PCDS Bulletin€¦ · PCDS Winter Bulletin 2015 Editorial Winter 2015 Welcome to the Winter PCDS...
Transcript of PCDS Bulletin€¦ · PCDS Winter Bulletin 2015 Editorial Winter 2015 Welcome to the Winter PCDS...
PCDS BulletinPrimary Care Dermatology Society
News, features, articles & meetings
for GPs, Nurses & Registrars on the
subject of dermatology
Winter 2015
ISSN 2055-7590
Visit www.pcds.org.ukAll enquiries to [email protected]
Get involvedBecome a Member
2nd Floor, Titan Court, 3 Bishop Square, Hatfield AL10 9NA T: 01707 226024 F: 01707 226001 E: [email protected] W: pcds.org.uk
Forthcoming Meetings 2016
Members of the corporate membership scheme
Primary Care Dermatology Society(PCDS)
Spring Meetingl 12th – 13th March – Hilton Deansgate,
Manchester
Summer Meetingl 16th June – Highcliff Marriott,Bournemouth
Autumn Meetingl 15th September – Cavendish, Conference
Centre, London
Scottish Meetingl 12th – 13th Novemebr – Dunblane Hydro
Top Tips in Dermatologyl 19th March – Londonl 10th September – Manchesterl 26th November – London
Lesion Recognition & an Introduction to Dermoscopyl 19th March – Londonl 10th September – Manchesterl 26th November – London
Improvers Skin Surgery Meetingl 15th – 16th April – Barnstaple
Cosmetic Dermatologyl 27th April – Cavendish, Conference
Centre, London
Dermoscopy for Beginners & Improversl 23rd March – Birminghaml 28th April – Cavendish, Conference
Centre, Londonl 23rd June – Leedsl 29th September – Cardiffl 1st December – Nottingham
Advanced Dermoscopyl 10th March – Manchester Conference
Centre, Manchesterl 6th October – Cavendish, Conference
Centre, London
Essential Dermatology Series 1l 14th September – Londonl 28th September – Cardiff
Essential Dermatology Series 2l 13th April – Londonl 26th May – Manchesterl 13th October – Milton Keynes
European Meetingl 13th – 15th May – Valletta, Malta
@PCDSUK
3
PCDS Winter Bulletin 2015
Chairman’s Report
Dr Stephen Kownacki Executive Chairman of the Primary Care Dermatology Society
CONVENIENCEDovobet® Gel Applicator is a simple, once daily1 solution for patients wanting to reduce the stress and mess of treatment, using no touch, targeted application
CONFIDENCE Dovobet® Gel is a fixed dose combination1 with proven efficacy2,3, patient preference over previous topical treatments4,5 and long established safety profile6
CONTROLThe shaped nozzle of the
Dovobet® Gel Applicator facilitates precise
application, delivering 0.05g with every squeeze1
Help your patients to take control of their scalp psoriasis with Dovobet® Gel Applicator 60g
Date of preparation: September 2015. UK 1008/11238e © L
EO, L
EO P
harm
a, U
K, S
epte
mbe
r 201
5, A
LL L
EO T
RADE
MAR
KS M
ENTI
ON
ED B
ELO
NG
TO T
HE L
EO G
ROUP
LEO Pharma, Horizon, Honey Lane, Hurley, Berkshire SL6 6RJ, UK. www.leo-pharma.co.uk® Registered trademark
Abbreviated Prescribing Information for Dovobet® 50 microgram/g + 0.5 mg/g gel Please refer to the full Summary of Product Characteristics (SmPC) (www.medicines.org.uk/emc) before prescribing.Indications: Topical treatment of scalp psoriasis in adults. Topical treatment of mild to moderate ‘non-scalp’ plaque psoriasis vulgaris in adults. Active ingredients: 50 µg/g calcipotriol (as monohydrate) and 0.5 mg/g betamethasone (as dipropionate). Dosage and administration: Apply to affected areas once daily. Recommended treatment period is 4 weeks for scalp and 8 weeks for ‘non-scalp’ areas. If it is necessary to continue or restart treatment after this period, treatment should be continued after medical review and under regular medical supervision. When using calcipotriol containing medicinal products the maximum dose should not exceed 15 g/day. Treated area should not exceed 30% of body surface. Safety and efficacy in children under 18 years have not been established. Safety and efficacy in patients with severe renal insufficiency or severe hepatic disorders have not been evaluated. Do not apply directly to the face or eyes. It is not recommended to take a shower or bath, or to wash the hair in case of scalp application, immediately after application as the gel should remain on the skin during the night or day. If used on the scalp usually between 1 g and 4 g/day is sufficient. Applicator: Prior to first use, the cartridge and the applicator head must be assembled. After priming, each full actuation delivers 0.05 g of Dovobet gel. Wash hands after use if gel gets on the fingers. Read detailed instructions for use in package leaflet. Bottle: Shake before use. Wash hands after use.Contraindications: Hypersensitivity to any constituents. Erythrodermic, exfoliative or pustular psoriasis. Patients with known calcium metabolism disorders. Viral skin lesions, fungal or bacterial skin infections, parasitic infections, skin manifestations in relation to tuberculosis, perioral dermatitis, atrophic skin, striae atrophicae, fragility of skin veins, ichthyosis, acne vulgaris, acne rosacea, rosacea, ulcers and wounds. Precautions and warnings: Avoid concurrent treatment with other steroids. Adrenocortical suppression or impact on the metabolic control of diabetes mellitus may occur. Avoid application on large areas of damaged skin, under occlusive dressings or on mucous membranes or skin folds. Do not use on the skin of the face or genitals. Avoid inadvertent transfer to face, mouth and eyes. Wash hands after applying. There may be a risk of generalised pustular psoriasis. With long-term use there is an increased risk of local and systemic corticosteroid adverse reactions in which case treatment should be discontinued. There may be a risk of rebound when discontinuing treatment. No experience of use in guttate psoriasis. There is limited experience of concurrent use with other anti-psoriatic products administered topically (to the same treatment area) or systemically or with phototherapy. Physicians are recommended to advise patients to limit or avoid excessive exposure to natural or artificial sunlight. Use with UV radiation only if the physician and patient consider that the potential benefits outweigh the potential risks. Contains butylhydroxytoluene which may
cause local skin reactions or irritation to the eyes and mucous membranes. Fertility, pregnancy and lactation: Only use in pregnancy when potential benefit justifies potential risk. Caution when prescribed for women who breast-feed. Instruct patient not to use on breast when breast-feeding. Side e� ects: Pruritus. Additional undesirable effects observed for calcipotriol and betamethasone: Calcipotriol: application site reactions, skin irritation, burning and stinging sensation, dry skin, erythema, rash, dermatitis, eczema, psoriasis aggravated, photosensitivity and hypersensitivity reactions including very rare cases of angioedema and facial oedema. Hypercalcaemia or hypercalciuria may appear very rarely. Betamethasone: local reactions, especially during prolonged application, including skin atrophy, telangiectasia, striae, folliculitis, hypertrichosis, perioral dermatitis, allergic contact dermatitis, depigmentation, colloid milia, generalised pustular psoriasis, infections. Systemic reactions are rare; adrenocortical suppression, cataract, infections, impact on the metabolic control of diabetes mellitus and increase of intra-ocular pressure can occur. Systemic reactions occur more frequently when applied under occlusion (skin folds, plastic), to large areas and during long term treatment.See SmPC for a full list of side e� ects.Legal category: POM. Marketing authorisation number and holder: PL 05293/0005. LEO Pharma A/S, Ballerup, Denmark. Basic NHS price: Bottle: £37.21/60 g, £69.11/2 x 60 g. Applicator: £37.21/60 g. Last revised: July 2015.
