Referral to emergency

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.

  • nil

For clinical advice, please telephone the relevant specialty service.

Central Adelaide Local Health Network

Northern Adelaide Local Health Network 

  • Lyell McEwin Hospital (08) 8182 9000, during business hours. After 5:00 pm contact either of the CALHN services. 

Southern Adelaide Local Health Network

Inclusions

  • extensive molluscum contagiosum in patients who are immunosuppressed
  • scabies
    • Norwegian scabies - this occurs when there are a large number of mites on the body and is seen in elderly or institutionalised people, e.g. patients who are immunosuppressed, mentally impaired, or living in nursing homes/hospitals
    • recurrent or treatment resistant/treatment failure scabies
  • tinea
    • extensive, treatment resistant tinea in patients who are immune suppressed and/or diabetic
    • scarring alopecia in inflammatory tinea capitis i.e. kerion
  • extensive, treatment resistant warts
    • in immunosuppressed patients
    • for consideration of intralesional bleomycin, interferon and oral retinoids.

Exclusions

  • warts
    • mild, limited and untreated disease
    • viral warts unless fulfilling above inclusion criteria

Triage categories

Category 1 (appointment clinically indicated within 30 days)

  • nil

Category 2 (appointment clinically indicated within 90 days)

  • recurrent or treatment resistant/treatment failure scabies i.e. persistent itch, or symptoms lasting greater than 3 months since treatment
  • scarring alopecia in inflammatory tinea capitis i.e. kerion

Category 3 (appointment clinically indicated within 365 days)

  • extensive molluscum contagiosum in patients who are immunosuppressed
  • extensive, treatment resistant tinea in patients who are immune suppressed and/or diabetic
  • warts: extensive, treatment resistant warts
    • in immunosuppressed patients
    • for consideration of intralesional bleomycin, interferon and oral retinoids.

Essential referral information

Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

  • past medical history, in particular diabetes mellitus, immune suppression e.g. transplant recipients
  • medication list
  • treatments trialled
  • drug history (warts)
  • consider screening for underlying immunosuppression, e.g. HIV, if appropriate

Clinical management advice

Referrals for Indigenous patients with viral skin infection/s may be triaged to a higher category due to challenges in this population related to access to care and increased risk of multiple viral skin infections, among others.

Molluscum Contagiosum

  • treatment of molluscum contagiosum is not essential as most lesions will resolve spontaneously. However, it can take a long time for the condition to resolve (6-12 months).
  • treatment is usually aimed at limiting the spread of the condition and alleviating symptoms such as itching. Any associated dermatitis may be treated with corticosteroid creams.
  • showering rather than taking a bath may limit the spread of infection.
  • treatment, if given, often needs to be repeated until the lesions clear.
  • treatments may include:
    • liquid nitrogen (cryotherapy) +/- Emla for children
    • gentle squeezing after pricking with a sterile needle
    • tape stripping (e.g. MicroporeTM tape applied over the lesions and changed at bath time).
    • benzoyl peroxide gel (2.5% or 5%) applied bd to induce an irritant reaction
    • curettage (surgically scraping the lesion)
    • 5% Imiquimod cream

Scabies

  • it is important to apply the cream all over the body and not just to the itchy areas. Make sure the cream is applied to all body parts paying particular attention to the elbows, breasts, groin/genitals, hands and feet (including under the nails). Any areas that are missed may cause the infestation to persist. Everyone in the household should be treated at the same time even if they are not itchy. Cream is left on for 8 hours.
  • the next morning all bed linen and clothes should be removed, changed and washed with hot water as this kills the mite and its eggs.
  • repeat Permethrin cream 7 to 10 days later.
  • oral ivermectin is indicated in cases of topical failure, inability to comply with topical therapy, non-adherence to topical therapy, institutional outbreaks, mass treatment of populations, and crusted scabies.
  • it is common for itchiness to persist for 4 to 6 weeks after scabies has been treated as outlined above.

Tinea

  • topical antifungals are appropriate for most cases
  • oral griseofulvin, fluconazole, itraconazole or terbinafine is appropriate for persistent or severe cases
  • all members of the household should be screened for tinea capitis and treated simultaneously if found to be affected. Sharing of potential fomites such as hairbrushes, hats, and pillows should be discouraged, and these should be properly cleaned.

Warts

  • most warts on the skin will disappear of their own accord. In children, even without treatment, 50% of warts disappear within 6 months and 90% resolve within 2 years. Warts are more persistent in adults, but may resolve eventually.
  • treatments should not cause any scarring as most warts may disappear on their own. Once started, it is important to persist with the treatment until the wart is gone.
  • keratolytic therapy with OTC preparations containing salicylic acid eg Duofilm gel, Upton’s paste
  • cryotherapy every 2 to 3 weeks
  • podophyllotoxin or imiquimod cream can be considered for genital warts
  • electrosurgery (curettage and cautery), excision and laser removal are used less commonly due to the potential for recurrence and scarring
  • use of diphencyprone (immunotherapy) is limited due to public hospital pharmacy’s production guidelines.

Clinical resources

Consumer resources

Reason for request

  • to establish a diagnosis
  • for treatment or intervention
  • for advice and management
  • for specialist to take over management
  • for a specified test/investigation the General Practitioner cannot order
  • for other reason (e.g. rapidly accelerating disease progression)
  • transfer of care from another tertiary service
  • clinical judgement indicates a referral for specialist review is necessary.

Patient demographic details

  • full name, including aliases
  • date of birth
  • residential and postal address
  • telephone contact number/s – home, mobile and alternative
  • Medicare number, where eligible
  • name of the parent or caregiver, if appropriate
  • preferred language and interpreter requirements
  • identifies as Aboriginal and/or Torres Strait Islander

Clinical modifiers

  • impact on employment
  • impact on education
  • impact on home
  • impact on activities of daily living
  • impact on ability to care for others
  • impact on personal frailty or safety
  • identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery, where surgery is a likely intervention.
  • Choice to be treated as a public or private patient.
  • Compensable status, e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.
  • Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
  • Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
  • Where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
  • A change in patient circumstance (such as condition deteriorating or pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
  • All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.