WINTER 2013
PRIMARY CARE DERMATOLOGY SOCIETY
BULLETIN
Editorial Winter 2013
This is my first bulletin as editor and I would like Unfortunately I was unable to attend but Stephen
to thank Helen for her fantastic contribution to
Hayes has documented some “gems” of wisdom for
the bulletin over the last 3 years – she will be a
us to view. By all accounts the social evening was a
hard act to follow! As I write this the wonderful
huge success as well judging by the photos!
Summer balmy weather seems a distant memory,
but the Autumnal colours in my local forest are
beautiful and almost (not quite!) compensate for the
rain and gales. As is often the case for this time of
year there has been a flurry of excellent meetings.
The Nottingham PCDS Autumn meeting covered a
variety of topics leaving the audience with excellent
The group “See Psoriasis Look Deeper” is a
collaboration established in 2012 with the aim of
addressing the link between psoriasis and mental
health. An article is enclosed in this bulletin to raise
awareness of this group highlighting an often
under-reported/recognised link.
tips on managing hair loss, acne and red legs to
A new regular addition to the bulletin is interesting
name but a few. Dr Ruth Murphy has kindly written
case studies that have been seen – Brian Malcolm
an article for the bulletin on managing common
has submitted a fascinating case of LEOPARD
genital conditions in children and adults based on
syndrome. It would be great if we could receive
her lecture – the main learning point I took home
contributions from across the PCDS membership and
from this was to remember the pH of vulva skin
not just from the Committee members. They do not
changes as we head into adulthood explaining why
have to be “weird and wonderful” (although any
children will rarely present with thrush, but instead
aliens would be most welcome as well) – remember
are more likely to have positive bacterial swabs. The the PCDS is for primary care physicians with an
interest in dermatology not an expertise. However, I
advanced dermoscopy course was again an
excellent update and reminder of lesion recognition
have discovered since joining the Committee that the
– Stephen Hayes in his article has summed it up in
knowledge of some of the Committee members is
Jonathan Bowling’s own words it was “a big day”.
frightening!! If anyone has any interesting cases they
The feedback from the minor surgery courses
(beginners and advanced) has been excellent and
would like to share please let me know via the PCDS
e-mail.
just last weekend the PCDS Scottish Meeting was
The essential dermatology and dermoscopy for
held at the Dalmohoy Hotel near Edinburgh.
beginners’ course are continuing due to the efforts of
continued on back cover
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All enquiries to dermatology@pcds.org.uk
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New look packs for 2013
Chairman’s Report
Last time I reported the sad loss of our Chair of Trustees and promised to inform you of
his successor. I am delighted to announce that her fellow Trustees unanimously elected
Gladys Edwards to that role in September. Gladys was the CEO of the Psoriasis
Association and so she brings experience of charity regulations as well as knowledge and
passion for good dermatological care, which she agrees with us, requires education for
healthcare professionals. The Executive Committee are delighted that we will continue to
be represented and watched over by such an eminent, experienced and committed Chair.
The curate’s egg is said to be “good in parts” and that describes reasonably well the
situation regarding the second half of this year. It is inevitable with the huge changes
occurring in different ways and at differing paces that everyone’s experience is likely to
be different. Some new service developments have started well and are providing good
and safe care but there are others where the contracts awarded are not working so well.
We at the PCDS have had a limited opportunity to influence the future of dermatology
provision of care through a review by the King’s Fund which the BAD have
commissioned. Indeed members in England were invited at very short notice by email to
attend and contribute as well as myself and two other Committee members. We await
the conclusions with vested interest.
We cannot fight local political disputes or support members in AQP disputes in detail but
there are often others who have experience that they are willing to share. My pleas for
anecdotal reports of good and problematic CCG contracts or service changes remain
unanswered but we would appreciate direct knowledge from “our side” rather than the
complaints from secondary care when they feel threatened by re-organisation of service
provision.
One new and significant development is the BAD and RCGP collaboration with PCDS
involvement to run a pilot for what we currently call GPwSIs to be formally accredited
initially using the existing Department of Health recommendations (which can be found
on the PCDS and DH websites). Costs of the pilot for 12-16 individuals are to be
generously and far-sightedly borne by the BAD but once established the aim is for the
RCGP to organise, and I fear charge for, such accreditation. The General Medical Council
have named the new status as “Credential(l)ing” not just for dermatology but also for all
GPs who develop a special interest. There will a standing panel of GPs, Dermatologists
and the PCDS (exact make-up to be formalised) who will see first if the existing
stakeholder accreditation rules are fit for purpose both for medical and surgical
dermatology specialists and then act as assessors for all those who wish to be approved
PCDS Bulletin Winter 2013
Primary Care Dermatology Society
cont. Chairman’s Report
and that means everyone who wants
to be employed by an approved
Brian Malcolm
PCDS Committee Member
provider!
The APPGS has a full agenda for
Leopard
Syndrome
2014 and will be expanding the
events at the Houses of Parliament
to draw attention to the
Implementation of the NICE Psoriasis
LEOPARD syndrome is a rare autosomal
Quality Standard; the poor provision
dominant condition, first described by
of undergraduate and VTS
Voron in 1976 , can be either sporadic or
inherited. It is classified as one of the
dermatological education; the need
“neuro-cardio-facial-cutaneous”
for restrictions on sun-bed use and
syndromes. LEOPARD is an acronym for
the provision of skin care for the
the cardinal features of the syndrome
elderly. All these have been flagged
namely Lentigines,ECG
up before but lack of significant
abnormalities,Occular Hypertelorism,
change shows the need for more
Pulmonary Stenosis, Abnormal
effort. PCDS members are allowed to
Genetalia, Retardation of growth and
join and attend these meetings or
Deafness. It is caused in 95% of cases
can let me know of their views which
by a mutation of any of 3 different genes
I can use to inform our politicians.
involved in cell growth. Diagnosis is
Finally, we are experimenting with
based on a finding of multiple lentigines
two Saturday morning “Top Tips in
plus 2 other cardinal features or 3
cardinal features without lentigines and
Dermatology” conferences next
an affected first degree relative. Early
year to see if there is demand for a
diagnosis is useful to both address the
weekend brief refresher. We feel
these will be particularly appropriate
growth retardation and possible cardiac
This 40 year old female patient was
abnormalities such as HOCM. In this
referred to the Dermatology
particular case an early diagnosis would
during the week and/or Nurse
Department for an opinion on a
have been useful to the mother as she
Practitioners, out of hours Docs and
changing pigmented lesion on her left
had been told that her daughter’s
nurses but also staff from A&E who
lower leg. This was subsequently
deafness had most likely been related to
are often faced with skin problems
diagnosed as a thin melanoma. It was
a rubella vaccination she had had 3
which too often result in unnecessary
noted however that she had widespread
months prior to conception. She had
admissions. As always please see
multiple lentigines.These were “lifelong”
suffered from a sense of misplaced guilt
for those who cannot get time away
the web site for dates and venues
and had not previously been a cause for
thereafter. The characteristic multiple
and alert colleagues who might
concern. There was also a history of
lentigines can be very striking as
benefit from these events. Initially
congenital deafness, short stature,
illustrated in this case but melanoma risk
there will be low cost and no
polycystic disease of the kidneys, mitral
is not considered to be high. Birth
sponsorship.
re-gurgitation and a coloboma of the right
weights are usually in the normal range;
optic disc. It was also noted that the
25% of patients suffer deafness; 50% of
patient demonstrated
males affected have bilateral
hypertelorism.These conditions had been
cryptorchidism. However, overall
to relax and pamper yourselves for I
managed in isolation by the various
prognosis is generally considered good
predict 2014 will not be any less busy
specialities but were collectively
with few serious complications.
than 2013!
suggestive of a diagnosis of LEOPARD
Best wishes for Christmas and the
New Year. Make sure you find time
Stephen Kownacki
Executive Chair PCDS
4
syndrome. This was subsequently
confirmed following genetic studies.