Reporting of Suspected Adverse ReactionsAdverse events should be reported. Reporting forms and information can be found at: www.mhra.gov.uk/yellowcard.
Adverse events should also be reported to Drug Safety at LEO Pharma by calling +44 (0)1844 347333 or e-mail [email protected]
References: 1. Dovobet® Gel Summary of Product Characteristics. Available at: http://www.medicines.org.uk/emc/medicine/23717. Accessed: August 2015. 2. Fleming C et al. Eur J Dermatol 2010; 20: 465-471. 3. Luger TA, et al. Dermatology 2008;217(4):321-8. 4. Hol K. Patient preference for topical psoriasis formulations. 19th Congress of the European Academy of Dermatology and Venerology (EADV), 6-10 October 2010, Gottenburg, Sweden. P572. 5. Reich K, et al. Efficacy of a fixed combination of with calcipotriol/betamethasone dipropionate topical gel in adult patients with mild to moderate psoriasis: blinded interim analysis of a phase IV, multicentre, randomized, controlled, prospective study. JEADV 2014. DOI: 10.1111/jdv.12774. 6. Kragballe K et al. Br J Dermatol 2006; 154(6): 1155-60.
Primary Care Dermatology Society Winter Bulletin 2015
www.pcds.org.uk
It really behoves us all to watch out for
and to fight against restrictions imposed
on us and our patients regarding choice
of treatments. The influence of CCG
“accountants” attempting to restrict our
choice of emollients and indeed whether
they should be prescribed at all must be
resisted as must the need for choice as
well as the right to receive such essential
medications – for that is what they are.
Because topical therapies overlap with
cosmetics in some minds the essential
nature of these products for patients with
significant dry skin diseases needs to be
constantly reinforced.
It is proving to be another successful
growth year for the PCDS with
membership approaching 3000! Some of
which is due to our offer of free
membership for Registrars but also
because of the increasing number and
scope of our events. We are experiencing
a big demand for Dermoscopy both for
the Dermoscopy for Beginners series
(RCGP accredited) and continued
popularity of the Advanced series with
Jonathan Bowling. In addition we have
seen a good take up for the Lesion
Recognition and Introduction to
Dermoscopy Saturday afternoon course,
aimed at healthcare professionals who
are not sure if dermoscopy is for them
but need the benefit of improved naked
eye (and ear) diagnostic skills.
NICE have endorsed the role and
importance of dermoscopy for lesion
recognition no matter to which speciality
the patient is referred. We therefore
expect an increase in the demand from
Plastic and General Surgeons, ENT as
well as some dermoscopy sceptics from
Dermatology! We were delighted to hear
Jonathan Bowling acknowledge the role
of the PCDS has played and continues
to offer with him and his consultant
colleagues in promoting the benefits of
dermoscopy. It was a salutary experience
that at the World Dermoscopy Congress
in Vienna this year there were more
members of the PCDS than of the BAD!
So far our decision to concentrate
courses to major population centres
seems to be wise as numbers are
increasing but we are happy to respond
to requests especially by the RCGP
Faculties or CCGs to visit venues where
demand is high and approximately 50
delegates can be assembled.
To date I have heard no more news of
the credentialing process but changes
take time and I remain hopeful.
We are again entering the RCGP
application to have dermatology chosen
as a clinical priority for the next 3 years.
Having been rejected last time around,
George Moncrieff has resubmitted our
offer to provide such a focus that anyone
involved in dermatology will recognise as
sorely needed for our patient’s sake. We
have passed the first stage and are
keeping our fingers crossed for the next
and more demanding process. An
example of the need was brought home
to me when BBC Radio 1 Newsbeat
asked me to respond to some awkward
I sincerely hope that by the time this edition of the PCDS Bulletin hits your
doormats or computer screens the dispute with the Health Secretary Jeremy
Hunt over “Junior Doctors’ hours and pay will have been settled. It does not
bode well for all other negotiating groups including us GPs when negotiating is
interpreted as “take it or leave it!” The goodwill and extra efforts that we (nearly)
all put into the running of our health service is interpreted as being soft touches.
5
PCDS Winter Bulletin 2015
Editorial Winter 2015
Welcome to the Winter PCDS
bulletin – I sincerely hope everyone is
enjoying the festive season. This issue
of the bulletin has a predominantly
psychodermatology theme as, by pure
coincidence, a number of articles have
passed my desk in the last few months
highlighting the need for greater
recognition of the psychosocial aspects
of skin disease. Dr Jon Goulding,
Consultant Dermatologist, has kindly
written an article based on his excellent
presentation given at the Spring PCDS
meeting titled "Where dermatology meets
psychiatry". He runs the only
psychodermatology service in the
Midlands holding a joint clinic with clinical
psychology colleagues. I still remember
feeling very jealous on hearing during
Jon's talk that at these clinics he has an
initial allocated 45 minute consultation
time with new patients (in comparison
with our 10 minute GP consultation times
and the patients with their lists and "while
I am here doc ...").
The Psoriasis Association have just
launched their Psoriasis Arthritis
Campaign highlighting the physical and
psychological impact of psoriasis – a
recent survey suggests at least 20% of
patients with psoriasis have feelings of
depression. Continuing with the
psychodermatology theme for the first
time a patient contacted the PCDS and
asked to write an article for the bulletin
around his experience of living with
lifelong acne. Initially I was going to edit
the article but, on reflection, I have left it
in its original form as I think it is extremely
important for us all to realise how skin
disease can impact on all aspects of life.
The article reminded me of the patient
experience items published in the BMJ
which I have always found thought
provoking. Changing Faces has just
published a new fact sheet around the
psychosocial needs of patients with skin
conditions (www.changingfaces.org.uk)
and the BAD together with input from the
PCDS have a sponsored a website
offering emotional support for patients –
www.skinsupport.org.uk.
Unfortunately I was unable to attend the
Scottish meeting at St Andrews but I
have heard from several sources is was a
huge success and extremely enjoyable.
Fiona Collier has submitted a review of
the conference which is very informative. I
Michelle Ralph PCDS Bulletin Editor
Primary Care Dermatology Society Winter Bulletin 2015
www.pcds.org.uk
was particularly interested in the advice
from Dr Dirschka on the use of 1%
ivermectin cream for the treatment of
rosacea supporting the theory that
demodex, a parasitic worm, may be
responsible for triggering a type IV
reaction in rosacea. I have had 2 patients
consult asking for this treatment in recent
months – both patients were European
and had seen Dermatologists in their
home countries. Julian has reviewed a
recent article on rosacea in his Journal
Watch on treatments for this condition
Finally, a tip from one of the PCDS
members, Rob Climie, if anyone needs to
buy a Woods Light for detecting
erythrasma/fungal skin disease then just
pop down to your local pet shop. He
bought a pee detector torch from Pets at
Home for £12 which worked fantastically
on a patient with a brownish groin rash –
the rash lit up with a beautiful coral pink
with the pee detector torch confirming
erythrasma. I am always on the lookout
for a bargain!
Wishing you all a happy and peaceful
New Year.
and rather sad questions from
a listener who wanted to
know why GPs know nothing
about skin diseases and
offered no psychological
support for her.
I prepared a sympathetic
response explaining the
dearth of dermatology training
in undergraduate education
and the very limited
experience of most in the VTS
years. Of course, I offered
advice about seeking out skin
aware GP partners and
websites such as our own
and www.supportskin.org.uk.
We all listened for my wise
words to be broadcast but all
we heard was an RCGP
Officer claiming medical
students get good
dermatology education as do
VTS Registrars! Obviously she
was not aware of the BAD
study findings or our
experience and that of
patients and patient support
groups.
