NICE has published Referral Advice – A guide to appropriate referral from general to specialist services, which deals with 11 common complaints (see News in this issue). The first condition covered is acne, reproduced below.
The referral advice is set out in the form of consensus statements based on the best available evidence. It is designed to help clinicians determine how urgently particular patients need to be referred. For a summary of the consensus statements see 'NICE referral summaries' in this issue.
Acne vulgaris can embarrass, disfigure, cause emotional upset and interfere with the patient's quality of life.
Acne lesions vary in their extent, distribution (face, neck, shoulders, back and chest), and in the involvement of inflammatory processes (from comedones through papules and pustules to cysts). The lesions usually begin to appear at puberty and, in 70% of patients, stop around 5 years later. In some, acne can persist lifelong.
The severity of acne can be assessed in terms of lesion site, type and number, the development of scars, the effect on the patient emotionally, and whether the lesions undermine confidence and self-esteem, or interfere with work/school or relationships. Treatment helps almost all patients with acne, and if started promptly can prevent scarring.
Treatment may typically include topical antimicrobials (benzoyl peroxide), topical antibiotics, topical retinoids, comedolytics (azelaic acid), topical keratolytics (salicylic acid), oral antibiotics and, in women, oral antiandrogens (see British National Formulary, Section 13.6).
Some topical treatments can be prescribed as combination products.
Selection of treatment will depend on the type and severity of the acne. Patients with painful, deep nodules or cysts (nodulocystic acne) are at high risk of scarring, and treatment should be started while awaiting the hospital appointment.
In those with less severe forms of acne, each treatment alternative should be tried for 2 months, then reviewed to assess whether it is having an effect.
Treatment should be changed if the patient and doctor feel that the response is inadequate. If treatment is effective it will generally be continued for at least 6 months.
These are in a position to:
- confirm or establish the diagnosis
- provide, in conjunction with other healthcare professionals, advice on the condition and its treatment, together with social and psychological support
- manage patients whose acne is resistant to, or intolerant of, treatments in primary care
- manage patients whose acne is particularly severe or who are at risk of, or are, developing scarring despite treatment
- assess the need for, and possibly provide, physical treatments
- manage the treatment of patients who require oral isotretinoin.
|Most patients with acne can be managed in primary care. However, referral to a specialist service is advised if they:|
|have a very severe variant such as fulminating acne with systemic symptoms (acne fulminans)|
|have severe acne or painful, deep nodules or cysts (nodulocystic acne) and could benefit from oral isotretinoin|
|have severe social or psychological problems, including a morbid fear of deformity (dysmorphophobia)|
|are at risk of, or are developing, scarring despite primary care therapies|
|have moderate acne that has failed to respond to treatment which should generally include several courses of both topical and systemic treatment over a period of at least 6 months. Failure is probably best based upon a subjective assessment by the patient|
|are suspected of having an underlying endocrinological cause for the acne (such as polycystic ovary syndrome) that needs assessment|
|The starring system developed by NICE to identify referral priorities|
|Arrangements should be made so that the patient:|
|is seen immediately1|
|is seen urgently2|
|is seen soon2|
|has a routine appointment2|
|is seen within an appropriate time depending on his or her clinical circumstances (discretionary)|
|1 within a day|
|2 health authorities, trusts and primary care organisations should work to local definitions of maximum waiting times in each of these categories. The multidisciplinary advisory groups considered a maximum waiting time of 2 weeks to be appropriate for the urgent category.|
Reproduced with kind permission from: Referral Advice – A Guide to Appropriate Referral from General to Specialist Services. London: NICE, December 2001.
The complete document can be downloaded from the NICE website www.nice.org.uk.