PCDS Bulletin Winter 2013
Primary Care Dermatology Society
Stephen Hayes
GPSI Southampton,
PCDS Committee Member
& Trustee
Advanced Dermoscopy
Cavendish Centre 3rd October 2013
Fingerprintcerebriform pattern seborrhoiec keratosis
Multiple colours and blue grey veil thin melanoma
Jonathan Bowling (JB) hoped we would leave here with a
Care for your dermoscope
few gems that will influence our practice. He introduced
Dermlite 2 devices can be disassembled to clean lenses and
Andy Affleck (AA) from Dundee, a keen advocate of
renew batteries. You can send it off or do it yourself, but be
dermoscopy who has published educational material and Ben
careful. Keep your dermatoscope clean! Alcohol wipes are
Esdaile (BE) from Oxford. BE presented a paper to the BAD
good. He mentioned the need for keeping the scopes safe;
which proves the economic benefits of dermoscopy, limiting
they have a tendency to disappear.
what primary care refers and secondary care excises.
Dermoscopy has an economic value in these cash strapped
times (something that commissioners are starting to notice – SH).
Difficult seborrhoeic keratoses
BE looked at difficult seborrhoiec keratoses (SKs), a common
cause of avoidable urgent referrals. Milia like cysts, comedo
Which device?
like openings, cerebriform/fat fingers, hairpin like vessels,
The old devices are still good, new ones are appearing: it’s
fingerprint structures and, moth eaten borders are typical
about ‘what works for you’. JB uses different devices for
features all dermoscopists know. But if these features are less
different scenarios, kept in a bespoke aluminium flight case.
pronounced diagnosis is harder. Hypo- or hyperpigmentation,
Shiny white crystalline/chrysalis structures in some BCCs and
trauma, inflammation or immune attack will all alter the
melanomas are seen better with the polarised head (they
appearance.
represent disrupted dermal collagen). Images from Smartphone
When inflamed, vascular structures in SKs become more
devices may be less good, there is also the issue of inadvertent
prominent with increased pigment. Lichen planus like
transfer to the ‘The Cloud’ (or one’s Facebook page? SH). JB
inflammation can be seen, hence the term lichenoid keratosis.
likes the new Lumio S with its bright light, big lens and x 4
A fine granular pepper like appearance may be seen.
magnification, but its a scanning only device with no image
Haemorrhage can be seen with trauma, but background
capture ability.
cerebriform structures and other signature SK features are still
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PCDS Bulletin Winter 2013
Primary Care Dermatology Society
Melanoma reverse net and veil
Gross asymmetry with peripheral black blotch and streaks
seen. A blue white veil appearance is seen in some seb Ks,
corkscrew, arborising and unclassifiable. Hairpin vessels point
leading beginners to fear melanoma, but a constellation of
to keratinising tumours, generally SKs but also SCC. SCC
other features (see above) can reassure that the lesion is a seb
hairpins tend to be bigger and radial. Classic sharply focussed
K despite an apparent blue white veil.
arborising BCC vessels are well recognised, contrasting with
Some SKs mimic melanomas and justify excision. We saw
some histologically proven SKs that all present agreed needed
excising based on their dermoscopic appearance. ‘If in doubt
cut it out...melanoma mimics everything.’
the comma (curvilinear) vessels in the dermal papillae going in
and out of focus in intradermal naevi, which can mimic small
facial BCCS. Dotted vessels are strongly suggestive of
melanocytic lesions, benign or malignant, but are also seen in
inflammatory lesions. Linear/irregular or polymorphous vessels
AA talked about the dermoscopy of small BCCs. Usually the
in solitary pink lesions require histology. The more variable the
diagnosis is made on history and examination, but as a Mohs
vessels, the more concern.
Surgeon he sees late, difficult BCCs and finds dermoscopy
good for detecting them smaller, thus easier excised.
Argenziano in J Dermatol Surg 2012: 38: 947-950 showed that
small BCCs have classical features of larger BCCs, e.g.
arborising vessels, micro ulcers and irregular pigmented
Several images showed how vessels appear different when
the pressure of the dermoscope was varied. A beautiful ‘string
of pearls’ vessel pattern in a clear cell acanthoma was shown.
JB defied anyone to produce a better example!
structures. Pigmented BCCs are less common in type 1 and 2
Odd and evolving naevi
skin. The more pigment present, the harder it is to exclude
Several combined naevi with blue naevi and other forms
melanoma: if in doubt, fast track. Two typical features of BCC
together were shown, for example an apparently typical blue
are enough for a diagnosis, three is a bonus. Not all BCCs have
naevus with a brown reticular component. Combined naevi
arborising vessels, some sclerotic BCCs are almost featureless.
could be tricky to tell from melanoma. When excising them,
Banal looking non healing ulcers are BCCs until proved
ask the histopathologist to comment on all parts of the lesion
otherwise.
as sampling error can deceive. The very atypical appearance of
Dermoscopic vessel patterns
benign naevi recurring after shave excision was shown. NB a
JB spoke about blood vessel patterns, stressing that they are a
combined naevus is not the same thing as a collision lesion.
component of information not always definite evidence. The
Congenital naevi tend not to evolve through life as acquired
twisted looped glomerular vessels of Bowen’s disease are
naevi do. The importance of establishing a patient’s normal
helpful when the overall picture points that way. A BCC was
mole pattern was stressed. A fairly banal looking reticular
shown which had a range of atypical vessels-glomerular,
naevus with a few irregular globules was excised and proved a
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PCDS Bulletin Winter 2013
Primary Care Dermatology Society
Suspects’ but there is clinical overlap. Try to make a positive
diagnosis but always ask ‘Could this be melanoma?’ and if you
can’t say ‘no’ confidently, refer for biopsy. Watch out for blue,
grey, dark rhomboids and obliterated gland openings. Actinic
keratoses may have the strawberry sign-light pips on a red
background. Flat ill-defined light brown lesions with or without
fingerprint signs can be benign solar lentigos or flat BCPS. As
always, regularity is reassuring.
Melanoma mimics and newly described signs
JB showed us a scalp melanoma mimicking an SK, with light
scale and apparent comedo like openings but somewhat
variable pigment and an unclear edge. Granular pigmentation
developing around follicles into rhomboidal structures are
Blue and mauve lacunae in fibrous stroma haemangioma
suspicious for facial lentigo maligna. Moth eaten edge and
fingerprint structures suggest simple lentigo/thin SK (which are
clinically indistinguishable).
Melanomas were revised with all the usual features mentioned
melanoma in situ, excised as solitary and changing. If the
patient had dozens of similar and stable lesions the index of
suspicion would be far lower.
plus 2 quite subtle ones. Globular reticular or beaded network
is a new description, looking like tiny dots on the lines.
Suspicious if uniform, very suspicious if irregular. (Watching
this, I realised that I had seen this sign but hadn’t realised it had
Special sites
a name. I think its a bit like dewdrops on spider webs – SH).
BE spoke about special sites beginning with acral naevi. The
Negative (or reverse) network is what used to be called
important thing to remember is that the eccrine ducts open on
irregular scar like depigmentation. In a small melanoma it may
the ridges giving lines of tiny white dots. Parallel furrow lesions
be the only feature. It is a feature of early melanoma. Globules
are benign. Lattices are of no significance, fibrillar patterns are
and regression in the same structure is very worrying.
due to pressure and look like brush strokes. They are harmless
Regression is seen as a loss of structure with irregular blue
on weight bearing areas of the foot but worrying the palms.
grey granules. JB prefers to avoid the term pseudopod as
The benefits of dermoscopy in avoiding painful and debilitating
these structures are difficult to reliably or meaningfully
surgery on the sole was stressed.
differentiate from peripheral streaks.
