RAG rating

n/a

Document type

Clinical policy

Place

Hertfordshire and West Essex ICB

Output type

Clinical Policies & Evidence-based Interventions

Document

Download

Surgical Removal of Benign Skin Lesions

Policy: Surgical Removal of Benign Skin Lesions 

This is a national Evidence Based Intervention policy formally adopted by Hertfordshire and West Essex Integrated Care Board. Please see https://ebi.aomrc.org.uk/ 
 

Summary

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.

Recommendation

This policy refers to the following benign lesions when there is diagnostic certainty, and they meet the criteria listed below:          

• benign moles (excluding large congenital naevi) 
• solar comedones 
• corn/callous 
• dermatofibroma
• lipomas 
• milia 
• molluscum contagiosum (non-genital) 
• epidermoid & pilar cysts (sometimes incorrectly called sebaceous cysts) 
• seborrhoeic keratoses (basal cell papillomata) 
• skin tags (fibroepithelial polyps) including anal tags 
• spider naevi (telangiectasia) – although multiple lesions may be a sign of underlying disorders in adults and children. Best initially addressed through advice and guidance
• non-genital viral warts in immunocompetent patients 
• xanthelasmata 
• neurofibromata 

The benign skin lesions, which are listed above, must meet at least ONE of the following criteria to be removed: 

• The lesion is unavoidably and significantly traumatised on a regular basis with evidence of this causing regular bleeding (more than twice weekly for at least four weeks caused by everyday activities i.e. not due to picking)
• There is repeated infection requiring 2 or more antibiotics per year 
• The lesion bleeds (more than twice weekly for at least four weeks) in the course of normal everyday activity
• The lesion causes pain requiring long-term daily medication
• The lesion is obstructing an orifice or impairing field vision 
• The lesion significantly impacts on function e.g. restricts joint movement 
• The lesion causes pressure symptoms which are unavoidable, cannot be managed conservatively and cause atrophy. Verruca on the feet do not normally meet this criteria as they can be pared back to avoid pressure symptoms.
• If left untreated, more invasive intervention would be required for removal 
• Facial viral warts causing significant psychological distress (e.g. school avoidance), in those aged under 18 years who are able to tolerate cryotherapy
• Lipomas on the body > 5cms, or in a sub-facial position, with rapid growth and/or pain. These should be referred to Sarcoma clinic.  

The following are outside  the scope of this policy recommendation: 

• Lesions that are suspicious of malignancy should be treated or referred according to NICE skin cancer guidelines 
• Any lesion where there is diagnostic uncertainty, i.e. genetic diseases, 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. 

Referral to appropriate speciality service (e.g. dermatology or plastic surgery): 

• The decision as to whether a patient meets the criteria is primarily with the referring clinician. If such lesions are referred, then the referrer should state that this policy has been considered and why the patient meets the criteria. The referrer should not guarantee treatment will be provided but explain that clinicians will consider the potential risks and benefits with the patient. A clinician will not offer treatment if the risks outweigh benefits
• This policy applies to all providers, including general practitioners (GPs), GPs with enhanced role (GPwer), independent providers of NHS care, and community or intermediate NHS services. 
  
  

For further information, please see: 

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

NICE Suspected cancer: recognition and referral [NG12]  
 

Rationale for recommendation 

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 and anaesthetic risks. However, in certain specific cases as outlined by the criteria above, there may be benefits for removing some skin lesions e.g. to avoid long-term pain and allow normal functioning.

Surgery to remove a benign or harmless skin lesion is a procedure that should only be carried out when specific criteria are met, to ensure most appropriate use of health care resources.
 

Patient information 

Information for Patients 

Surgery to remove a benign or harmless skin lesion is a procedure that should only be carried out when specific criteria are met. This is because the medical evidence tells us they may often disappear of their own accord over time or there are risks associated with surgical intervention which may be worse than the benefits of treatment. It is important the NHS focuses most of its resources on people with these problems where there is good evidence that treatment is of great benefit.

About the condition 

A lesion is a general term that we use for things like moles, cysts, skin tags, warts, ulcers and other lumps and bumps we sometimes get on our skin. These lesions might have an impact on our appearance but are otherwise are usually harmless. Some benign lesions, such as warts or verrucas, usually clear up on their own. However, if they don’t then your pharmacist can provide useful information on how to manage them.

Treatment to remove skin lesions should only be carried out in certain circumstances and if certain criteria are met. If your GP has concerns or if the lesion persistently catches on your clothing or bleeds recurrently then you can be treated by an appropriate healthcare professional or referred to a specialist for an opinion.

As with all treatments, when deciding what’s best, you should consider the benefits, the risks, the alternatives and what will happen if you do nothing.

What are the BENEFITS of the intervention? 

Treatment to remove a skin lesion should only be carried out in certain circumstances, for example, if the lesion is likely to remain painful, bleeds regularly, if it becomes repeatedly infected or if it impacts on your everyday activities, such as interfering with movement or vision.

What are the RISKS of the intervention? 

Surgical removal carries a risk of complications such as bleeding, permanent scarring (which may look worse than the original problem) and infection. Some procedures to remove the lesion may require general anaesthesia, which carries a general risk. This risk is greater for some patients such as small children and therefore may outweigh any potential benefits of removal of the skin lesion.

What are the ALTERNATIVES? 

Most benign lesions can be left alone. Your GP or pharmacist can advise you if the lesion is troublesome. 

What if you do NOTHING? 

Doing nothing is usually the best course of action for most benign lesions.   

Patients who are not eligible for treatment under this policy may be considered on an individual basis where their GP or consultant believes exceptional circumstances exist that warrant deviation from the rule of this policy. Individual cases will be reviewed as per the ICB policy.