The recent summer meeting in Warwickshire was an educational and social success

and enjoyed by delegates and sponsors alike. The numbers however were less

healthy and your committee have therefore decided to concentrate such meetings in

major centres and to move the timing of this summer two day meeting to the spring

when the pressure of holidays interferes much less. In addition we note the

popularity of international speakers especially on dermoscopy which provided us

with our biggest audience so far earlier this year.

We have scheduled the main 2 day meeting next year for March 16th/17th in central

Manchester when we are pleased to confirm the return of Professors Argenziano

and Iris Zalaudek to continue their dermoscopy course and in addition there will be

parallel sessions of more general dermatological interest for those less interested in

dermoscopy. Delegates will be able to dip in and out as they wish. Please watch the

website and email/postal invitations for more details in the Autumn.

Please also consider passing on such notifications to your partners and colleagues

who may be interested and/or in need of dermatological stimulation (whoops, that

sounds like I am suggesting some form of massage therapy!) Advertising in the

medical media is extremely expensive and we would rather spend our resources on

educational events than on publishers profits so we rely on you, our members to

help to promulgate the society, its ideals and advantages especially delivering quality

education at reasonable cost.

Primary Care Dermatology Society Autumn 2012

Bulletinpcds.org.uk

Chairman’s Report

The PCDS Trustee Committee

Mr Peter Lapsley Dr Tom PoynerDr Stephen Hayes Dr Jane RakowskiGladys EdwardsSandra Webb Dr Andy Jordan

Your requests and advice as to topics, good speakers and venues etc., is always

valuable and we are particularly keen to hear from those who do not regularly attend

meetings since we may not be providing what you want or need. Please let us know.

Something new is a joint Essential Dermatology meeting with the RCGP in the

Oxford region on 29th November which we hope represents a collaboration for future

development and we would be interested in talking to other regions of the RCGP.

Although I am not by inclination a reader of horror stories I always read the

“Cautionary Tales” in my recent MDU magazine. I was struck by a skin case that

went wrong but because the GP operator of a possible BCC on a woman’s back had

adhered to NICE and local guidelines the case was successfully defended. The

circumstances involved warfarin, valvular heart disease and subsequent bleeding and

infection eventually causing endocarditis. We may call them “guidelines” but failure

to follow them could result in expensive and distressing consequences even if

adherence does not guarantee perfection. My only question required the date of

surgery and the accreditation of the GP since a possible BCC should be referred to a

community skin cancer surgeon or secondary care according to the NICE IOG for skin

cancer. I wonder if the GP had a dermatoscope and the ability to use it? If not I could

recommend training provided by a well - known primary care organisation!

I have been informed that Leo Pharma are currently launching their Give your skin a

feel campaign which may involve some of you in promoting the awareness of skin

lesions as well as sun protection but many more are likely to receive patients with

lesions for diagnosis who have responded to this campaign. We would be interested

to hear of any consequences of such media emphasis.

I am delighted to inform you all of the MBE presented to Dr Julia Schofield for

services to dermatology. A more worthy recipient I could not imagine. She has long

supported the PCDS, provided clear and stimulating lectures and involved us in many

standard and accreditation stakeholder committees in which she has had a major

role. We congratulate her.

Stephen Kownacki

Executive Chair

Editorial Spring 2012

I hope that everyone has had a fantastic Summer. Having

just returned from a lovely 2 weeks in the South of France

I’m finding the weather outside is a little depressing. At

least I can now go for a run without fear of sunburn or

dehydration. It has been a really exciting Summer, starting

with our Summer meeting in Kenilworth. We had some

excellent speakers and it was particularly great to welcome

Dr Ralf Hartmann and his family, from Berlin, who gave a

fascinating talk about his experiences in Afghanistan. Then

came the spectacle that was the Olympics. There obviously

was a great atmosphere at the Olympic Park greatly enhanced

by Great Britain doing so well in the medals table. Many of us

are now feeling bereft and wondering what we will do as the

evenings draw in. Never fear, this edition of the Bulletin is well

worth a read!

