Guidelines for Skin Surgery in General Practice
Surgical treatment should not be attempted without a clinical diagnosis. If the diagnosis is not known, it is impossible to know whether surgical intervention is appropriate or necessary.
If surgery is desirable for cosmetic reasons it is essential that the optimal result can be achieved. Unsightly scars are a common cause for complaint and levels of expectation are higher when treatment is performed solely for cosmetic reasons. Confident diagnosis and reassurance is often the treatment of choice for benign conditions.
Biopsy of a rash is often unhelpful unless:
- There is a good differential diagnosis
- The correct biopsy site has been selected
- The result can be discussed with a dermapathologist
Biopsy of rashes or tumours prior to referral to a dermatologist is unnecessary.
Appropriate Surgical Procedures:
- Shave excision for non-pigmented or lightly pigmented benign moles
- Snip/cautery for skin tags and polyps
- Curettage and cautery for seborrhoeic keratoses, pyogenic granulomas and filiform warts on the lips and nose
- Cryosurgery for viral warts, actinic keratoses, molluscum contagiosum
- Excision of histiocytomas (if painful); epidermoid cysts, lipomas
- Recurrent ingrown toe nail – lateral phenolic matricectomy
Viral warts: When treating viral warts remember:
- Up to 80% respond to paints and gels in 100 treatment days
- Plane warts on the face are best left untreated
- Warts unresponsive to conservative treatment may be treated with cryosurgery
- Cryosurgery is very painful and not well tolerated by children
- Mosaic plantar warts are often resistant to cryosurgery
- Curettage of warts may result in scarring
CAUTION: Elliptical excision of benign moles often leaves a noticeable scar, especially on the upper trunk, shoulders and tops of arms. Beware of surgery in keloid-prone sites. Consider carefully whether a benign mole need be excised. Elliptical excision of seborrhoeic keratoses is inappropriate; curettage and cautery is the treatment of choice. Submit all specimens for histology.
- Avoid using braided silks sutures which leaves stitch marks unless removed early.
- Avoid using alcohol based antiseptic solutions – they are a fire hazard with diathermy or cautery.
- Avoid treating skin malignancies unless appropriately experienced. They require excision with adequate lateral and deep margins.
- Avoid incisional biopsies of moles. Refer patients with suspicious moles. These lesions should always be excised with a defined margin along the correct anatomical axis.
British Society for Dermatological Surgery
Drawn up with R.C.G.P. December 1994
Dermatological surgery and nurses
What does this mean to the individual nurse? There is more than one interpretation depending on whose viewpoint you take but most nurses understand that they cannot fulfil the UKCC Code of Professional Conduct for autonomous practice unless they direct their own development and extended role to improve the patients journey through the NHS.
Autonomy should be considered in relation to professional accountability, the power to make decisions and act upon them, and to take responsibility for those actions (Jones 1996)
Nurses need to fully explore their code of conduct and scope of professional practice and use their tools with the knowledge they have about their patients to develop services that meet their needs. Continuity of care may mean that a diagnostic biopsy is part of the diagnosis process, or to reduce anxiety in the worried well waiting for the result of the biopsy – reduced waiting time is beneficial.
Authority and autonomy for a nurse is derived from a sound educational base to practice and the ability to apply theoretical concepts to the provision of high quality care.
Any extension of the role should focus around the patient and not the individual practitioner. However acknowledgement of ones limitations should be the backbone to the guidance one requires to achieve competence and to use freely when placed in a position of unsafe practice due to lack of competence.
The resulting use of the Scope of Professional Practice is acknowledging that nurse training is different from our medical colleagues, skills and competencies have to be achieved to ensure fit to practice status and patient safety.
Jones M (1996) Accountability in practice. A guide to professional responsibility for nurses in general practice. Dinton Quay Books
UKCC (1992) Code of Professional Conduct London UKCC
UKCC (1992) Scope of Professional Practice London UKCC
The Nurse Biopsy Role
Formalising the Training
The major stumbling block when developing the nurse biopsy role in your dermatology department is the ratification of the documentation by your hospitals Trust board.
The UKCC’s Scope of Professional Practice (1992) provides clear, precise guidelines for nurses to follow when developing a role that expands upon their first level training. The “Scope” is a structure that supports continuing professional development and helps to clarify and refine the processes involved in expansion of practice.
- Identify where expansion of practice will clearly benefit the patient
- Document how the nurse will update their knowledge, skills and competences and keep them updated
- Recognise limitations to knowledge
- Ensure we do not compromise existing standards
- Acknowledge our own accountability
- Avoid inappropriate delegation
Perform a risk assessment, and then discuss the role with your senior nurse manager.
Develop a written package to underpin the proposal. The framework must include:
- Introduction – what the nurse will be expected to do, who will use the framework and how the knowledge will be acquired.
- Health and Safety
- Rationale for expanding practice
- Education and verification – including aims and objectives and competencies – an educational establishment must be involved with this
- Referral Guidelines
- Updating Practice
- Validation of document
- Draft copies of framework sent to Nursing Development Unit and Senior Nurse Manager
- Framework will be amended and returned, until the NDU are satisfied
- Ratification form sent from the Nursing Development Unit when all the documentation has been finalised
The framework is now ready to be ratified. The completed document is reviewed and must be signed by:
- Nursing Development Unit
- Director of Operational Services/Chief Nurse- on behalf of the Trust Board.
Unless you have got a surgically trained nurse, the dermatology doctor will train the nurse in the skills for performing surgery. The theoretical input should be broken down into separate components and each component assessed, tested and sign as competent by the doctor. The training can be broken down as follows:
- Anatomy and Physiology
- Local Anaesthesia
- Safe use of the equipment
- Techniques for surgery
- Wound care and management of complications
- Consent: usually dealt with as per the hospitals policy
A recognised surgery course such as the BSDS course will finalise the nurse training.