We will keep trying.
Christmas Greetings and a
Happy New Year
For further information, please
visit www.pcds.org.uk
PCDS Winter Bulletin 2015
Dermoscopy: Tape Strippingfor the Little Black MoleDr Stephen Hayes PCDS Executive Committee Member
Round or oval shaped naevi of 3-4mm are often
referred just because they are black. But small
black moles are a variant of normal, and as long as
there is nothing else wrong with them (e.g. history
of recent change, irregular shape and border,
significant dermoscopic atypia etc) the patient can
be reassured and advised – especially if a full skin
check reveals other similar naevi. The darker the
patient's skin, the darker their moles will be.
Figures 1 to 5 are a few examples, not all from the
same patient.
Dermoscopy can reassure by revealing a regular
reticular network with or without a black centre. A
central black blotch may be due to superficial
melanin in corneocytes and often the technique of
tape stripping may lift them off, revealing a more
reassuring underlying network. NB 'central' does
not mean perfectly central, the cases shown are
'good enough' central back blotches and contain
no worrying features. A peripheral/eccentric black
blotch in an otherwise irregular/growing mole
should be viewed with suspicion, but there will
usually be other features.
Tape stripping involves taking a piece of ordinary
adhesive tape, pressing it sticky-side down on the
lesion and ripping off sharply. Repeat 3 or 4 times,
often a black spot will be seen on the tape (figures
6 and 7 – showing the black keratinocytes removed
by tape stripping).
Little black moles, especially when multiple, are
almost always harmless. Reassure, but as ever,
advise patients to watch out for and report
significant changes.
P.S. when reassuring 'worried well ' patients
presenting with trivial moles, it is helpful to show
them some melanoma images on an ipad.
continued from page 3
4
Primary Care Dermatology Society Winter Bulletin 2015
www.pcds.org.uk
7
PCDS Winter Bulletin 2015
6
PCDS Winter Bulletin 2015
What is the platform I write this from?
I couldn’t say the word “acne” out loud until the age of 42, such was the toll it had
taken on me. I was 24 when a holistic approach at primary care level would have
picked up my true distress and I would not have slipped through the system. I believe
there needs to be a better connect between health professional and patient because
there is a silent turmoil with acne. Now completely liberated to share my experiences I
would like to adopt a no holds barred writing style to try to, in some way, reveal the true
extent of living with acne from the patient’s perspective. I hope this article may prove
insightful and thought provoking.
Describe acne
I would describe acne as being under non-stop attack where you receive new physical
wounds daily. I propose that spots are viewed as wounds because in any other context that’s
what they are. They come to a head, open up, bleed, weep and scab. If you’re lucky they
don’t scar but in many cases they do. Your skin is sore and never settles. The wounding
keeps coming at you, wave after wave. Most days I would have some blood on my clothes
from the acne on my back. Pillow slips and bed sheets were similarly stained on occasion.
From puberty my acne was constant. It did not diminish in any way as an adult, and in my
case it affected my face, lips, scalp, neck and back. My first course of Roaccutane was from
July 2012 until December 2012. The acne came back resulting in my most recent treatment
which was from August 2014 until April 2015. I fear the acne may return once more so while
The Importance of PsychosocialTreatment for Acne
there is a window I am currently visiting a London clinic to
address some scarring issues.
Why is acne so underestimated?
With acne you are in a state of distress all the time. This is
nothing to do with vanity, it’s because your skin hurts and you
feel physically and emotionally upset. It is relentless. The
feeling in the pit of your stomach doesn’t go. I believe that
over a certain period of time the non-stop physical wounding
becomes traumatising. You become overwhelmed. However,
the magnitude of acne’s whole life impact is underestimated
because the degree of upset renders people with acne mute.
It is incredibly rare for a teenager or adult with acne to be
able to express their angst proactively, and as a
consequence all emotional turmoil is bottled up. This is very
destructive on overall mental wellbeing. It also means friends,
parents, teachers, work colleagues, etc, are all likely to be
completely unaware of the devastation the acne is causing.
Give some examples of how acne materially affects teenagers
Let me take adolescent acne first to illustrate how its impact
is so profound.
Once you have actually got yourself ready for school your
concentration, performance, mood, participation and even
attendance at all throughout a school day is governed by
your skin. Indoor fluorescent lighting is invariably harsh and
highlights all imperfections. Natural light, coming in through a
classroom window or canteen can be even harsher. For a
young person with acne how the light is hitting you is all that
you focus on. The coping mechanism often is to become
withdrawn. Even though you may desperately want to
participate in class, you don’t, and your quality of learning is
hugely affected by your poor concentration.
During the day acne can affect your eating at school because
the act of opening your mouth will agitate the face and lips.
As there may be a risk of provoking spots by eating you
sometimes avoid it altogether. Of course this is not a healthy
situation for mind or body.
Moving on to physical education and sport, anything that
involves sweating and your face being under exertion will be
avoided. Also, for someone with acne on their back,
removing clothing and thereby exposing this hidden acne is
terrifying. Sport is often played under floodlights and the
Hyperpigmentation Moderate inflammatory acne
Michael Willcocks
same avoidance thought process that applies in all harsh light
environments is equally applicable in the sporting arena too. The
dreadful shame is that girls and boys may be very sporty but
their participation is halted by their acne.
Equally as traumatic a prospect is going on a school trip that
involves communal sleeping and bathroom arrangements. For
somebody with acne the thought of washing in public, with no
privacy to get ready in the morning, overrides everything else. It
is very distressing to not even put yourself forward to go on
these brilliant occasions even though you would love nothing
more.
One very important point is the mental toll of all this. You want to
do things, participate, join in and be normal. Not only is that
often not possible but additionally you have to invent excuses to
friends, parents and teachers to justify your behaviour and
actions. This frequently forces you to lie which is a very real
extra burden. It compounds your distress and illustrates further
why bottling up true feelings about acne is so destructive.
By no means have I covered everything in this section but I must
mention academic achievement. The lowering of concentration
is one of the biggest impacts of acne on pupils. If you take the
toll of acne in the classroom week on week, month on month,
and then the impact on revision and, ultimately, on an
examination, acne is an influence on academic achievement.
Given acne is the most mainstream physical condition affecting
students I believe this impact goes completely unrecognised.
What about quality of life issues specifically for an adult with acne?
In my opinion adult acne does not receive enough attention. I
say that because once your student days are behind you the
psychological and social impact of your skin condition is
accentuated. If you are being held hostage by acne, and by that
I mean being denied the opportunity to live life how you
otherwise would, the psychological damage very quickly
becomes acute. This is because, unlike during student days,
your friends’ lives inevitably move on to new stages and reach
new milestones, leaving you behind. With every year that
passes this contrast is more and more telling, and it heightens
the feelings of anxiety and depression you feel resulting from
your condition. Personally, I fell into a black hole. The two
fundamental social pillars of adult life, namely relationships and
employment, were wholly determined by my acne and this is
something I still have to recover from.
9
PCDS Winter Bulletin 2015
8
PCDS Winter Bulletin 2015
How can careers be affected by acne?
The daily routine of employment demands punctuality, high
levels of concentration, and the self-confidence to work in
close proximity with colleagues. All these demands are
compromised by acne. A very common thread when adults
with acne give feedback on their careers is “I could have been
so much more”. If your skin happens to be going through a
phase of some spots being open wounds rather than bumps, I
found exposing that to others devastating.
How did I cope in employment?
