone for complex cases
After-hours: the registrar covers all acute derm queries; out-of-hours GP queries → advise to call 111 or attend A&E if urgent

Advice & Guidance (A&G) Referrals

A&G requests sit separately to formal referrals. They are reviewed on the A&G worklist on e-RS/EPR. Target response time is 2 working days. See the Advice & Guidance section for full guidance on responding.

📬 Managing CPC (Clinical Post-Clinic Admin)

After each clinic, there is a set of tasks that must be completed before you finish for the day. These are sometimes referred to collectively as CPC — the post-clinic admin that keeps patients safe and the department running smoothly.

⚠️ Do not leave clinic without completing your CPC tasks. Outstanding results, unsigned letters, and unbooked follow-ups are a significant patient safety risk and create unnecessary work for admin and nursing staff.

CPC Checklist — End of Every Clinic

Letters: Dictate or type all clinic letters on the day. Do not leave letters for another day — target is signed within 5 working days of the appointment.
Follow-ups: Book all required follow-up appointments via the Outcome Form (Mpage) before closing the EPR encounter. Use the correct order type (see Follow-Up Ordering section).
Referrals: Submit any cross-specialty referrals (e.g. to rheumatology, gynaecology, plastics) on EPR before leaving clinic.
Results: Check for any outstanding results for patients seen today — histology, bloods, microbiology. Action and document in EPR. Flag any abnormal results to your registrar if same-day action is needed.
Prescriptions: Issue or action any prescriptions generated in clinic — electronically via EPR where possible.
Tasks: Review your EPR task list — clear any tasks generated from today's clinic (e.g. "chase result", "send information leaflet").
Safety-netting: For any patient discharged today, confirm safety net is documented: patient knows when and how to re-refer if symptoms change.

Outstanding Results — Daily Action

Check the EPR results inbox at the start and end of each working day
For histology: results usually arrive 7–10 working days after biopsy. For any cancer result, call histopathology (Ext. XXXXX) and inform your registrar immediately
Blood results: abnormal monitoring bloods (e.g. raised LFTs on methotrexate, renal impairment on ciclosporin) → discuss with your registrar before acting
Document that you have reviewed and actioned every result in EPR — "result seen, no action required" is an acceptable entry if appropriate

Managing Correspondence from GPs & Other Teams

GP letters / queries are reviewed via EPR correspondence inbox — check daily
If a GP is asking for advice on a patient not known to the department, direct them to the A&G pathway via e-RS
For queries about existing patients, review the EPR record and respond in the correspondence thread — copy in your supervising consultant where appropriate
Urgent GP queries (e.g. suspected TEN/DRESS) → ask them to send the patient to A&E and inform your registrar

🎓 Study Leave

Junior doctors in dermatology are entitled to study leave as per their deanery/HEE contract. It is your responsibility to plan and request study leave in good time, arrange cover, and ensure your absence does not compromise patient care.

How to Apply for Study Leave

Check your study leave allowance for the rotation — confirm with your educational supervisor at the start of the post. Typically 30 days per year pro-rated (check your contract).
Identify the course / conference / exam and get details: dates, location, cost, educational rationale.
Give minimum 4–6 weeks' notice for planned study leave — more for conferences requiring travel. Do not assume approval.
Submit a study leave request via [Trust study leave portal / OLM / ESR] — attach course details and any prospectus or confirmation email.
Obtain approval from your educational supervisor and clinical supervisor / consultant lead.
Once approved, notify: the department admin team (front desk — ext. 6954), your co-junior(s), and confirm clinic cover has been arranged.
For exam leave (e.g. MRCP, MRCS): separate provisions usually apply — discuss with your TPD (Training Programme Director).

ℹ️ Cover arrangements: It is your responsibility to arrange cover for your clinics and on-call commitments while on study leave. Speak to your rota coordinator and co-juniors well in advance. Do not simply "go on leave" without confirming cover — this puts colleagues and patients at risk.

What Counts as Study Leave?