Asymmetry, irregular dots and globules, streaks, polymorphic
AA showed us some difficult melanomas. We all miss
vessels, chaos and blue white veil are seen in acral melanomas
melanomas sometimes, dermoscopy doesn’t always help. It
as elsewhere, the parallel ridge pattern is an early sign. Beware
can mimic blue naevus, angioma, BCC or SK. Beware
of ill-defined grey brown pigmentation. Longitudinal benign
changing, nonspecific and eccentric lesions. Desmosplastic
lines in the nails were benign if completely symmetrical, due to
melanomas can feel firm, mimicking dermatofibromas, rare but
benign naevi. Melanoma gives non parallel irregular
deadly Merkel cell cancers can look like nodules or cysts. Their
pigmentation and Hutchinson’s sign. This is shown nicely in
only dermoscopic feature is pink background and
JB’s dermoscopy book.
polymorphous vessels, not very specific. As ever, we should
Irregular pigment and nail dystrophy was melanoma until
fear solitary growing pink tumours and don’t rely on
proved otherwise. Beware also the solitary dystrophic nail,
dermoscopy. Dermoscopy cannot distinguish between
amelanotic melanoma can present like this.
pyogenic granuloma and amelanotic melanoma-excise promptly
AA explained that facial skin architecture gave a different
and get histology.
dermoscopic appearance due to the lack of rete ridges.
JB said blue naevi on the scalp can be tricky: have a lower
Pseudonetwork forms as pigment surrounds adnexal gland
threshold for obtaining histology if recent change and atypical.
openings. There are only so many possible lesions on the face,
Lymphoma deposits on the scalp can perfectly mimic BCCs
illustrated by the line up image from the film ‘The Usual
clinically and dermoscopically, as can cylindromas. A constant
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PCDS Bulletin Winter 2013
Primary Care Dermatology Society
theme was that lesions change
Ruth Murphy PhD FRCP
over time and we should strive to
Consultant Adult and Paediatric Dermatologist
Nottingham University Teaching Hospitals
become more familiar with the
earlier signs. A few odd lesions
such as traumatised
lymphangiomas and followed up
angiokeratomas (they involute)
were shown.
Oral and Vulval Disease in
Adults and Children
Melanoma morphology
Typical melanomas are a composite
blend of different features arranged
in 2D and 3D. They change over
Vulval and oral disease is a common
time. Patients with type 1 skin are
reason for presentation to both
more likely to produce lightly
primary and secondary care. There are
pigmented melanomas for genetic
many disorders which can affect this
reasons (phaeomelanin). Beware
region but in this brief article we will
the larger solitary patch or plaque in
consider, atopic irritant vulvitis, lichen
such patients, the dermoscope may
sclerosus and aphthous ulceration.
add little apart from dotted vessels
When understanding vulval problems in
and mild atypia. He showed a slide
children, it is first necessary to
of a colour poster with 172
appreciate that the vulval skin prior to
melanomas arranged according to
colour from pink to black, quite an
eye opener! More melanomas are
Figure 1: shows typical atopic vulvitis with erythema
and lichenification of the skin giving the appearance
of ‘surface wrinkling’
menarche is particularly delicate. The
lack of oestrogen, means that the vulval
epithelium is thin, making the underlying
pink or largely pink than is generally
vasculature more visible and appearing
thought, a minority are truly black.
pinker than post-adult vulval skin.
Dermoscopy is amongst other
things forcing us to look again at
Without an appreciation of this, it is easy
the question ‘what do melanomas
to assess normal vulval skin as inflamed.
really look like?’
Additionally, since the vulval pH
It was as JB said ‘a huge day’.
pre-menarche is alkaline to neutral
secondary infection with streptococcal
and staphylococcal organisms is
common and candida infection, requiring
the post menarche acidic environment to
thrive, is rare.
Atopic eczema will commonly affect the
vulval skin as well as the flexures.
Sometimes, the vulva is affected with
only mild symptoms elsewhere. It is
therefore easy to miss atopic or
non-specific irritant vulvitis in this age
Figure 2: shows lichen sclerosus in a prepubertal
child. There is obvious pallor and a haemorrhage at
the base of the posterior fourchette, the hall mark of
poor disease control
group and easy to incorrectly diagnosis
thrush.
Simple vulval care at all ages, such as
washing with emollients e.g. hydramol
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PCDS Bulletin Winter 2013
Primary Care Dermatology Society
ointment and applying a bland
therapy can be discontinued and will
small number of affected individuals.
moisturiser at night before bed will
often cease to apply the steroid cream.
After exclusion of all underlying causes
effectively protect the vulval skin. When
In most instances the disease will reflare
for aphthous ulceration, there will be a
a diagnosis of atopic vulvitis has been
and in order to switch off the
sub-set of individuals who just have
made pulses of a mild topical steroid for
inflammatory process it is necessary to
recurrent oral and genital aphthous
4-6 days per month may also help.
repeat the treatment cycle again with
ulceration. These individuals will be
Swimming in chlorinated water will also
the same intensity as when the disease
variably affected and for some it will be
irritate the skin and cause, in susceptible
first presented. This is essentially,
very debilitating.
individuals, an irritant vulvitis. Care
applying the supra potent topical steroid
should therefore be taken to wash the
daily for one month then alternate days
vulval skin after swimming and to use an
for one month then one to two times
emollient as a soap substitute as well as
per week. The continued use of supra
a general emollient applied at night.
potent steroids once or twice per week
Lichen sclerosus is a common condition
which affects the anogenital region. All
ages and both men and women can be
affected. There is a bimodal peak of
presentation; pre pubertal and post
menopausal.
needs to be stressed. Individuals worry
about the thinning affects of topical
steroids and need reassurance for their
continued use. This is particularly
important given that the vulval skin in
under treated lichen sclerosus will lead
to thinning and tearing and affected
Some individuals will purchase over the
counter preparations for mouth ulcers,
some though will seek medical help.
Topical steroid mouth washes may be
useful for those with more severe
disease such as soluble betamethasone
or Prednisolone four times a day a
reducing down over a two to four week
period. Some will benefit from steroid
applied directly to the ulcer in an orabase
preparation or as a steroid inhaler
directed at the affected site and some
The commonest presentation is in
individuals need to know that the
female adults after the menopause. In
appropriate use of topical steroids is
this group the symptoms are usually
needed to avoid this happening. In
intractable itch in the genital region,
addition it is useful to emphasise that
often worse at night. In children, the
poorly controlled disease results in
symptoms of itch may be less obvious
irritation with vulval erosion which leads
and in this group there may be issues
in turn to secondary infection with
with constipation as the affected peri -
bacteria and candida.
anal skin loses elasticity and easily splits
In children, this needs to be emphasised
on defaecation. Sometimes children are
revision, topical therapy optimising or
to preserve the normal vulval
observed rubbing their genitalia or
sometimes more potent therapy such as
architecture and function into adulthood.
grinding their bottoms on the floor or
immunosuppressive treatments or
All affected children should really be
seats at school. Treatment with a
thalidomide. This is particularly important
under a specialist and the need for
reducing course of supra potent topical
for individuals with persistent debilitating
continued use of topical steroids
steroids is excellent at gaining disease
disease interfering with function and or
requires frequently reinforcing during
control and winning the patient’s
leading to scarring.
clinic visits.
confidence. It is important though to
stress that the package insert for drug
information will advise to apply sparingly
and avoid the genital region. Your
patients will require reassurance that
this treatment is appropriate and that
you will be following them up to guide
their usage and avoid unwanted
side-effects (BAD guidelines, 2010).
individuals will even tolerate super potent
steroid ointment applied to the ulcer over
night. It is necessary to refer those
individuals with severe and recurrent
disease requiring therapeutic intervention
to either an oral medicine department,
maxillofacial surgery or dermatology as
sometimes the diagnosis requires
Aphthous ulcers (simple mouth ulcers)
References
occur in all ages and may affect the oral
Br J Dermatol. 2010 Oct;163(4):672-82.
and or genital regions. These ulcers tend
British Association of Dermatologists' guidelines for
the management of lichen sclerosus 2010.
to run in families and tend to worsen
with iron deficiency anaemia or in the
Neill SM, Lewis FM, Tatnall FM, Cox NH; British
Association of Dermatologists
context of coeliac or inflammatory bowel
disease. Since an essential diagnostic
criterion for Behçets disease is recurrent
aphthous ulceration, a small percentage
Most individuals, when their lichen
of those affected will go on to develop
sclerosus is under control, wonder if
the disease, but this will only be a very
9
PCDS Bulletin Winter 2013
Primary Care Dermatology Society
Stephen Hayes
GPSI Southampton,
PCDS Committee Member
& Trustee
PCDS Scottish Meeting
Edinburgh 9th & 10th November 2013
The PCDS Scottish meeting
at the Dalmahoy Hotel,
Edinburgh, was as usual well
organised and well attended.