Please find time to have a peek at Bob Sarkany’s article on

photodermatoses. It doesn’t disappoint in making a very

difficult subject seem very easy. Julian has been squirreling

away in piles of journals and done an excellent summary of the

salient points to save you time reading them yourselves. Iain

has given us some snippets from his travels in Rwanda and

4

promises more interesting cases in future editions. Sorry, in

advance for the jokes that come with the articles… There are

also more sewing tips from Christy and a short tutorial on

dermoscopy.

For future editions, Frances Humphreys has promised me an

article on urticaria made easy, everyone’s heart sink subject.

Many of you will have seen Ivan Bristow give some excellent

and humorous talks on podiatry. I have an article up my sleeve

by him for the next edition, which won’t disappoint.

If anyone has any ideas of interesting articles or case histories I

would be really happy to receive them via pcds@pcds.org.uk

Finally an apology to Dr Jon Goulding and any observant

readers who may have noted that there was a photo of

calciphylaxis mimicking vasculitis and not of bullous change

with incipient skin necrosis, as stated,in his last article on

cutaneous vasculitis.Helen Frow

Dr Ralf Hartmann and his daughter join committee and society members for pre - dinner drinks at the Summer Meting in Kenilworth

5

Dermoscopy Tutorial

This traumatised seborrhoeic wart has keratin as well as looped vessels in halosand blood

This patient complained of a mole on her upper back that had recently itched and bled.

This traumatised seborrhoeic keratosis also shows the frogspawn appearance ofmultiple looped (short hairpin) vessels in halos plus blood.

Dermoscopy reveals looped vessels in halos (‘frogspawn’) throughout the lesion plus micro bleeds. There are some tiny charcoal

flecks in from 11 o’clock representing thrombosed capillaries. Features of melanoma or BCC were absent. A typical traumatised

seborrhoeic wart.

Learning points

Traumatised seborrhoeic keratoses often cause concern with a recent history of change, itch and bleeding. Many such lesions

are referred urgently as suspected melanomas. Dermoscopy will often reveal positive features of seborrhoeic warts and absent

features of a melanoma. Lesions often drop off between the first and second consultations. Charcoal flecks representing

thrombosed capillaries are often seen in the later stages. Photography and review in 2 weeks is a safe alternative to urgent

referral, but only if the doctor has been trained and is consciously competent. Stephen Hayes

6

My previous articles have set out to address what I

consider to be some essential aspects of skin surgery.

The final stage of your procedure and, just as crucial is

how you are going to close the wound once you have

performed your biopsy or surgical excision. It is this skill

which significantly affects the cosmetic outcome and the

suturing process should not be underestimated. It is

important not to relax mentally at this stage but take enough

care to ensure the wound is closed correctly. Bear in mind

that the scar may be the only detail of the operation which

concerns your patient.

The reason for suturing any wound is to bring opposing skin

edges together to allow the healing process to take place.

Your decision about suture technique, suture placement

and type of suture depends on the anatomical site, depth of

skin and degree of tension. A badly designed excision

which creates difficulty bringing skin edges together or,

over tightening the sutures will cause strangulation at the

wound edges. Excessive wound tension and strain

following suturing also increases the risk of wound

dehiscence and will inevitably lead to a poor cosmetic

result.

Photo 1 Photo2

Sewing with ChristyChristy’s tips and advice for safe andefficient operating

7

In this first of two articles I will look at the instruments and

materials required for suturing as well as some basic principles

and techniques. Suturing methods and indications for use will

be covered in the next issue of the journal.

When thinking about instruments the suture holder has a very

important function in your instrument pack and ideally should

be of good quality. The suture holder not only allows you to

hold onto the needle itself but it is also used to grasp the

suture filament when tying knots. Suture filaments can be

extremely fine, the 6-0 Ethilon used on the face, is the same

diameter as human hair. Some disposable instruments are not

delicate enough to hold this fine thread resulting in the filament

slipping through the jaws of the holder. As I have said in

previous articles try to invest in the best instruments within

your budget as they will help to make skin surgery a lot less

frustrating.