I didn’t. Despite a good degree from the University of
Manchester my coping mechanism was to withdraw into self
employment. It was a flawed coping mechanism to try to have
a degree of control over when open wounds were exposed to
others. From that moment on my CV showed no logical
progression or ambition, my education counted for little at all,
and I was lost. To be brutally frank about it, it was an entirely
negative, self-destructive, life defining reaction to year after year
of being incessantly upset by a skin condition. My example
underlines the vital importance of a holistic assessment of
adults, as well as teenagers, who are brave enough to present
to a GP or nurse with acne.
How does acne affect intimate relationships?
As an adult with acne I had one intimate relationship. It only
lasted a few months because of my condition. I always wore a
t-shirt because of the very extensive acne on my back. It meant
I didn’t have to reveal my back to her. There were many other
barriers the acne presented, both physical and psychological,
that got in the way of a healthy intimate relationship. For me,
my skin and intimacy were incompatible. Over the years it was
always a sadness to me that, if I liked a woman and I thought
she might like me, I knew I would never do anything about it.
What is my message for health professionals?
I acknowledge the limited time constraints of the GP or nurse
appointment. However, I believe it is vital to establish the
degree of emotion within the patient so that those in real
distress with their acne may be identified.
The key point is that, having come to the GP surgery, most
patients will still not be able to proactively express their angst. It
needs to be prompted out. My recommendation is two-fold
and applicable to both teenagers and adults.
Firstly, before any physical examination, I recommend the
patient is praised for coming in, along the lines of “I would
never underestimate the impact of acne on all aspects of your
life. I know how brave you have been to get this far.” I believe in
the majority of cases this would transform the GP or
nurse/patient dynamic.
Secondly, after examining the extent of the acne, I would
recommend the health professional asks two follow up
questions, “Have you ever been able to talk about your acne to
anybody before?” And, “Tell me how your acne affects you on
a day-to-day basis.”
A proactive pathway is key
Crucially, the patient should leave the first appointment
believing they are now on the path, however long it takes, to
being fully treated for their acne. This is especially relevant if
they are not being referred to a Consultant Dermatologist
immediately. This is because many will see this as a genuine
disappointment, and it can be interpreted that their acne is not
being taken seriously. However, they are very unlikely to voice
this disappointment at the time. I believe it is, therefore,
essential to emphasise to the patient that they will be called in
after a certain amount of time to review how their prescribed
treatment is going. I believe this proactive follow up by the GP
or nurse is key.
“They are just spots”
In December 2012, after my first course of Roaccutane, I
experienced clear skin for the first time as an adult. The
emotion of this release was intense. To be able to wash my
face and just go, and for that new reality to quite quickly feel
normal, it was a totally different life.
There was an added poignancy in that new normality. I realised
the near impossibility of doing justice with words in describing
to those around me, friends, family, potential future employers,
policy makers, commissioners, the gut-wrenching hold of acne
on your day-to-day life.
I hope I may have made a valuable contribution in trying to do
that in this article.
Primary Care Dermatology Society Winter Bulletin 2015
www.pcds.org.uk
!
!
% %) ) ) )
)
%% % % % % % % %%
%! ! ! ! ! ! ! ! ! ! ! ! !
! ! ! ! ! ! ! ! ! ! ! !! !
!! ! ! ! ! ! ! ! ! ! ! ! !! ! ! ! ! ! ! ! ! ! !
! ! ! ! ! ! ! ! ! ! ! ! !! !
!! ! ! ! ! ! ! ! ! ! ! ! ! !
! ! ! ! ! ! ! ! ! ! ! !! ! ! ! ! ! ! ! ! ! !
! ! ! ! ! ! ! ! ! ! !! ! !
!! ! ! ! ! ! ! ! ! ! ! ! ! !! ! ! ! ! ! ! ! ! ! ! ! ! !
! !!
! ! ! ! ! ! ! ! ! ! ! ! ! ! !! ! ! ! ! ! ! ! ! ! ! ! ! !
! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !! ! ! ! ! ! ! ! !
!)
!!!
% % % % % %%% % % % %
% % % % %% % %
%%
PRESS RELEASE
How do prescribers in primary care manage acne?
A team of Dermatologists at Harrogate and District Foundation Trust are conducting a research study to
discover how prescribers manage acne and to establish current prescribing practices.
Last year, the team conducted an Acne Priority Setting Partnership, collaborating with both the public and
professionals. This process identified several research questions and concerns relating to the management of
acne and the information provided to patients during consultations.
Led by Dr Alison Layton, Consultant Dermatologist, this study aims to understand how acne is currently being
treated by primary care prescribers, whilst further identifying how prescribers keep informed about acne
treatments. Having collated this information, the team will feedback evidenced-based information in order to
support and optimise prescribing for acne.
The success of the study depends on the participation of healthcare professionals, and we would like to invite
primary care prescribers, to complete the short questionnaire via Survey Monkey:
https://www.surveymonkey.com/s/Acne_treatment_survey
The survey is supported by the British Skin Foundation and the National Institute for Health Research, and
should take 10 minutes to compete. All information is strictly confidential and will be held on a secure NHS
database. At the end of the study, 20 participants will be randomly selected and will receive a £25 Amazon
voucher.
FOR FURTHER MEDIA INFORMATION, PLEASE CONTACT:
Dr Heather Whitehouse MBBS MRCP
Clinical Research Fellow in Dermatology
Harrogate District Hospital
07525026476
Thursday 27th August 2015
11
PCDS Winter Bulletin 2015
10
PCDS Winter Bulletin 2015
no punches were pulled, resulted in a
narrow win for the sun-worshippers.
The Saturday evening ceilidh, always a
highlight of the weekend, lived up to the
usual standard, with quirkily-named
band, ‘For occasions such as these’
providing traditional music with gusto.
Sunday’s programme commenced ,
following an outstanding breakfast, with
an equally good presentation about
Paediatric rashes, by Dr Elizabeth
Ogden. She displayed a very useful
chart listing the features of the common
childhood exanthemas, which is now
available on the PCDS website. I chose
Dr Christy Chou’s Minor Surgery Tips
from the workshop options, and found
it very useful. A number of informative
videos on Minor Surgery are available
on the PCDS website.
A round-up of gems from Dermatology
Meetings this year followed, promising a
succession of ever-more effective
biologic drugs for severe psoriasis;
confirming the safety and efficacy of
topical pimecrolimus in eczema over a
5 year period, and providing strong
evidence for a reduction in vulval
scarring, adhesions and squamous
carcinoma with standard super-potent
steroid regimes.
Finally, a highly challenging quiz, and
then we were off into the weather,
which had failed to improve over the
weekend, unlike our Dermatological
knowledge!
First was a brief introduction by Dr Iain Henderson, who had once again excelled in
organising this highly rewarding weekend. He introduced Dr Thomas Dirschka, of
Witten-Herdecke in Germany, who is renowned in the field of rosacea. Rosacea is
one of those conditions which is common, but often hard to manage to the patient’s
satisfaction, and he highlighted the effect on patients’ quality of life. The importance
of categorising the predominant type of the rosaceal lesions (erythema/telangiectasiae
vs. papulo-pustular) led into the effectiveness of different therapies for these
subtypes. He was not a fan of lymecycline for the inflammatory lesions of rosacea,
judging it ineffective in comparison with doxycycline. A key message was that 40mg
of doxycycline has sufficient anti-inflammatory activity to control rosacea effectively
with no anti-bacterial effects, and fewer adverse effects than the traditional higher
doses. This is also effective for ocular rosacea, which can present before the skin
signs. New topical treatments for rosacea, including topical vasoconstrictor
brimonidine gel, were highlighted, or rather lowlighted, as pictures showed the
dramatic blanching effect of this treatment on the erythema of rosacea. A test dose
was advised, as the amount needed to achieve a satisfactory appearance varies
widely between individuals. Dr Dirschka also showed data on the effectiveness of
topical 1% ivermectin, an anti-parasitic and anti-inflammatory, which acts on the
disturbing parasitic worm, Demodex, thought to trigger a Type IV reaction in rosacea.