This is a summary of key
learning points from the talks I
was able to attend, omitting
the more obvious things.
The staff!
Colin Clarke, Consultant Dermatologist and Clinical Director
Glasgow Royal Infirmary, presented on ‘What the summer
brought in’ under the categories, ‘sun, sea, sand and
Dr Brian Malcolm – Challenging Paediatric Quiz
strolling out’. The sun causes photodermatoses such as
polymorphous light eruption (mainly females) and juvenile
spring eruption of the ears in boys. Some Glasgow patients get
to foreign body reactions and granulomas, best removed with
a steroid jab from a doctor in Spain which allows them to
splinter forceps or maybe sticky tape/hot wax.
sunbathe for a fortnight without an attack of PLE. The sun
aggravates rashes like erythema multiforme and porphyria
cutanea tarda.
Sand may harbour various hookworm species leading to
cutaneous larva migrans. Caution: it does not only affect the
feet. We saw a case where dozens of lesions over a sunbather’s
Pseudoporphyria can occur with sunbeds and naproxen.
back mimicked a generalised dermatitis. Cutaneous
Phytophotodermatosis from strimmers is well known but many
lieshmaniasis, spread by sand fly bites, has now arrived in
garden plants can be problematic if brushed against, including
Tuscany.
fennel, dill, lime and various umbelliferous plants. It’s not just
giant hogweed.
Frank Powell from Dublin showed us some facial rashes,
including a striking photo of confluent head and neck lupus in a
The sea can cause sickness too. We saw a case of seal pox, an
young outdoor worker from the pre-steroid era which sadly
orf like condition acquired from handling captive seals. This
proved fatal. He also showed us some microscopic images of
used to affect seal hunters and could lead to amputation of the
demodex folliculorum in rosacea papules, although the precise
finger.
role of the mite in causation was not made entirely clear. The
Jellyfish stings could be worse than just uncomfortable: the
purple striped jellyfish has a range of poisons including
neurotoxin and vasoconstrictors. Anaphylaxis is possible. We
saw a case where ulceration and scarring of both thighs had
resulted. Initial treatment consists of washing off the tentacles
with sea (not fresh) water.
A chef caught mycobacterium marinum (fish tank granuloma)
from cleaning a turbot. I had not realised this was possible. The
demodex mite lives in oil glands in the face and may cause
pityriasis folliculorum, which apparently affects some water
phobic young females. The alcohol in after shave apparently
protects men from this obscure condition! The little pest also
causes conical dandruff of the eyelashes. Careful washing helps.
We also saw photographic evidence of lip licking dermatitis,
denied by the mother. Emulsifying ointment can help as it tastes
nasty (I have used Calmurid for the same reason – SH).
organism can be grown in the lab but you must specify what
Ivan Bristow gave a useful presentation on foot problems,
you are looking for, since it requires a cooler temperature than
punctuated with his trademark photo shopped funny slides. He
other mycobacteria. The calcareous spines of sea urchins can
reminded us that melanoma on the foot is often amelanotic and
be seen on x-ray. As well as toxicity and sepsis they may lead
often misdiagnosed. Diabetic foot ulcers lead to an amputation
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PCDS Bulletin Winter 2013
Primary Care Dermatology Society
Four wise
monkeys!
Ceilidh
Professor Chris Bunker
Professor Frank Powell
every 30 seconds world-wide; prevention is better than cure.
All the usual infective skin problems from herpes and viral
The foot is a biomechanical marvel, enduring great stresses
warts to Fournier’s gangrene of the scrotum are more common
10,000 times a day. When your foot hurts, all of you hurts. Still
and severe with HIV. Seb derm and psoriasis are worse,
recovering from a painful and costly ankle injury in June 2012, I
extreme drug rashes occur. Strange things like pseudomonas
felt sympathy. Metatarsalgia is common in the elderly and can
panniculitis and bacillary angiomatosis (due to a cat scratch
often be helped by correct foot inserts: much cheaper than
organism) are seen. Skin and especially anogenital cancers are
hospitalisation. Fungal nail disease is always secondary to
increased in HIV, although Kaposi is no longer so common.
fungal skin disease and is spread from foot to groin by pulling
Incidentally, Kaposi is among the differential of the new solitary
up underpants. To clear fungal nail disease, reducing the bulk of
pink nodule.
the diseased nail gives better cure rates. Use oral and topical
antifungal, and occasional follow up cream to prevent
recurrence, which is common. Cork insoles help with juvenile
plantar dermatosis (toxic sock syndrome). Microwaving trainers
to decontaminate them is bad. Don’t do it! Final tip – ‘sausage
toe’ (swollen red digit) in diabetes sometimes means
osteomyelitis.
Prof Bunker expressed alarm at the rise of illegal recreational
drug crystal meth, which elevates libido and is contributing to a
significant rise in HIV infection, citing an epidemic in young
black men in New York. Bottom line: HIV testing should be on
the list of routine blood tests for ANY out of the ordinary skin
problems.
Chris Bunker, President of the BAD and an old friend to the
Dr Fiona McDermot gave a thorough presentation on
PCDS gave a powerful presentation about HIV/AIDS and the
dermatological emergencies covering all the usual things like
skin. He was at the front line of the AIDS epidemic as a junior
erythroderma, generalised pustular psoriasis, staphylococcal
doctor at the Middlesex in the 1980s and told us harrowing
scalded skin syndrome and the syndrome formerly known as
tales of many young men he admitted with pneumonia, Kaposi
DRESS (Drug Reaction with Eosinophilia and Systemic
sarcoma and candida who were dead by the morning. Doctors
Symptoms). They don’t always have eosinophilia. The
were among the sufferers. Anti-retroviral therapy has changed
syndrome is a delayed reaction to drugs (a fatal case involving
the outlook tremendously and thousands now live with HIV as
trimethoprim was discussed) with multi organ hypersensitivity
a chronic disease like diabetes. They experience all kinds of
syndrome. The cutaneous features are variable; death tends to
skin problems, as he showed us. Surprises and a-typical
be from liver failure. Also potentially deadly is toxic epidermal
presentations are the rule.
necrosis. Patients have extremely fragile skin and needed great
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PCDS Bulletin Winter 2013
Primary Care Dermatology Society
care in moving, ideally should be laid on a sheet soaked with
between 2 and 10%, but in his clinic there have been no cases
50:50 and not moved around. Thankfully these potentially fatal
in 20 years. The mainstay of treatment for this and most
skin problems are rare, but evidently they do occur and ‘it could
inflammatory genital dermatoses was steroid to treat
be you!’. Watch out for the patient with a bad rash who is
inflammation and barrier products to protect the skin from
systemically unwell and be prepared to pick up the phone fast.
urine. Failing this, circumcision, as practiced by the ancient
Prof Bunker gave a pictorial tour-de-force on Sunday morning
looking at peri-anal and male genital disease. It would take too
Egyptians for health reasons (as he showed us with a
hieroglyphic) was the answer.
long to document this. A key recommendation for peri-anal
Beware penile pre-cancerous lesions such as Bowenoid
dermatoses was pre-defaecation application of a decent barrier
papulosis, Bowen’s disease and especially erythroplasia of
product to protect the epidermis. Another was not to forget the
Queyrat, which may lead to invasive malignancy in 40% of
basic principles of good history taking and examination,
cases. Penile cancer affects 400 men and kills about 100 in
including a digital rectal exam when appropriate.
