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

Inclusions

  • culture of nail plate is negative
  • nail conditions that cause a significant impact on the patient’s quality of life and cannot be treated with antifungal medications or simple measures

Exclusions

  • nail dystrophy
    • not yet investigated in primary care with nail clipping for microscopy and culture
    • of uncertain aetiology, negative nail clipping
  • pincer nail deformity and onychogryphosis - these cannot be managed medically by Dermatology, consider referral to podiatry
  • ingrown toenails, refer to podiatry

Triage categories

Category 1 (appointment clinically indicated within 30 days)

  • pigmentation change clinically concerning for subungual melanoma
  • suspected malignancy, other than melanoma

Category 2 (appointment clinically indicated within 90 days)

  • nail dystrophy if severe. 20 nails, significantly impacting quality of life

Category 3 (appointment clinically indicated within 365 days)

  • nil

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.

  • clinical history and examination
  • nail clipping for microscopy and culture

Additional information to assist triage categorisation

  • number of nails affected; finger and toes
  • other known dermatoses e.g. psoriasis
  • impact on quality of life
  • treatments tried

Clinical management advice

  • dermatophyte infections are treated with oral terbinafine or itraconazole for 3 to 6 months
  • non-dermatophyte fungal infections can be treated with the same medications however the success rate is lower
  • topical antifungals such as amorolfine, are of little value in most nail infections, however, may be of some use in the management of superficial white onychomycosis.
  • onycholysis can be managed by keeping the nail short and the nail bed dry; white vinegar soaks (1:10 vinegar-to-water) for a few minutes daily can treat Pseudomonas infection; a topical steroid lotion applied under the lifted nail may promote reattachment of the nail
  • pincer nail deforming and onychogryphosis cannot be managed with medical treatment; referral to a podiatry service may be appropriate

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.