He suggested an initial 12 week course of topical Ivermectin followed up by
intermittent use, boosted by combining it with Doxycycline where necessary. And it
emerged that rosacea is yet another skin disease which is exacerbated by smoking!
Next, Dr Colin Fleming gave a lively presentation on lesion recognition. A particularly
useful point for me was that deep solitary pits on the face are basal cell carcinomas
until proved otherwise, even in the absence of a rolled or pearly edge. There was a
spirited exchange on the subject of eyelid basal cell carcinomas, with the consensus
that they were difficult lesions where Ophthalmology input was essential. A pragmatic
approach to managing nodular basal cell carcinomas in debilitated elderly patients
(‘Nursing Home BCCs’) suggested a trial of topical imiquimod or topical 5-fluorouracil
cream, with the former being more effective but more irritant. Individual deposits of
metastatic melanoma can also, apparently, show a useful palliative response to
topical imiquimod. Dr Fleming also gave the unsettling advice that the scalp is a
common site for warty melanoma, which can be tricky to diagnose, unless you use
your dermatoscope to observe the characteristic grey veil.
Two psoriasis presentations took us up to lunch. The importance of diagnosing and
treating psoriatic arthropathy, present in 30% of psoriatic patients, was emphasised.
A suggested tool was the PEST (Psoriasis Epidemiology Screening Tool) score; with
a score over 3 suggesting a Rheumatology opinion be sought. In Scotland, the
shortage of Rheumatologists will make this a challenge. The other stand-out point for
me was that obesity has been shown to have a strong association with psoriasis,
both for the development of the disease and disease severity, and for the
development of psoriatic arthropathy.
After lunch, there were useful tips on dermatologic manifestations of systemic
disease (nodular prurigo is associated with HIV, diabetes and Hepatitis C, so screen
for these).
Then Dr Danny Kemmett, a veteran of many PCDS meetings, delivered a poignant
and fascinating reflection on his career in Dermatology. The challenging cases he
presented illustrated how much Dermatology has changed over the past 3 decades,
and also that the patients with difficult-to-manage disease that you’ve struggled with,
are the ones you’ll always remember.
This was followed by a pugnacious debate between Dr Colin Fleming and Dr Richard
Weller on the topic: “The sun is good for you”. A highly entertaining debate, in which
Fiona Collier GP & GPSI in NHS Forth Valley
PCDS Scottish Meeting –Old Course, St Andrews
16th – 18th November 2015
Stepping out of the rain and wind,
and into the elegant setting of the
Old Course Hotel, St Andrews, every
new arrival at the PCDS Scottish
Meeting had a similar look of relief
mixed with anticipation. The buzz
and bustle of the exhibition area,
and the eclectic lecture programme
promised an interesting weekend.
We were not disappointed. While
storms raged and golfers clung to
each other for support outdoors
(probably), we were entertained and
educated by a mixture of stalwarts
of many a PCDS bunfight, seasoned
with some feisty new faces.
Primary Care Dermatology Society Winter Bulletin 2015
www.pcds.org.uk
Old Course, St Andrews, Scotland
What is psychodermatology?
Psychodermatology refers simply to the overlap between conditions affecting the skin
and the mind. On the one hand there are those patients with primary psychiatric
disease and secondary skin manifestations. Examples include delusional infestation,
body dysmorphic disorder, dermatitis artefacta and skin picking disorder. On the
other hand there are the far more numerous patients with primary skin conditions of
any type and secondary psychosocial comorbidities, such as depression, anxiety or
substance use disorder to name but a few.
One of the key points here is to recognise that every single patient with a
dermatological problem exists somewhere on this spectrum, with pure skin disease
at one end, and pure psychiatric problems at the other (Figure 1). It is helpful to make
this point in consultations, to normalise the patient experience, and when attempting
to introduce the psychosocial agenda. While the typical patient with a solitary actinic
keratosis may not need a thorough discussion of their state of mind, we should be
wary of making such assumptions. Patients with visible skin complaints are frequently
highly distressed, yet do not readily divulge such concerns, hence the need to make
gentle enquiries of this type on a routine basis.
Why is psychodermatology important?
Psychodermatology is a relatively newly recognised sub-specialty. Sadly, services are
incredibly limited in the UK at present – both under-staffed and under-resourced –
despite an enormous unmet patient need. This has been demonstrated in several
national surveys,1 and highlighted recently by the All-Party Parliamentary Group on
Skin2 and the King’s Fund.3 Up to 85% of dermatological patients say that
psychosocial aspects of their skin disease are a major component of their illness.4
Suicidal ideation and suicide risk is higher than average in patients with a range of
skin diseases.5 The British Association of Dermatologists (BAD) has published a
useful report outlining the minimum standards recommended for provision of
psychodermatology services in the UK.4 A dedicated service should exist on a
regional basis at least, given the patient demand, yet even this basic tenet is not
being met in most areas. As such, until greater recognition is achieved for this
complex and deserving group of patients, it remains the responsibility of all of us to
act appropriately on their behalf. Although challenging at times, this is a fascinating
and rewarding branch of medicine, with the potential to make an enormous
difference to patients, their families and our colleagues.
How should one approach the psychodermatological patient?
The general approach to the patient with a psycho-dermatological problem should
be the same as for any other condition. A thorough evaluation of the problems
presented should be conducted, alongside an assessment of the patient’s ideas,
concerns and expectations. However, while the average patient with a
straightforward dermatological condition may be in your consulting room for 5-10
minutes, you will never bring things to a satisfactory conclusion so quickly with a
psychodermatological issue. Perhaps the single most important point in helping
such patients is to set aside sufficient time, both at the outset, and thereafter.
Much time on the first appointment is likely to be spent simply listening and
empathising, defusing anger and hostility, building rapport, and demonstrating an
open mind to diagnostic possibilities. This is on account of the understandable
tendency among such patients to have consulted many doctors previously, in a
desperate attempt to find someone who accords with their views, or who can give a
satisfactory explanation for their symptoms. Unfortunately, previous experiences of
this type are usually characterised by disappointment and frustration on the part of
Primary Care Dermatology Society Winter Bulletin 2015www.pcds.org.uk
13
PCDS Winter Bulletin 2015
12
PCDS Winter Bulletin 2015
This article is based on a lecture
delivered at the 2015 PCDS Spring
meeting entitled ‘Where
Dermatology meets...Psychiatry’.
This hinterland is occupied by a
vast tribe of complex patients often
failed by the silo-based approach to
modern medicine. Rather than talk
in didactic terms about individual
conditions, I hope to demonstrate
the generic approach to the
psychodermatological patient which
should yield dividends in clinic. The
central message is that GPs in
general, and those with a special
interest in dermatology in particular,
are optimally placed to care for
patients with psychodermatological
problems.
Psychodermatology: What,Why How?
Dr Jon Goulding, BSc, BM BCh,MMedEd, FHEA, FRCP,Consultant Dermatologist, Heart of England NHS Foundation Trust
the patients (and most probably the
doctors).
History
Although it helps to stick broadly to the
conventional consultation structure, a
more fluid approach can yield
unexpected dividends. By following
patients’ emotional cues as they arise,
one can arrive at the nub of the issue or
hidden agenda surprisingly quickly.