Suture holders have a ratchet mechanism for grasping the

needle, only close the holder to the first click of the ratchet as

excessive pressure can damage both the needle and the

needle holder. The correct way to hold the suture holder is to

put your thumb and forth finger through the holes in the

handle, use the middle and little fingers to stabilise the base

and extend the index finger along the suture holder towards

the tip to guide the needle accurately (photo 1). Alternatively

the needle holder can be held in the palm (photo 2) this is a

useful technique to use when the needle is entering and

exiting the skin. The palming technique allows 360 degree

control of needle movement making it much easier to enter

the needle into the skin at 90 degrees. Holding the suture

holder in the conventional way can force your wrist, elbow and

shoulder into very awkward positions. Suture needles are

usually curved and a quick rotational movement of the wrist is

needed to direct the needle where you need it to go.

In skin surgery, two main types of needle are used; cutting or

reverse cutting. The reverse cutting needle is less likely to tear

the skin edges due to its design as it presents a flat triangular

section to the skin rather than a sharp tip. It is worth

mentioning the prime reverse cutting needles which are less

traumatic to the skin as they have a smaller cross sectional

body, but they are of course more expensive. Loading the

suture needle correctly is essential. The needle is made up of

three sections; the sharp tip which penetrates the tissue, the

mid section or body and, the swage which is the thick end

where the suture material is attached. The needle should be

grasped close to the tip of the suture holder jaw, right angles

to the jaw and approximately 2/3 from the tip of the needle

(photo 3). If the needle is incorrectly inserted into the suture

holder there is an increased risk of bending the needle,

difficulty in penetrating the skin and poor angle of penetration.

Photo 3 Photo 4

8

The skin needs to be stable to allow entry and

exiting of the needle. Depending on preference a

fine toothed forceps or skin hook can be used to

steady the skin edges but, be very gentle. Avoid

using your fingers to stabilise the skin when exiting

as there is a risk of needle stick injury, use your

forceps. Grasp the needle with your forceps once

through the skin taking care not to grab the tip

which will result in damage to the needle.

The needle should always enter the skin at a 90

degree angle as this minimises trauma and ensures

capture of the full skin thickness. Once the skin has

been penetrated rotate the wrist so that when

exiting on the opposite side you take a ‘tissue bite’

of the same depth. Try using the ‘palming method’

described earlier as this allows for greater for

dexterity. Wound edges which meet at the same

level minimise the risk of ‘stepping’. Always insert

the needle 3 to 4mm from the wound edge and exit

at the same distance on the opposite side, placing

your suture less than 2mm from the wound edges

can result in necrosis. The spacing of each suture

along the length of the wound depends on location,

degree of skin tension and the condition of the skin.

Generally on the head and neck a 3 to 5mm gap

between sutures is average but, if there is a high

degree of skin tension or if the wound lies over a

joint then the distancing is less.

Once you are happy with the placement of your

suture it must be held in position by tying a surgical

knot. Tying knots with your instruments is

preferable as it uses less suture material and

reduces the likelihood of over tightening. In skin

surgery the square knot is commonly used as it cuts

down the risk of your knot slipping or unravelling

following surgery. The easiest way to describe this

is to imagine you are looking at the wound as a

vertical line in front of you. Start suturing from the

right hand side of the wound and exit on the left,

the loose end of the suture will now be on the right

hand side. Pull the suture gently through the skin

leaving the loose end approximately 2-3 cm long,

release the needle, and allow this to fall onto the

sterile drape. Place the suture holder between the

two ends of the thread. Rotate the thread clockwise

around the needle holder twice, then take hold of

the short, loose end of the suture and pull through

the loops crossing your hands so the loose end of

the suture and the end attached to the needle swap

sides. As gently as possible pull the wound edges

together.

The next step is virtually the same, place the suture

holder back between the two threads, the loose

end is on the left hand side and the needle end on

the right hand side. Now do exactly the same, but

perform a single rotation of the thread counter

clockwise around the suture holder. Again grab the

loose end pull through the loop and swap hands,

tighten the knot enough to approximate not

strangulate the wound edges. Repeat step one with

a single rotation for the final ‘throw’. This technique

automatically creates the square knot designed not

to slip. This is the most conventional way of tying

surgical knots; sufficient for polyfilament sutures

such as Silk or Vicryl. When using a single filament

nylon suture like Prolene you may want to add an

additional single throw to make sure the knots are

fully secure. Place the knots to one side of the

wound, leaving them directly over the top of wound

will increase the possibility of post op infection.