Britain per annum and usually results in the doctor being sued
An interesting theory was that male lichen sclerosus was
for failing to prevent or diagnose.
fundamentally a disorder of micro-incontinence of urine due to
I missed a few talks and do not report the Scottish NHS
a dysfunctional navicular fossa (the cavity just inside the
independence debate in which I took part. Space prevents
meatus) which led to retention of a drop or two of
mention of all the dermatological gems of wisdom that were
post-micturition urine. This was not an issue in circumcised
offered: you had to be there. Credit to all involved in planning
men, whom Chris rarely sees in his male genital disease clinic.
and delivering this first class educational and social event,
The rate of penile cancer in lichen sclerosus is reported at
which traditionally is our last of the year. Onwards to 2014!
Julian Peace
GPSI Sheffield & PCDS Treasurer
Book Review
Ethnic Dermatology
Principles and Practice
Dadzie, Petit and Alexis (Eds)
Pubs - Wiley Blackwell (March, 2013)
ISBN-13: 978-0470658574, 318 pages
12
We must start this review by
and very well laid out. It starts by defining
commenting upon the title of this
the challenges of ethnic dermatology and
book. It is a reflection of the history
then deals with signs and symptoms
of Dermatology that such a book is
specific to pigmented skin. The remaining
even needed. For much of the last 200
chapters cover a broad sweep of
years or so, the study of Dermatology
dermatology – dealing with problems of
has been the study of Caucasian skin
pigmentation (too much, too little,
and yet, on with a global perspective, it
missing altogether or in the wrong place),
is white skin that actually forms the
of tumours, infections, hair and scalp
ethnic minority. This book, hopefully, will
issues and treatment problems specific
go some way towards addressing this
to pigmented skin. I was impressed by
disparity. It is also worth describing the
the scope of this book, but also how
book for, although it appears slim, the
accessible it is. Some chapters contain
paper used is both thin and of very high
detail that borders on the esoteric, but in
quality meaning that a lot of pages are
broadly speaking, there is much here to
crammed between the covers and the
recommend to the general reader. As
quality of the numerous pictures is
with all medical textbooks, the price
uniformly excellent. It also smells
approaches prohibitive levels, but if a
wonderful!
copy can be accessed or sourced, much
The book is divided up in to chapters
can, and should be learned from it. I
that read more like individual essays –
haven’t seen the ‘Kindle’ version, but, on
the authors being a veritable
a good, colour tablet, this should be
international ‘Who’s who’. Very
similarly excellent and rather cheaper. It
comprehensive, very well referenced
won’t smell as nice though.
PCDS Bulletin Winter 2013
Primary Care Dermatology Society
See Psoriasis:
Look Deeper
Two members of Luther Pendragon with Paul Bristow (Mental Health Foundation) Helen McAteer (Psoriasis
Association) and Dr Sandy McBride, Consultant Dermatologist at Royal Free Hampstead NHS Trust at the
Primary Care conference
For up to approximately 1.8 million people in the UK who
came together to raise awareness of the need for healthcare
are affected by psoriasis, it is more than just a skin
professionals to look at psoriasis holistically, to consider both
1,2
condition . The multi-faceted nature of psoriasis means that
the physical symptoms and psychological wellbeing, and
the effects go beyond visual signs and symptoms2. It can
ensure people with psoriasis receive the care and support they
impact on emotional and physical wellbeing and in some
need. Approximately two thirds of people with psoriasis have
people it is associated with depression, anxiety and suicidal
physically mild psoriasis, in that it covers less than 3% of their
thoughts, particularly in those affected with more severe
body surface area8, and so are treated solely in primary care.
psoriasis3-6.
However, people often feel that because their psoriasis is not
Despite the documented impact on emotional wellbeing, these
widespread, GPs regard it as a minor skin complaint and are
wider effects often go unrecognised and untreated, and it was
dismissive of the emotional aspects. This leaves many to
for this reason that the See Psoriasis: Look Deeper campaign
continue unaided on the isolating and emotional journey
was launched5,7.
associated with psoriasis5,7. Some say even in secondary care
they are not receiving the whole person care they need to
See Psoriasis: Look Deeper is a collaboration formed in 2012
manage their psoriasis effectively.
to address the link between psoriasis and mental health. The
collaboration consists of The Psoriasis Association; Mental
The campaign began by asking patients to write a postcard to
Health Foundation; Dr Sandy McBride, Consultant
their psoriasis, describing how psoriasis makes them feel and
Dermatologist at Royal Free Hampstead NHS Trust; Dr
express the impact the condition has on their life. These then
Christine Bundy, Senior Lecturer in Behavioural Medicine at
became the focus of the campaign and the collaboration used
the University of Manchester and Toby Hadoke, actor,
them to author a report stressing the importance of this issue,
comedian and someone living with psoriasis. The collaboration
and calling for better quality of care for people with psoriasis.
13
PCDS Bulletin Winter 2013
Primary Care Dermatology Society
The report was launched at an event in the Houses of
Julian Peace
Parliament where patients, clinicians and MPs all gathered
GPSI Sheffield & PCDS Treasurer
to raise awareness of the issue.
The collaboration has now been working together for over
a year and has made significant progress in bringing its
messages to a number of audiences, through media
activity, speaking at events, attending conferences,
Journal Watch
August – November 2013
collecting more postcards from patients and clinicians and
creating its own campaign website.
Looking forward, the group also has exciting plans for
2014. They will publish an academic review of the patient
The last Journal Watch coincided with
postcards written at the start of the campaign, and also
the end of the home Ashes cricket
look to do the same for postcards written by clinicians.
series; this edition comes around the
They are also currently producing a series of patient
start of the Ashes tour ‘down under’.
support booklets that will help patients to understand and
Our first paper does seem to have
overcome some of the psychological aspects of the
appeared at a particularly timely
condition. These promise to be a great resource for those
manner.
whose lives are affected by psoriasis, their relatives, carers
The Merkel cell carcinoma (MCC) is a bit of a rarity – but, in
and clinicians, and will be available on the See Psoriasis:
keeping with all other skin cancers, its incidence is increasing
Look Deeper website in early 2014.
year on year. One of the problems with MCC is that its
If you are interested in the work of the campaign, you can
presentation is relatively non-descript, the last one that I saw
find out more, and download a copy of the report, by
just looked like a small epidermoid cyst. A review of MCC in
visiting their new website
Australia1 (!) looks at features that may be able to help us
www.SeePsoriasisLookDeeper.co.uk
diagnose these particularly nasty tumours earlier. Clinically, the
most prevalent features were a cherry red colour, shiny
surface, nodular morphology and sharp circumscription. Under
References
1. What is Psoriasis, 2011, Accessed at:
https://www.psoriasisassociation.org.uk/silo/files/No1%20what%20is.pd
f Accessed: September 2012
2. Kimball AB, Gieler U, Linder D, et al. Psoriasis: is the impairment to a
patient’s life cumulative? J Eur Acad Dermatol Venereol 2010;24:989–1004.
our old friend the dermoscope, we are looking for poorly
focused blood vessels which tend towards linear irregular and
polymorphous forms. Milky pink and white areas are also
prevalent, along with rather structureless areas and
architectural disorder. Pigmented areas are conspicuous by
3. Kurd SK, Troxel AB, Crits-Christoph P, Gelfand JM. The risk of depression,
anxiety, and suicidality in patients with psoriasis: a population-based cohort
study. Arch Dermatol 2010;146(8):891–5.
their absence – in fact, even the suggestion of pigmentation
4. National Institute for Health and Clinical Excellence. Psoriasis: the
management of psoriasis. NICE guideline. Draft for consultation, May 2012.
http://www.nice.org.uk/nicemedia/live/12344/59182/59182.pdf. Accessed:
September 2012
A lot of papers, or even research, exist to answer specific
5. Eedy D, Burge S, Potter J, et al, on behalf of The British Association
Dermatologists and Clinical Effectiveness and Evaluation Unit, Royal
College of Physicians Clinical Standards Department. An audit of the
provision of dermatology services in secondary care in the United Kingdom
with a focus on the care of people with psoriasis. January 2008.
contemplate at the start of the process. For this team2 in The
6. Gupta MA, Gupta AK. Depression and suicidal ideation in dermatology
patients with acne, alopecia areata, atopic dermatitis and psoriasis. Brit J
Dermatol 1998;139:846–850.