Specialty conferences (e.g. British Dermatology Nursing Group, BAD meeting)
Postgraduate examinations (MRCP Part 1, Part 2 written, PACES)
Approved teaching courses, simulation days, skills training
Mandatory training days (these may be separate from study leave — check with your rota coordinator)
Academic commitments (if you are an academic trainee)

What Does NOT Count as Study Leave

Personal commitments or holidays — these are annual leave
Non-approved courses or events not relevant to your training
Private revision time at home (this is annual leave)

⚠️ Costs & reimbursement: Study leave funding is limited. Confirm your budget and the reimbursement process before booking anything. Keep all receipts. Reimbursement forms are available via [Trust intranet / ESR portal]. Retroactive requests may be declined.

Useful Contacts for Study Leave

Query	Who to Contact
Approving study leave	Educational Supervisor + Clinical Supervisor
Study leave budget & reimbursement	Medical Education / Postgraduate Centre — [Ext. XXXXX]
Rota cover arrangements	Rota Coordinator — [Ext. XXXXX]
Deanery / training programme queries	Training Programme Director (TPD) via deanery portal
Mandatory training dates	Medical Education — [intranet calendar link]

Advice & Guidance (A&G) allows GPs and other clinicians to seek specialist input without a formal referral. Requests are reviewed on the A&G worklist — target response time 2 working days.

Receiving A&G Requests

A&G requests arrive via [e-RS / EPR A&G module]. The on-call registrar or nominated clinician reviews these on a daily basis.

Log in to [e-RS / EPR] and navigate to the A&G worklist
Review the clinical information and any attached images
Respond with: diagnosis (if possible), management recommendation, safety net, and whether an appointment is needed
If appointment needed — triage appropriately (routine, urgent, 2WW) and convert to referral within the platform
Log your response and close the task

What Makes a Good A&G Request?

✅ Ideal A&G request includes: Clinical photo (key!), duration, distribution, symptoms (itch, pain, bleeding), prior treatments and response, relevant medications, relevant comorbidities, specific clinical question.

⛔ Not suitable for A&G: Suspected malignancy (use 2WW), acute emergency (attend A&E), complex systemic disease requiring examination, cases needing procedures (patch testing, biopsy).

Clinical Photography for A&G

Good quality photos dramatically improve A&G quality. GPs can submit via the A&G platform or [local image sharing system]. See the IT section for guidance on taking and uploading clinical photographs.

Common A&G Scenarios

Presentation	Typical Response
Mild eczema not responding to OTC treatments	Advise moderate TCS, emollient routine, soap avoidance. Routine referral only if failed 3 months of prescribed TCS.
Single pigmented lesion query melanoma	If photo provided and benign: reassure. If any concern: refer as 2WW. Do not manage melanoma via A&G.
Mild psoriasis on body	Recommend potent TCS ± vitamin D analogue (Dovobet). Routine referral if failed or moderate–severe.
Acne not responding to GP treatment	Review regimen, advise step up. Refer if: severe, scarring, female with hormonal features, or psychological impact.
Urticaria — acute	Non-sedating antihistamine (cetirizine 10mg od). If angioedema — A&E. Refer if >6 weeks (chronic).

Inpatient and A&E referrals arrive as EPR referrals and are usually managed by the junior, with registrar/consultant escalation. There is no derm bleep — all referrals come via EPR.

📥 Managing an EPR Ward Referral

Check the EPR referral worklist at the start of each ward-cover day — do not rely on being phoned
Read the referral: reason, ward, urgency, and what the parent team has already done
Do not accept verbal-only referrals — insist on a written EPR entry
Review the patient in person — do not manage complex cases on phone advice alone
Document your assessment and plan in EPR; state clearly who is following up (derm vs parent team) and whether derm will review again
Discuss every new consult with your registrar or supervising consultant — same day for anything acute
If a biopsy is needed on the ward: arrange kit, consent, and check special protocols (e.g. DIF in Michel's medium — see Procedures)