When you are not using the suture needle it is very

important to store it safely to prevent accidental

injury, this is achieved by ‘parking’ the needle in the

suture holder. Clip the needle on the ‘swage’ with

the needle point towards the body of the holder, do

not grasp the tip in case you need to use the suture

again (photo 4).

The suture packet holds a lot of information for the

surgeon about the needle and thread/filament

(photo 5). When choosing the suture needle a

Photo 5

9

reverse cutting or, reverse cutting prime needle

would be my first choice, they are less traumatic

and therefore less likely to tear the delicate skin

edges. This pack contains a 3/8 of a circle needle

which is ideal for skin surgery and 19mm indicates

the needle diameter. The illustration of the needle

on the outer packaging is true to size. Underneath

this illustration is the information about the filament;

in this case it is 45cms in length and the number,

5.0 signifies the diameter.

The diameter of your suture is dependent on the

anatomical site. My practice is to use either 6.0 or

5.0 for the face, head and neck area as this

diameter produces very little scarring there is also

less skin tension around the face. On the trunk and

legs a thicker thread is required and here a 3.0 or

4.0 would be more suitable. The smaller the

number on the packet, the thicker the thread, each

size increases in thickness by approximately 50%

which is worth bearing in mind when thinking about

scarring. Finally, the product code on this pack of

5.0 Ethilon is W1618, there are many variations of

needles and sutures so be careful when ordering.

Suture material falls into basic groups;

Non-absorbable or Absorbable, Monofilament or

Polyfilament.

Non-absorbable sutures retain their strength

indefinitely. For skin surgery my preference would

be a nylon monofilament such as Ethilon or Novafil

(Ethilon is generally considered to be a superior

suture material). Another option is Prolene which is

a stronger suture however, it is more elastic and

slippery making it difficult to handle and less user

friendly. When first taking your nylon

(monofilament) suture out of the packet it is worth

giving the thread a good tug to get rid of the elastic

memory which can make suturing awkward as it

curls and tangles. The advantage of monofilament

sutures is that they are easier and less traumatic to

insert and remove on the other hand they are more

difficult to knot.

Polyfilament sutures are made from braided

materials making them stronger and easier to

handle, the fibres are twisted together to give extra

strength. There is a higher infection risk with

polyfilament sutures as bacteria can collect

between the braids however, this has been

minimised in those with an anti-microbial coating

such as Vicryl plus. Silk sutures are rarely used now

as they can cause excessive scarring, whenever

possible do not use a Silk suture on the face.

Absorbable sutures widely available are Vicryl which

is polyfilament or the single filament Monocryl, a

transparent suture that can be difficult to see

however, dyed variations available.

Vicryl rapide is a useful polyfilament suture as it is

designed to be absorbed within 8 to 14 days. It can

be used as a superficial skin suture for interrupted

suturing or for sub dermal techniques. The quick

absorption rate makes it ideal for use in children or

genital areas where suture removal causes anxiety

or embarrassment, it can also be useful for the

older person where transport or mobility problems

can be an issue.

Remember your choice of suture and needle is

determined by the location of the wound, thickness

of the skin and the amount of tension to bring the

wound edges together.

Look out for suturing methods and indications in the

next issue.

Christy Chou

Trust Surgeon

Department of Plastic Surgery

University Hospital of Durham

and Primary Care Skin Surgeon

Darlington and County Durham PCT

10

Photosensitivity is a common presentation in the

Dermatology Clinic and the management of these patients

poses unique challenges.

In practice, there are two ways that photosensitivity can

present. Patients who complain of a reaction to sun exposure,

and patients with a rash which the Doctor notices is in a

light-exposed distribution.

This review will provide a framework to begin to diagnose and

manage photosensitive patients.

Why does sunlight cause so much skin disease?