7. Nelson PA, Chew-Graham CA, Griffiths CE, Cordingley L; The IMPACT
Team. Recognition of need in health care consultations: a qualitative study
of people with psoriasis. Br J Dermatol 2012; doi:
10.1111/j.1365-2133.2012.11217.x. [Epub ahead of print]
8. The psoriasis and psoriatic arthritis pocket guide, 2009, Accessed at
http://www.psoriasis.org/document.doc?id=354 Accessed November 2013
14
would make one think of an amelanotic melanoma instead.
questions. Sometimes, a more nebulous start point ends up
answering questions that the researcher didn’t really
Netherlands, a questionnaire study about nail psoriasis helped
to nail (sorry!) down the prevalence of this disease
manifestation. It seems odd, that prior to this paper, the best
estimates of the prevalence of nail disease in psoriasis varied
from 10% to 81% hardly accurate figures. This was a big
study, and showed nail disease to be present in 66% of
psoriasis sufferers – although the researchers do qualify that,
because of bias, this may actually represent prevalence
somewhere between 18% and 66%. It also tends to be
associated with more widespread or more severe forms of the
PCDS Bulletin Winter 2013
Primary Care Dermatology Society
disease. It is also associated with specific localisations of the
Now, another favourite topic: – scabies. This is a common
disease – in particular joint, genital, scalp and ‘inverse’. What is
parasite that causes untold distress and seems to be all but
also evident is how few patients are being offered targeted
impossible to treat with current methods. It has always
treatment for their nails. This is partly because of the paucity of
seemed a little odd that if Tiddles or Fido get scabies, they can
availability of such treatments, but also because they are
be treated orally, but if we, as much larger primates, get it, we
perceived to be of limited efficacy. Nail psoriasis is of particular
have to cover ourselves in creams, lotions and potions. This
concern to most sufferers; we need to concentrate upon it
study7 compares oral ivermectin to topical lindane and finds it
better.
as efficacious in first usage, and more efficacious if used
Staying with psoriasis, but moving to Denmark, we now have a
large study3, looking at twins, to determine the heritability of
psoriasis. The data was drawn from 10,725 twin pairs, and
showed a lifetime prevalence of psoriasis to be around 4%.
twice. Sadly, lindane is not a common strategy in the UK, but if
similar results can be obtained, without evidence of ill effect,
then oral treatment may become more than a veterinary
sideline.
The heritability was shown to be 68%, showing that the
We have commented previously on the poor correlation
development of psoriasis is complex and multifactorial.
between reported cases of non melanoma skin cancer (NMSC)
Although genetic factors play a significant role in its
in the UK. From The Netherlands comes a similar report8,
pathogenesis, the actual expression of psoriasis is influenced
showing that the way the data is recorded is significantly
by environmental factors. What these environmental factors
flawed. As in the UK, only the first recorded NMSC is
actually are remains to be determined.
effectively counted. As we well know, patients may have many
Now we move on to Vitamin D, and sunbeds. From Norway, a
basal cell carcinomas – even at first presentation. To ignore a
country blessed with even less natural Ultraviolet (UV) than we
multitude of such lesions displays a rather cavalier approach to
receive in our green and pleasant land, comes a study
data, and a similar disregard for public health priorities. Until
comparing Vitamin D supplementation with sunbed use. A daily
the cancer registries get this sorted out, the rising incidence of
dose of 2,000 units of Vitamin D is equivalent to twice weekly,
skin cancer can only be an estimate. This is doubly important,
whole body UV exposure to a dose of 4.8 standard erythema
as NMSC can easily be considered to be a chronic disease –
doses – but at a significantly lower risk.
the presence of a single lesion conveys a significantly
4
increased risk of a subsequent lesion developing – so
More sunbeds: from Germany5 this time. Increasingly, we
think of sunbeds as human carcinogens and yet usage of these
cost-effective measures need to be developed to stem this
rising tide before it overwhelms us.
infernal machines seems remarkably slow to reduce. This study
looks at lifetime usage of sunbeds – usage that seems
Whilst in this particular field, we are becoming increasingly
remarkably consistent. Average annual exposure was around
interested in actinic keratoses, yet we seem to have great
180 minutes and this stayed constant for nearly 86% of the
difficulty in pinning down the exact natural history of these
subjects studied. Curiously, however, the age at first exposure
pesky lesions. A high powered team from Berlin9 have
is actually decreasing meaning that the health message is
attempted to deal with this information vacuum. Their
failing to reach the younger age groups. It is here that future
conclusion, sadly, is that the available data is not of good
interventions should be targeted.
enough quality to make definitive statements. In particular, the
I have mentioned before about the importance of reading all the
available information before drawing a conclusion. An example
comes to mind in a report6 about the use of infrared light, at a
rate of progression from actinic keratosis to invasive squamous
cell carcinoma remains obscure. More studies, inevitably, are
required – hopefully, of more robust methodological quality.
specific wavelength, to treat and enhance the healing process
Back to the UK, and we return to another heart sink condition –
in herpes labialis. The results of this study are quite good – time
scalp psoriasis10. This systematic review looks at the evidence
to healing was reduced from 177h to 129h in the study group
behind various treatment modalities. The review is
relative to the control group. Several explanations for this are
comprehensive, looking at 26 randomised controlled trials and
put forward and the results seem promising. The lead author,
involving 8,020 participants. This is no small number, but it
however, is closely linked to the company that distributes the
should be borne in mind that the scalp is involved in almost
light-emitting diode devices used in the paper. Independent
80% of people with psoriasis. This creates a significant disease
verification of these results would be nice before we could look
burden and it would be nice to know how best to treat it! On a
at recommending such a product for our patients.
six point global improvement score, potent or very potent
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PCDS Bulletin Winter 2013
Primary Care Dermatology Society
topical corticosteroids were deemed more effective than
pilot study13, from Italy, is a half head study (pause and reflect
vitamin D3 analogues alone, but when steroids and D3
on the results if this study was spectacularly successful...)
analogues were used together, there was a small, but
comparing intralesional PRP, triamcinolone and placebo.
demonstrable extra benefit – this did not, however, reach the
Regrowth in the study group found that PRP produced regrowth
level of improvement achieved with very potent steroids used
greater than that achieved by triamcinolone – the current gold
as monotherapy. There is, however, still uncertainty regarding
standard treatment. Once more, more extensive controlled
the atrophic potential of corticosteroid preparations for scalp
studies are now needed to confirm this preliminary data.
psoriasis.