Whatever route is taken in expounding
the patient’s concerns, it is vital that a
holistic biopsychosocial assessment is
conducted (Figure 2). This translates into
three broad sets of questions along the
lines of: “Tell me about your skin”, “How
have you been feeling?” and “What’s
going on at home/work?” A detailed
dermatological history is fundamental,
since one of the guiding principles of
Figure 1 Figure 2
Figure 3 Figure 4
15
PCDS Winter Bulletin 2015
Primary Care Dermatology Society Winter Bulletin 2015
www.pcds.org.uk
psychodermatology is not to miss a diagnosis of organic skin disease. However, it is
all too easy in a busy clinic to neglect the psychosocial context, despite this usually
constituting the most fruitful and illuminating line of questioning.
It helps to ask what was happening when it all started, since there is often a traumatic
physical or psychological trigger event which helps to explain subsequent
developments. Additional specific questions are recommended regarding personal
and family psychiatric history, substance abuse, and the possibility of domestic abuse
or neglect. Obtaining a corroborative history is often invaluable, but it is useful to
spend some time with the patient alone, if they happen to attend with friends, family
or carers. I tend to write patient quotes verbatim and reflect these back to the patient.
This helps to build rapport, paints a vivid clinical picture, and can act as useful
currency in future negotiations with the patient.
Examination
A full dermatological examination is mandatory, especially if a primary psychiatric
condition is suspected after taking a history. Firstly, it presents another opportunity to
diagnose occult dermatological disease, and secondly, by following the expected
medical process, it adds weight to your future assertion that it is not the skin per se
that is the cause of the patient’s symptoms. The physical examination should include
an assessment of the entire skin surface, including ‘review areas’ such as the nails,
scalp, buccal mucosa, and genitals if appropriate, to maximise diagnostic yield. I
always examine specifically for scabietic burrows, and lymph nodes in all major
groups.
A mental state examination is also crucial (Figure 3). This is largely performed through
preceding conversation, but additional direct questions may be needed regarding the
possible experience of illusions or hallucinations, or if an assessment of cognition is
deemed necessary.
Investigations
There is no firm rule regarding investigations for the patient with
psychodermatological disease. It is often the case that none are required. Blood
tests, skin swabs and scrapings, and skin biopsies are often performed however,
again to confront the dual issues of avoiding misdiagnosis, and meeting patient
expectations.
A common scenario is the presentation of specimens gathered by the patient (Figure
4). This almost always confirms a diagnosis of delusional infestation, and it is of the
utmost importance to consider them seriously, inspect them thoroughly (perhaps
using a dermatoscope), and send off for laboratory analysis. I encourage such
patients to provide more samples if so desired, passing on universal containers and
microbiology request forms; it demonstrates that their conviction regarding infestation
is being taken seriously, and again provides currency as negative results return.
Every patient who is referred to my psychodermatology clinic fills in a series of
screening questionnaires: the Dermatology Life Quality Index (DLQI),6 the Generalised
Anxiety Disorder scale (GAD-7)7 and the Patient Health Questionnaire depression
scale (PHQ-9).8 These are usually
administered after the patient has been
examined. Any potential awkwardness is
dispelled by explaining that they are
given to every patient, and that they may
not be relevant in their case. If a
compelling psychosocial agenda has not
been broached thus far, I find these
indices invaluable to start or continue
such discussion, since one can highlight
the inevitably high scores returned by the
patient. Additional scales are sometimes
used, such as the Derriford Appearance
Scale (DAS-24)9 in suspected body
dysmorphic disorder. These are useful
not only in diagnosing psychiatric (co-)
morbidity, but also in assessing response
to treatment.
Management
When the patient has been thoroughly
assessed as outlined above, the time
comes to summarise one’s thoughts and
suggest further management. On
account of the complex and time-
consuming nature of psycho-
dermatological problems, it may not be
possible to cover everything in one
session. There is certainly no rush to
arrive at a final diagnosis and institute
definitive treatment. The approach to
management therefore needs to be fluid,
according to the rapport established with
individual patients, and their level of
insight.
In broad terms, the aim with such
patients is to move gradually along the
spectrum shown in Figure 1, from a
position where patients feel sure they
only have a skin problem, to a state
where they accept that there is a
psychological dimension. This process
takes time, so take your time. Along the
way, it is crucial to treat the skin and
mind equally, since focusing on either
alone will rarely lead to success. It certainly makes sense to optimise treatment for the
skin, since this may yield prompt benefits, increasing patients’ trust and confidence.
Management often requires a degree of negotiation, even salesmanship, to convince
the patient that your suggestions are grounded in accepted practice and personal
experience of success. Much time needs to be spent on basic psychoeducation,
reassuring patients that they are not alone, that you’ve seen many people in a similar
situation before, and that their condition is distressing but treatable. As a general rule,
avoid confronting patients, such as those with dermatitis artefacta, when you know
they are inducing skin lesions themselves. This will lead to a rapid breakdown in the
therapeutic relationship and gains nothing, however tempting it may be. Similarly,
don’t collude with patients, such as those with delusional infestation; a line has to be
drawn where you stand your ground regarding aetiology, gently but firmly.
In cases where there is great resistance to the psychological agenda, reflecting limited
or absent patient insight, it helps to focus on the visible distress and negative impact
on patient well-being and daily functioning. Seeking mutually acceptable ways to try
and improve this side of things may be more palatable than overt discussions about
psychopathology. Finally, ensure a risk assessment is conducted and documented,
both from the point of view of self-harm and suicide, but also if the patient has
contact with children, or if abuse or neglect is suspected. There should be a low
threshold for referral to psychiatric services or the local safeguarding team as
indicated.
Conclusions
I hope to have demonstrated the importance and worthiness of taking an active
interest in psychodermatology. Believe it or not, it can be immensely satisfying, and
patients seem to genuinely value the approach taken in our clinic. The bottom line is
that this should apply to all dermatology patients, to a greater or lesser extent. For
those with greatest need, adequate time has to be set aside, either in a dedicated
clinic, or with longer appointments in close proximity.
Do seek out and engage with your local Psychodermatologist, if you can find them!
Sitting in a clinic offers the ideal way to observe the specialty at first hand. At the very
least, please pick up the ‘phone to discuss potential or current patients, as the more
information one has the better. If further reading is sought, I would suggest Practical
Psychodermatology (Bewley et al, 2014) as an excellent and very readable primer.
There is also the opportunity to attend the annual meeting of Psychodermatology UK,
as well as the newly formed Psychodermatology section at the BAD annual meeting.
14
PCDS Winter Bulletin 2015
References
1. Lowry CL, Shah R, Fleming C, Taylor R,Bewley A. A study of service provision inpsychocutaneous medicine. Clin ExpDermatol 2014; 39(1):13-8.
2. All Party Parliamentary Group on Skin. Thepsychological and social impact of skindiseases on people’s lives. London, 2013.Available at:http://www.appgs.co.uk/publication/the-psychological-and-social-impact-of-skin-diseases-on-peoples-lives-final-report-2013/(last accessed 27 March 2015).
3. The King’s Fund. How can dermatologyservices meet current and future patientneeds, while ensuring quality of care is notcompromised and access is equitable acrossthe UK? Available at:http://www.bad.org.uk/shared/get-file.ashx?id=2348&itemtype=document (lastaccessed 1 May 2015).
4. Working Party Report on MinimumStandards for Psycho-Dermatology Services2012. Available at:http://www.bad.org.uk/shared/get-file.ashx?itemtype=document&id=1622 (lastaccessed 27 March 2015).
5. Millard LG, Millard J. Suicide indermatological patients. In: Rook’s Textbookof Dermatology (Burns, Breathnach, Cox,Griffiths, eds), 8th edn. Chichester: Wiley-Blackwell, 2010; 64.48-9.
6. Finlay AY, Khan GK. Dermatology LifeQuality Index (DLQI) - a simple practicalmeasure for routine clinical use. Clin ExpDermatol 1994; 19:210–16.
