Skin Lesions Without Malignancy

Prior approval – To ensure the best outcomes, patients must have stopped smoking at least 4 weeks prior to referral

Removal of benign skin lesions means treating asymptomatic lumps, bumps or tags on the skin that are not suspicious of cancer

Treatment carries a small risk of infection, bleeding or scarring and is not usually offered by the NHS if it is just to improve appearance

In certain cases, treatment (surgical excision or cryotherapy) may be offered if certain criteria are met

A patient with a skin or subcutaneous lesion that has features suspicious of malignancy must be treated or referred according to NICE skin cancer guidelines

This policy does not refer to pre-malignant lesions and other lesions with potential to cause harm

If, following a referral to secondary care or Community services (where applicable), malignancy is no longer suspected (and if the lesion has not already been excised for diagnostic purposes), any further treatment must be in line with the policy set out below

It is therefore important that patients understand the reason for referral, and that referral in these circumstances will not automatically lead to excision of a benign lesion

Treatment of benign skin lesions, with no risk of malignancy or infection, is considered to be cosmetic and should not be referred or treated

This policy refers to the following benign lesions when there is diagnostic certainty and they do not meet the eligibility criteria for removal:

• Benign moles (excluding large congenital naevi)
• Solar comedones
• Corn / callus
• Dermatofibroma
• Lipomas
• Milia
• Molluscum contagiosum (non-genital)
• Epidermoid and pilar cysts (sometimes incorrectly called sebaceous cysts)
• Seborrhoeic keratoses (basal cell papillomata)
• Skin tags (fibroepithelial polyps) including anal tags
• Spider naevi (telangiectasia)
• Non-genital viral warts in immunocompetent patients
• Xanthelasmata
• Neurofibromata

  Ganglia (other than hand/wrist ganglia).

The benign skin lesions, which are listed above, must meet at least ONE of the following criteria to be removed and prior approval will need to be obtained:

• The lesion is unavoidably and significantly traumatised on a regular basis with evidence of this causing regular bleeding or resulting in infections such that the patient requires 2 or more courses of antibiotics (oral or intravenous) per year:
• There is repeated infection requiring 2 or more antibiotics per year
• The lesion bleeds in the course of normal everyday activity
• The lesion causes regular pain
• The lesion is obstructing an orifice or impairing field of vision
• The lesion significantly impacts on function e.g. restricts joint movement
• The lesion causes pressure symptoms e.g. on nerve or tissue
• If left untreated, more invasive intervention would be required for removal
• Facial viral warts
• Facial spider naevi in children causing significant psychological impact
• Lipomas on the body > 5cms, or in a sub-fascial position, with rapid growth and/or pain – these should be referred to Sarcoma clinic

The following are OUTSIDE of the scope of this policy:

• Lesions that are suspicious of malignancy should be treated or referred according to NICE skin cancer guidelines
• Any lesion where there is diagnostic uncertainty, pre-malignant lesions (actinic keratoses, Bowen disease) or lesions with pre-malignant potential should be referred or, where appropriate, treated in primary care
• Removal of lesions other than those listed above

If (following a secondary care referral) malignancy is no longer suspected (and if the lesion has not already been excised for diagnostic purposes), any further treatment should be in line with the policy set out below

Referral to Dermatology or Plastic Surgery

• The decision as to whether a patient meets the criteria is primarily with the referring clinician
• If lesions are referred, then the referrer should state that this policy has been considered and why the patient meets the criteria
• This policy applies to all providers, including general practitioners (GPs), GPs with enhanced role (GPwer), independent providers, and community or intermediate services

There is little evidence to suggest that removing benign skin lesions to improve appearance is beneficial

Risks of this procedure include bleeding, pain, infection and scarring. Though in certain specific cases as outlined by the criteria above, there are benefits for removing skin lesions, for example, avoidance of pain and allowing normal functioning

References

https://ebi.aomrc.org.uk/interventions/removal-of-benign-skin-lesions/

NICE Improving outcomes for people with skin tumours including melanoma [CSG8]

NIICE Suspected cancer: recognition and referral [NG12]

Higgins JC, Maher MH, Douglas MS. Diagnosing Common Benign Skin Am Fam Physician. 2015 Oct 1;92(7):601-7. PubMed PMID: 26447443.

Tan E, Levell NJ, Garioch JJ. The effect of a dermatology restricted-referral list upon the volume of referrals. Clin Exp Dermatol. 2007 Jan;32(1):114-5. PubMed PMID: 1730591