Returning to dermoscopy, we look at an American study
On to another systematic review11, this time to look at the
concerning the development of new naevi in adults. We know
efficacy and effectiveness of basic skin care interventions for
that naevogenesis is a dynamic process that occurs throughout
maintaining skin integrity in the aged. Ageing is linked with both
life, but adults produce far fewer naevi than children. The rate, in
functional and structural changes within the skin that makes it
this study at least, is surprisingly high – 202 new naevi per 1000
intrinsically vulnerable to damage. The current evidence base to
person years. These naevi tend to be reticular (47.1%) in form,
support basic intervention is surprisingly weak, something this
with homogenous (22.1%) patterns and reticuloglobular (15.4%)
review attempts to address. After an extensive search, a total
patterns also commonly found. These patterns are maintained
of 33 studies were included and looked predominantly at
through the life of the naevi.
treating dry skin conditions and preventing incontinence
For many years, it has been an accepted fact that the English
associated dermatitis and superficial ulceration. Emollients
incidence of melanoma follows a gradient, high in the south,
containing humectants (lactic acid, urea, glycerine etc) tend to
lower in the north. A new study15, however, suggests that there
be more effective in treating dry skin symptoms; however, the
is a reversal in this trend – specifically in young women aged
usefulness of occlusive products in preventing incontinence
10-29. This follows the national trend for sun-bed use and may
dermatitis is unclear. The quality of the studies was relatively
also be linked to the frequency and type of holiday sun exposure
poor, and almost no studies exist on the effects of cleansing
in this population. The rise is split between the second most
regimes, or on head to head comparisons of different emollient
deprived and the second most affluent groups and is at a
regimes. It seems to be a common theme in systematic
maximum in the North-West. Perhaps this provides the
reviews that the conclusion is reached that more research is
evidence for the need for education and targeted intervention to
invariably required...
address this worrying development.
With this in mind, it is nice to be able to report on a study12 that
Economics is plagued by the principle of unexpected
does actually make a proposal for future care without significant
consequences, medicine too, I guess. The green lobby seem to
reservation. Basal cell carcinoma is the commonest malignancy
be now providing us with an entirely new set of problems in the
in the UK. It has a significant impact on healthcare budgets and
drive to save the planet. Since the demise (mostly) of the
causes significant morbidity for patients. Superficial basal cell
filament light bulb, the majority of domestic lighting has been
carcinoma (sBCC) is treated effectively by the use of topical
provided by compact fluorescent lamps (CFLs) or, more recently,
Imiquimod; however, no uniform histological definition of sBCC
LEDs. What is not widely reported is that CFLs emit a
actually exists. This study suggests that a definition, as with
measurable amount of Ultra Violet radiation16. It is also not
other cutaneous carcinomas, based upon tumour thickness
particularly clear that CFLs come as both single envelope and
would be a good suggestion. Lesions less than, or equal to
double envelope designs. Single envelope CFLs produce
0.40mm in thickness could be treated with topical agents with
enough UV, under experimental conditions at least, to trigger an
no risk of recurrence, thicker tumours than 0.40mm are much
exacerbation of photodermatoses in a large number of sufferers.
more like to come back. This does seem to be good data and a
LEDs are exempt from this, as are double envelope CFLs. Now
robust suggestion – I leave this to the great and the good to
if they could only produce bright enough LEDs, everyone would
verify it.
be happy.
Platelet rich plasma (PRP) seems an unlikely new
In keeping with the study regarding melanoma above, as we
dermatological treatment modality, but preliminary studies
start to understand more and more about basal cell carcinoma
suggest that it may have a beneficial role in hair growth. It
(BCC), the true incidence of this common malignancy – and it’s
seems logical that it was only a matter of time before its effects
regional distribution – remains uncertain. What does appear
were investigated in the treatment of Alopecia Areata (AA). This
clear is that BCC follows a more predictable pattern, at least for
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PCDS Bulletin Winter 2013
Primary Care Dermatology Society
now17. In the UK, the incidence is highest in the south and
follows a decreasing gradient as you move northwards
through the UK. It is also a class conscious carcinoma, as
the highest incidence is also found in the least deprived
socioeconomic groups. Worryingly, the incidence is rising
for those below the age of 49.
The Winter 2013 issue of Dermatology in practice is published
So, there you have it, another selection of the papers that
in December and features:
caught my eye this quarter. Until next time, thank you for
reading, and thank you for your feedback, it really is much
appreciated.
References
1. Jalilian et al – Clinical and dermoscopic characteristics of Merkel cell
carcinoma. BJD2013:169;294-297.
Comment: The changing work of the dermatologist
Neill Hepburn, Editor of Dermatology in practice, introduces the
issue with his thoughts on the transition that dermatology has
recently been going through.
Common skin allergens: hazards on the high street
Ian Coulson and Laura Cuddy’s article outlines the common
2. Klaassen et al – Nail psoriasis: a questionnaire-based survey.
BJD2013:169;314-319.
causes of contact dermatitis. Many of the allergens involved
3. Lønnberg et al – Heritability of psoriasis in a large twin sample.
BJD2013:169;412-416
investigate the risks that arise as a result of using sun beds and
4. Lagunova et al – Effect of vitamin D supplementation and ultraviolet B
exposure on serum 25-hydroxyvitamin D concentrations in healthy
volunteers: a randomised, crossover clinical trial. BJD2013:169;434-440.
5. Bock et al – Sunbed use in Germany: trends, user histories and factors
associated with cessation and readiness to change. BJD2013:169;441-449.
6. Dougal and Lee – Evaluation of the efficacy of low-level light therapy using
1072nm infrared light for the treatment of herpes simplex labialis.
CED2013:38;713-718
7. Mohebbipour et al – Comparison of oral ivermectin vs. Lindane lotion 1%
for the treatment of scabies. CED2013:38;719-723.
are found in popular high-street products. The authors also
dermal fillers, as well as the problems with waxing.
The genetics of basal cell carcinoma
In their article, Nicholas Collier, Faisal Ali and John Lear
examine the genetics of the most common human cancer –
basal cell carcinoma (BCC). Recent research into the molecular
genetics of BCCs has uncovered many of the pathways
fundamental to their development. The article explores these
pathways in light of the new findings.
Update on the treatment of actinic keratosis
8. Van der Geer et al – The incidence of skin cancer in dermatology
CED2013:38;724-729
9. Werner et al – The natural history of actinic Keratosis: a systemic review
BJD2013:169;502-518.
10. Mason et al – Topical treatments for chronic plaque psoriasis of the
scalp: a systematic review. BJD2013:169;519-527
11. Kottner et al – Maintaining skin integrity in the aged: a systematic review
BJD2013:169;528-542.
12. McKay et al – Thickness of superficial basal cell carcinoma (sBCC)
predicts Imiquimod efficacy: a proposal for thickness-based definition of
sBCC BJD2013:169;549-554.
13. Trink et al – A randomised, double-blind, placebo- and active-controlled,
half head study to evaluate the effects of platelet-rich plasma on alopecia
areata. BJD2013:169;690-694.
14. Oliveria et al – Clinical and dermoscopic characteristics of new naevi in
adults: results from a cohort study. BJD2013:169;848-853.
Colin Morton et al give an update on the new therapy options
that have become available to manage actinic keratosis (AK).
After exploring why AK should be treated and who will benefit
from treatment most, the authors give a review of recently
approved topical treatments.
Monk’s moments: Occupational health
In his ever-fascinating column, Barry Monk laments on the
changing nature of occupations, with dermatology, of course,
being a main casualty of change.
FAQs: What is ‘Breslow thickness’ in melanoma?
Richard Jerrom and Neill Hepburn introduce Breslow thickness
in our short FAQ section, which aims to give quick overviews of
common questions.
15. Wallingford et al – Regional melanoma incidence in England, 1996-2006:
reversal of north-south latitude trends among the young female population.
BJD2013:169;880-888.
Dermatology in practice is a review-based journal which aims to
16. Fenton et al – Energy-saving lamps and their impact on photosensitive
and normal individuals BJD2013:169;910-915.
specialists. The latest issue of the journal is available free of
17. Musah et al – Regional variations of basal cell carcinoma incidence in the
UK using The Health Improvement Network database (2004-10)
BJD2013:169;1093-1099.
print distribution list. Visit www.dermatologyinpractice.co.uk
publish practical articles for GPs, nurses and dermatology
charge online and readers may also request to join our free
for details.
17
PCDS Bulletin Winter 2013
Primary Care Dermatology Society
Stephen Hayes
represented a substantial increase in detection of early
melanomas compared to pre-SCREEN outcomes (up 108% in
men, 133% in women) and a more modest increase in detection
of invasive melanomas (up 27% men and 53% in women). The
attached graph shows a reduction in mortality from about 2
years after the project began.