7. Spitzer RL, Kroenke K, Williams JW, LöweB. A brief measure for assessing generalizedanxiety disorder: the GAD-7. Arch Intern Med2006; 166:1092-7.
8. Kroenke K, Spitzer RL, Williams JBW. ThePHQ-9: validity of a brief depression severitymeasure. J Gen Intern Med 2001; 16:606-13.
9. Carr T, Moss T, Harris D. The DAS-24: ashort form of the Derriford Appearance ScaleDAS59 to measure individual responses toliving with problems of appearance. Br JHealth Psychol 2005; 10:285-98.
We start with a paper that, once again
highlights the need for evidence upon
which we can base our clinical
decisions. I like to think that this article
represents the cutting edge of
dermatology, perhaps even the sharp
end of research, so it is fitting that we
now turn our gaze to acupuncture.
Although the benefits of acupuncture as
an antipruritic have anecdotal evidence,
it has taken a systematic review1 to
demonstrate the paucity of ‘proper’
evidence available. In fact, despite
several studies having been performed
over the years, none were considered
eligible to be included in a formal review.
There were also mentions of controlled
trials where ‘sham acupuncture’ was
used as a control. Curiouser and
curiouser. There is currently no available
evidence for the use of acupuncture in
atopic dermatitis, and consequently no
evidence based recommendations or
conclusions can be drawn. Some
studies suggest a role for acupuncture
in regulating itch, but these need to be
confirmed by randomised control trials.
I have always been taught (and teach)
that the hair loss in psoriasis is
temporary, and unusual. However, we
here have a rather splendid article2 all
about psoriatic alopecia. Not only can
psoriasis cause alopecia in lesional skin,
it can also trigger a more generalised
telogen effluvium. In some cases, it can
even scar – leading to permanent hair
loss. There is also a greater risk of
developing alopecia areata in those
suffering from psoriasis.
Staying with psoriasis, we continue our
perusal of the co-morbidities associated
with the disease. We are becoming
increasingly familiar with the concept of
the plaques of psoriasis merely being
the cutaneous manifestation of a
systemic, immune mediated disease. As
we look ever closer, more and more
associations are being made – and
now3 we can add Non-Alcoholic Fatty
Liver disease (NAFLD) to the list. This
study closely links the presence of
NAFLD with the metabolic syndrome
and its severity with cigarette smoking.
Incidentally, I believe this to be the first
paper I have reviewed that has come
from Iran. Welcome!
Whilst on the same theme, we can take
a look at cardiovascular risk factors,
also associated with psoriasis. During
the inflammatory response, Osteopontin
(OPN) is expressed by natural killer cells,
activated T cells and macrophages. It
has been suggested that OPN is
actually over expressed in the plasma of
patients with psoriasis, and appears to
be linked to an increased risk of
cardiovascular disease in these
patients. This study4 looks at levels of
OPL, selenium and prolactin in a group
of patients with psoriasis and matched
‘healthy’ controls. Whilst high plasma
levels of OPL are a predictor for the
presence of psoriasis, there is no
discernible difference in the levels of
prolactin or selenium. As OPL has been
reported to be a potential clinical marker
for the prediction of arteriosclerosis, this
adds to the list of biological markers
that have promise in monitoring disease
activity in this most fickle of diseases.
A brief diversion takes us to another
troublesome disease – acne. Whilst
isotretinoin is a proven efficacious
therapeutic option for the more severe
end of the spectrum, the BAD
guidelines suggest that it should not be
used in patients with peanut allergy.
Some brands of isotretinoin used to
contain peanut oil and could,
theoretically, provoke an anaphylactic
response in susceptible individuals. In a
wonderfully named ‘therapeutic
vignette’, a team from London have
looked at this5, and concluded, after
testing this in six, peanut allergic acne
patients, that the risk is small. This is
17
PCDS Winter Bulletin 2015
In the midst of domestic chaos – we had to have some windows replaced, a
new boiler, redecoration and replacement carpets – between doing the day job,
making cups of tea and endlessly sweeping up, a few snatched moments has
allowed me to prepare this edition’s missive. Onward!
16
PCDS Winter Bulletin 2015
Journal WatchAugust – October 2015
Julian PeaceGPSI Sheffield & PCDS Treasurer
mainly because both commercially
available isotretinoin preparations have
been peanut free since 2009, but it has
been replaced by soya oil which can
cross react! Confusing, isn’t it? It seems
that the guidance is ripe for revision, in
the interim, it seems prudent to
recommend the administration of the
first dose on isotretinoin, in an allergic
individual in a setting where anaphylaxis
could be adequately dealt with.
We have mentioned before the advent
of a new treatment for chronic
spontaneous urticaria – the recombinant
humanised monoclonal antibody
Omalizumab. Several guidelines have
incorporated omalizumab into existing
guidelines as an ad-in therapy as a third
line agent. I had not, previously, been
aware of the GRADE (Grading of
Recommendations, Assessment,
Development and Evaluation) approach
to assessing data (see, I learn too!), but
a team6 has used this approach to
assess the currently available evidence
for both effectiveness and safety of
omalizumab. The evidence, you will be
pleased to hear, is high quality for both
efficacy and safety over a six month
period. Whilst a secondary, or even
tertiary centre drug at the moment, we
should still be aware of such
developments in fields that so closely
affect our primary care patients.
Back to disease associations, this time
looking at hidradenitis suppurativa (HS).
In recent years, we are being
encouraged to look considerably
deeper than skin deep with many
diseases and HS is no exception. From
Israel, and using an extremely worthy
cohort of 3207 patients comes a study7
looking at potential associations. It is
probably no surprise to discover that
HS is associated with a number of co-
morbidities, most closely with diabetes,
hyperlipidaemia, obesity, hypertension
and the metabolic syndrome. Targetted
screening seems appropriate.
The scientific method sometimes
throws up papers that have to address
what, on the surface, appear to be
chance associations. It is, however,
such chance associations that have
been behind many of the greatest
advances in science, both medical and
conventional. It has been suggested
that statins, because they have been
shown to down regulate immune
mechanisms activated in psoriasis,
could be linked to a reduced risk of
developing psoriasis. Sadly, this
appears not to be so. A large (205,820
enrolees) cohort study8 demonstrates
that despite high adherence to statins in
a subgroup of the cohort, this was not
associated with a meaningful reduction
in the risk of developing psoriasis. The
road to progress is paved with the
scattered detritus of a thousand
negative studies.
Keloid scarring can be both
psychologically damaging for the
sufferer, but also remarkably frustrating
for the treating Doctor. Whilst steroids
are the first line treatment for keloid
disease, their use is limited by a high
incidence of resistance, recurrence and
side effects. By taking a cohort of
patients, injecting their scars with
intralesional triamcinolone, and then
looking at the physiological changes in
both responders and non-responders, a
team in Manchester10 has
demonstrated that a natural variation in
glucocorticoid receptor expression may
determine the response to treatment.
This receptor is present at higher levels
Primary Care Dermatology Society Winter Bulletin 2015
www.pcds.org.uk
at baseline in those who respond to
steroids, and also at higher levels in
keloid tissue in responders compared to
non-responders. That this can be
determined by a non-invasive test – full-
field laser perfusion imaging – makes it a
potentially useful finding in managing
this rather troubling condition.
Rosacea appears to be the disease du
jour at the moment. In the last year two
new products have hit the UK market
and several studies have appeared both
before their release and in their wake. A
systematic review11 (including GRADE
assessment!) attempts to pull this
information overload together for mere
mortals such as we. Moderate evidence
of efficacy is available for topical
metronidazole, whilst the evidence for
the efficacy of topical ivermectin,
brimonidine (in erythema alone) or
azelaic acid was considered high quality.