🚨 Common Ward Scenarios

Presentation	Key Points	Escalation
Suspected SJS / TEN / DRESS	Stop culprit drug immediately. SCORTEN for TEN. Assess mucosae, skin detachment (Nikolsky). Bloods incl. eosinophils, LFTs (DRESS).	Consultant same day — TEN may need burns unit transfer
Erythroderma	>90% BSA red. Causes: eczema, psoriasis, drug, CTCL. Risk: fluid loss, temperature dysregulation, high-output failure. Greasy emollient liberally, monitor fluids/temp.	Registrar same day
Widespread blistering	Consider bullous pemphigoid vs pemphigus. Biopsy: lesional (formalin) + perilesional (Michel's for DIF). Swab if infection suspected.	Registrar / consultant — new bullous disease needs urgent senior review
"Bilateral cellulitis" referral	Usually venous eczema / lipodermatosclerosis — true cellulitis is rarely bilateral. Look for eczema signs, check temperature/CRP trend. Treat with potent TCS + emollient, not more antibiotics.	Advice usually sufficient; review if diagnostic doubt
Purpura / suspected vasculitis	Biopsy within 24–48h of lesion onset for best yield. Urine dip (renal involvement), vasculitis screen. Document distribution + systemic features.	Registrar; renal involvement → same-day medical escalation
Herpes zoster / eczema herpeticum	Eczema herpeticum: punched-out erosions on eczema — swab for HSV PCR, start aciclovir empirically. Ophthalmic zoster → same-day ophthalmology.	Registrar; ophthalmic involvement → ophthalmology same day

📞 Escalation

On-call derm registrar: contact via [Alertive / phone] — there is no derm bleep
Supervising consultant of the week: [rota link / number]
Out-of-hours: registrar covers all acute derm queries; GP queries out of hours → 111 or A&E if urgent

⛔ Red flags needing same-day senior input: skin failure (TEN, erythroderma), new bullous disease, purpura fulminans, necrotising infection, any unwell child with a rash.

🔥 Content coming soon. Guidance for the Hot Clinic will be added here.

Admin, Pathology & MDT

Pathology first — you are responsible for the results you generate, and they land in your Message Centre inbox. Every result takes one of four routes: use the decision tree, then the meeting guides below.

🧪 Path Result Decision Tree

A result lands in your inbox — which route?

Scenario	Route	Action
Benign / expected, fully excised	Action yourself	Letter to GP + patient with result and plan. Discharge or arrange surveillance. Acknowledge the result in EPR.
Cancer needing discussion — melanoma, high-risk SCC, MCC, DFSP, involved/close margins	Skin Cancer MDT	Forward the result as an EPR message to the Skin Cancer MDT inbox [inbox name] with a short clinical summary (site, size, context, what's been done). Tell the patient a plan will follow MDT. Order Derm 2WW F/U per MDT outcome.
Diagnostically uncertain — clinico-pathological mismatch, unusual histology, complex case	CPC Meeting	Submit to the monthly CPC meeting (below). Send an interim letter to the GP explaining the result is under specialist review.
Very complex / rare	Oxford Regional	Discuss with your consultant first → they refer to the regional meeting in Oxford (below).

⛔ Never leave a cancer result unactioned. Unexpected malignancy → forward to the MDT inbox the same day and inform your consultant.

📋 Skin Cancer MDT

Meets: [Day, time, location / virtual link]
How to refer: forward the pathology result via EPR message to the Skin Cancer MDT inbox [inbox name], with clinical summary and photos where available
Submission deadline: [e.g. 48h before the meeting]
Coordinator: [Name — Ext. XXXXX]
Who to send: melanoma, SCC (high-risk or per protocol), MCC, DFSP, incompletely excised tumours, cases needing WLE margins or onward oncology/plastics referral
After MDT: the clinician who saw the patient actions the outcome — letter, WLE booking or onward referral, and the correct follow-up order (Derm 2WW F/U for VHRFU/HRFU)

🔬 CPC Meeting (monthly)

Purpose: clinico-pathological correlation — uncertain path, discordant clinical/histological findings, complex management decisions
Meets: [Day of month, time, location]
How to submit: [process — e.g. email case details + slide request to coordinator]
Bring: clinical photos, dermoscopy images, the histology report, and a focused question
After discussion: document the CPC outcome in EPR and write to the GP/patient with the final plan

🏛️ Oxford Regional Meeting

Purpose: very complex or rare cases needing supra-regional input (rare tumours, complex CTCL, difficult management dilemmas)
Route: via your consultant — cases are not submitted directly by juniors
Meets: [frequency, location / virtual]
Prepare: full case summary, imaging, histology (slides may need sending to Oxford in advance), and clinical photos

⏱️ Chasing & Turnaround

Routine histology: 7–10 working days; mark urgent / 2WW on the form for faster turnaround
Urgent cancer results: call histopathology directly — Ext. XXXXX
Check your results inbox at the start and end of every working day