GPSI Southampton, PCDS Committee Member & Trustee
Melanoma Focus
It is still early days, issues such as cost effectiveness, interval
cancers and possible harms have not yet been fully evaluated,
but overall it was felt that the SCREEN project gave good
evidence for effectiveness of skin cancer screening and showed
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that such screening was feasible in a population-based setting.
Fiona Walter, GP and Clinician Scientist at the University of
Cambridge presented on ‘The Missed Melanoma-a Primary
Care View for Improvement’. She presented the results of a
NAEDI (National Awareness & Earlier Diagnosis Initiative) funded
study which was conducted at 2 hospitals (1 English, 1 Scots)
and interviewed patients with thinner and thicker melanomas
!
Melanoma Focus (formerly The Melanoma Study Group)
met for a day conference at the RCP in London on October
15th. I was booked to attend but did not make it, however was
able to study the presentations. Most presentations were very
secondary care focussed but two were of particular interest to
PCDS members. This is a brief summary of key points.
Professor Alexander Katalinic of the University of Lübeck,
Germany, presented on ‘Screening for melanoma, a
European perspective.’ National skin cancer screening had
been rolled out in Germany following a pilot study in Schleswig
!
Holstein in 1998. The project’s acronym was SCREEN (Skin
Cancer Research to provide Evidence for Effectiveness of
Screening in Northern Germany). Whole body examination from
scalp to toes was carried out and documented by a physician,
cost E25 (paid by health insurance), time 10 minutes. Screening
was done by any physician (mainly GPs) with the condition of
an 8 hour training course. Out of a 1,800,000 target population
360,000 people were screened (73% by GPs) leading to 16,000
excisions yielding 3,100 skin cancers. Of these, 20% were
melanomas, 67% BCCs, 13% SCCs.
The number needed to screen was 116 for any skin cancer, the
excision to cancer rate was 1 in 5 for all skin cancers, 1 in 28 for
melanoma which was considered acceptable. These results
18
The review showed that while GP diagnostic skills could be
better, much of the delay was due to the patient not noticing or
failing to act on key symptoms and signs. Longer patient delay
was more common in older people, men, the less educated and
on tricky sites such as the sole and back. There was conflicting
evidence about the relationship between delay and tumour
thickness at excision.
Patients admitted delaying presentation for all sorts of reasons.
Some worried about time off work, not wanting to waste the
doctor’s time, being busy moving house – all the things that
make us procrastinate. Others assumed it was an insect bite,
others were given incorrect reassurance by GPs or practice
nurses. Thinner melanomas tended to be picked up as ‘ugly
ducklings’, thicker ones on symptoms such as bleeding, itch or
pain. Thin and thick melanomas alike were picked up due to
change in size, shape and texture and due to other people
commenting on them not looking right.
Recommendations were made: better education for patients
and practitioners, ‘making best practice standard practice’,
safety netting, and referral for patients who consulted more than
once about any lesion. GPs should think about giving written
advice about when to make contact again and, given the study
finding that less educated people presented with thicker
melanomas, take special thought for less literate patients to
make sure they knew when and how to re-consult. Practices
should conduct significant event discussions in all cases of
delayed cancer diagnosis.
Melanoma Focus meets twice annually, once in London and
once elsewhere. The next Regional Meeting will be at Merton
College, Oxford on Friday 16th May 2014. For further details see
melanomafocus.com.
Like Jack,
Dermol can also
do two things
at once!
Dermol knocks out Staph
and soothes itchy eczema
Dermol
A family of antimicrobial emollients
WASH SHOWER LOTION CREAM BATH
The Dermol family of antimicrobial
emollients - for patients of all ages who
suffer from dry and itchy skin conditions
such as atopic eczema/dermatitis.
Dermol® Wash, Dermol® 200 Shower Emollient
and Dermol® 500 Lotion Benzalkonium chloride
0.1%, chlorhexidine dihydrochloride 0.1%, liquid
paraffin 2.5%, isopropyl myristate 2.5%.
Dermol® Cream Benzalkonium chloride 0.1%,
chlorhexidine dihydrochloride 0.1%, liquid paraffin
10%, isopropyl myristate 10%.
Uses: Antimicrobial emollients for the management of dry and
pruritic skin conditions, especially eczema and dermatitis, and
for use as soap substitutes. Directions: Adults, children and the
elderly: Apply direct to the skin or use as soap substitutes.
Dermol® 600 Bath Emollient Benzalkonium
chloride 0.5%, liquid paraffin 25%, isopropyl
myristate 25%.
• Specially formulated to be effective and acceptable on sensitive eczema skin
• Significant antimicrobial activity against MRSA and FRSA (fusidic acidresistant Staphylococcus aureus) 1
www.dermal.co.uk
• Over 15 million packs used by patients 2
Uses: Antimicrobial bath emollient for the management of dry,
scaly and/or pruritic skin conditions, especially eczema and
dermatitis. Directions: Adults, children and the elderly: Add to
a bath of warm water. Soak and pat dry.
Contra-indications, warnings, side-effects etc: Please refer
to SPC for full details before prescribing. Do not use if sensitive
to any of the ingredients. In the unlikely event of a reaction stop
treatment. Keep away from the eyes. Take care not to slip
in the bath or shower. Package quantities, NHS prices and
MA numbers: Dermol Wash: 200ml pump dispenser £3.55,
PL00173/0407. Dermol 200 Shower Emollient: 200ml shower
pack £3.55, PL00173/0156. Dermol 500 Lotion: 500ml pump
dispenser £6.04, PL00173/0051. Dermol Cream: 100g tube
£2.86, 500g pump dispenser £6.63, PL00173/0171. Dermol
600 Bath Emollient: 600ml bottle £7.55, PL00173/0155.
Legal category: P MA holder: Dermal Laboratories, Tatmore
Place, Gosmore, Hitchin, Herts, SG4 7QR. Date of preparation:
February 2012. ‘Dermol’ is a registered trademark.
Adverse events should be reported. Reporting
forms and information can be found at
www.mhra.gov.uk/yellowcard. Adverse events
should also be reported to Dermal.
References:
1. Gallagher J. et al. Poster presented at EADV Congress 2009.
2. Dermol Range – Total Unit Sales since launch. Dermal
Laboratories Ltd. Data on file.
Members of the corporate
membership scheme
Forthcoming Meetings 2014
Top Tips in Dermatology
l
8 February, Leicester
l
1st March, Winchester
th
Dermatology Day
PCDS & RCGP
l
13th February, Swansea
l
6th March, Newmarket
Advanced Dermoscopy
l 27th March, Manchester
Essential Dermatology
l
3rd April, Crewe
l
14th May, Hemel Hempstead
l
21st May, Northampton
More Essential Dermatology
(previously L2)
l
11th June, London
Dermoscopy for Beginners
l
15th May, Cambridge
l
12th June, London
l
18th June, York
Primary Care Dermatology
Society (PCDS)
Spring Meeting
14th, 15th and 16th March,
Warwickshire
Summer Meeting
5th June, Leeds
cont. Editorial
the Committee passionate to educate primary care. There is an extensive programme across the
country planned for next year – please inform your colleagues, nurses and trainees. The feedback
from these days is excellent and they are not expensive!
You have been emailed with a request to conduct an audit in conjunction with Galderma to gather
some evidence regarding the distress caused by the erythema due to Rosacea. This is in advance
of a possible treatment in the future so no treatment is offered at this time. We as GPs are in a
prime situation to ask patients on our disease register to complete a DLQI and for a simple
(mild/moderate/severe) assessment of clinical severity. There is a contribution towards any admin
costs per patient. If you are able to help then please contact the PCDS at the usual address.
Happy Christmas!
Michelle Ralph
PCDS Committee Member
@PCDSUK
2nd Floor, Titan Court, 3 Bishop Square, Hatfield AL10 9NA T: 01707 226024 F: 01707 226001 E: pcds@pcds.org.uk W: pcds.org.uk