In oral treatments, the evidence is a little
more sparse – many treatments have
become customary because of
observed efficacy in practice, rather
than in studies. Only a couple of old
studies exist for tetracycline, and none
are reported for Lymecycline (my current
drug of choice). Low dose doxycycline
has high quality evidence of efficacy, as
does low dose isotretinoin – which
comes out slightly better than higher
doses of doxycycline. The evidence for
laser and light based therapies is, sadly,
low quality. Watch this space, where
one novel drug appears, several others
often follow...
When patients are discharged from an
outpatient clinic, the decision to
discharge can, sometimes, seem
somewhat arbitrary. Whilst resolution or
cure is an obvious end point in the out-
patient attendance, a huge number of
other influences are placed upon the
clinician in order to guide their decision
making process. From Cardiff, comes a
detailed analysis of these influences12 –
it makes fascinating reading. Five main
themes of influence were identified –
disease-based influences, clinician-
based influences, patient-based
influences, practice-based (both
primary and secondary care) influences
and policy-based influences. Several
inappropriate influences were identified,
none of which were clinically based.
This is a complex area, and to see it
broken down like this is a salutary
experience.
In a similar vein, when we advise
patients to undertake a particular
course of action, the factors that
influence the compliance with that
advice are many and varied. In some
cases, this can be particularly
deleterious to the condition that the
patient suffers from. Cutaneous Lupus
Erythematosus (CLE) is a photo-
aggravated dermatosis and yet despite
advice to undertake sun protection
measures, including sunscreen use, the
uptake in Ireland13 was a very poor
23%. That being married was a positive
factor in sunscreen use comes as little
surprise – when someone is there to
remind the index patient, compliance
increases. One possible explanation
offered is that the flares of CLE
triggered by ultraviolet radiation can be
delayed by several weeks – if an
immediate association is not made by
the patient, compliance suffers.
Like the internet, the BJD is becoming
increasing full of CATs, but in the case
of dermatology journals, that stands for
Critically Appraised Topics.
Diphenylcyclopropanone (DPCP) has
18
PCDS Winter Bulletin 2015
been used since 1983 as topical immunotherapy to treat alopecia areata (AA)
however, because of environmental problems – such as sensitisation of the
care-givers applying the agent – can its use still be justified in the light of current
knowledge14? It is, of course, the fact that DPCP is such a potent contact
allergen that makes it such a useful agent. The CAT shows that despite low
quality of evidence for effectiveness and safety, in about half of patients with
AA, hair growth is achieved. As any growth is seen to be a positive outcome,
patients seem prepared to take significant risks to achieve this end point. Few
studies exist within the last ten years and, as the importance of well designed,
adequately powered and well-conducted studies gains ever more importance,
future trials are needed to find the place of DPCP in modern practice.
It seems a while since we talked about eczema – in recent years huge
advances have been made in the treatment of psoriasis whilst eczema seems
to have languished somewhat, a forgotten tea cup in the cupboard of
dermatology. Whilst we have nothing new to discuss about treating this
condition, at least someone is still looking at and sorting out the epidemiology15
that could help direct therapy in future. Whilst we know that both atopic and
non-atopic eczema are common in adolescence, there is limited information
regarding the clinical manifestations of these two, disparate aetiologies within
this transition period. Around 10% of adolescents have eczema, with a female
predominance, the majority had started their disease in early life, but around a
quarter experienced it for the first time in adolescence – 59% were considered
to be atopic, the remainder, naturally, non-atopic. One in four had moderate to
severe disease – a not inconsiderable disease burden to be dealt with. Atopic
eczema tends to have an earlier onset, and a more severe course. Now, new
treatment options, please...
We have mentioned Janus Kinase (JAK) inhibitors before, as an oral agent they
are showing significant promise as a systemic agent for the treatment of
psoriasis. There has always been the possibility, that as a relatively small
molecule, a topical formulation of this novel group of drugs may become
available. Well, lookee here16, what do we have? A report of successful initial
trials of the catchily named JAK1/JAK2 inhibitor, INCB018424. As many of the
cytokines implicated in the pathogenesis of psoriasis signal via the JAK
pathway, this seems to make pharmacological and physiological sense. A twice
daily application is well tolerated with little systemic absorption or side effect.
Although only a short (28 days) study, this is something to watch closely.
Finally, a little bit of dermoscopy. Acral lesions are extremely difficult, and, as we
learn more and more about their dermoscopic appearance, the received
wisdom regarding parallel ridge pattern becomes less clear. Indeed,
approximately one third of acral melanomas (AM) do not show this ‘defining’
pattern. A new algorithm is called for. Using six variables, and with an author list
that sounds like the Who’s Who of modern International dermoscopy, the
‘BRAAFF’ checklist is proposed as a system with the highest diagnostic
accuracy for AM. It is scored, thus:-
B – Irregular blotch +1
R – Parallel Ridge Pattern +3
A – Asymmetry of structures +1
A – Asymmetry of colours +1
F - Parallel furrow pattern -1
F – Fibrillar pattern -1
A score of greater than, or equal to 1 is necessary for a diagnosis of melanoma
using this checklist. It seems to have significant merit.
Another year comes to a close, as we enter a bright, shiny new year of
dermatology, I thank you for your company – and thank you for reading to the
end!
References
1. Tan et al – Efficacy of acupuncture in the management of atopic dermatitis: a systematic review.CED2015:40;711-716.
2. George et al – Psoriatic alopecia. CED2015:40;717-721.
3. Abedini et al – Patients with psoriasis are at a higher risk of developing non-alcoholic fatty liver disease.CED2015:40;722-727.
4. Toossi et al – Assessment of serum levels of osteopontin, selenium and prolactin in patients withpsoriasis compared with healthy controls, and their association with psoriasis severity. CED2015:40;741-746.
5. Spierings et al – Should we be prescribing isotretinoin to patients with peanut allergies?CED2015:40;824-825.
6. Urgert et al – Omalizumab in patients with chronic spontaneous urticaria: a systematic review andGRADE assessment. BJD2015:173;404-415.
7. Shalom et al – Hidradenitis suppurativa and metabolic syndrome: a comparative cross-sectional studyof 3207 patients. BJD2015:173;464-470.
8. Chodick et al – Adherence to statins and the risk of psoriasis: a population-based cohort study.BJD2015:173;480-487.
9. Lee et al – Risk of skin ulcerations associated with oral nicorandil therapy: a population-based study.BJD2015:173;498-509.
10. Rutkowski et al – An abnormality in glucocorticoids receptor expression differentiates steroidresponders from nonresponders in keloid disease. BJD2015:173;690-700.
11. Van Zuuren & Fedorowicz – Interventions for rosacea: abridged updated Cochrane systematic reviewincluding GRADE assessments. BJD2015:173;654-662.
12. Harun et al – Appropriate and inappropriate influences on outpatient discharge decision making indermatology: a prospective qualitative study. BJD2015:173;720-730.
13. Gutmark et al – Sunscreen use in patients with cutaneous lupus erythematosus. BJD2015:173;831-834.
14. Kuin et al - Diphenylcyclopropenone in patients with alopecia areata. A critically appraised topic.BJD2015:173;896-909.
15. Johansson et al – Atopic and nonatopic eczema in adolescence: is there a difference?BJD2015:173;962-968.
16. Punwani et al – Downmodulation of key inflammatory cell markers with a topical Janus kinase 1/2inhibitor. BJD2015:173;989-997.
17. Lallas et al – The BRAFF checklist: a new dermoscopic algorithm for diagnosing acral melanoma.BJD2015:173;1041-1049.