Ultraviolet radiation (UV) makes up a small part of sunlight but

UV is uniquely damaging to the skin (Fig. 1). UV chemically

reacts with, and alters, proteins, lipids and, more worryingly,

DNA in skin cells. Although there is a sophisticated and

effective set of defences in the skin against UV damage, when

these responses go wrong, the photosensitive diseases result.

Photodermatoses versus photoaggravateddermatoses

Photosensitive skin diseases are divided into two groups. The

photoaggravated dermatoses are ‘normal’ dermatoses which,

in some patients, worsen with sun exposure. The most

common is atopic eczema which flares after sun exposure in

15-20% of patients. Many other dermatoses are sometimes

aggravated by ultraviolet, from lupus which is almost always

photoaggravated, to pemphigoid where photoaggravation is

rare (Table 1).

The photodermatoses (Table 2) are true sun-induced skin

diseases: they do not occur in the absence of sunlight.

Patients with photoaggravated dermatoses are managed for

the underlying dermatosis, apart from the extra UV

photoprotection they require. This review will cover the

management of patients with photodermatoses.

What types of diseases are the photodermatoses?

Most of the photodermatoses are inflammatory diseases. This

is less mysterious than it might seem. Ultraviolet has profound

effects on the skin’s immune system. For a few days after UV

exposure, immune responses in the skin are suppressed. UV

alters molecules in the skin which can then appear ‘foreign’ to

lymphocytes, potentially inducing autoimmunity. So UV can

Managing the Photosensitive Patient

Dr Robert Sarkany FRCP MD

Head of Photodermatology, St John’s Institute of Dermatology, London

Figure 1. Ultraviolet is the portion of the spectrum of light in sunlight which isuniquely damaging to the skin, and is the cause of much Dermatological disease

11

cause autoimmune and other inflammatory reactions. The

commonest inflammatory photodermatosis is polymorphic

light eruption. Chronic actinic dermatitis and actinic prurigo are

not rare. Solar urticaria and hydroa vacciniforme are

(fortunately) uncommon.

Not all photodermatoses are inflammatory. In drug

photosensitivity and porphyria, light directly activates

molecules in the skin (i.e drugs and porphyrins) to become

destructive. These are the ‘phototoxic’ photodermatoses.

Drug phototoxicity is very common.

The rarest photodermatoses are the DNA repair disorders.

Repairing the damage that UV in daylight constantly does to

keratinocyte and melanocyte DNA is crucial to prevent skin

cancer. Faulty DNA repair causes Xeroderma pigmentosum

and other severe inherited diseases.

The main photodermatoses ‘in a nutshell’

Inflammatory Photodermatoses

• Polymorphic Light Eruption: Affects 1 in 6 young women.

Causes itchy papules, plaques and vesicles. Often spares

the face and hands.

• Actinic Prurigo: commoner in children. Flares in summer.

Causes multiple small nodular prurigo-type lesions on the

arms and face, and sometimes a more confluent

eczematous rash on the face. Can be treatment resistant.

• Chronic Actinic Dermatitis: a severe exposed site eczema,

worse in summer. Can be lichenified and even

pseudolymphomatous and nodular. It is an allergic dermatitis

to UVB. Often associated with non-photosensitive contact

allergic dermatitis to multiple allergens. Commoner in the

elderly.

• Solar urticaria: rare and severe. Life-limiting urticaria on

exposure to daylight often even in winter. Generally in young

adults and may persist for decades and be

treatment-resistant.

• Photoallergic contact dermatitis: a light-dependent form of

contact allergic dermatitis. Presents with an acute eczema

starting within a day or two of sun exposure. Since the allergy

(in the UK) is usually to a sunscreen ingredient, it occurs only

where sunscreen has been applied.

• Lupus: subacute lupus (and sometimes systemic lupus) can

cause a PLE-like eruption, but it tends to persist longer than

PLE. Always think of lupus and check ANA in a photosensitive

patient.

• Hydroa vacciniforme: a severe inflammatory scarring

photodermatosis that affects young children and is often

treatment resistant. It usually resolves after two to three

years but can leave severe facial scarring.

Phototoxic Photodermatoses

• Drug photosensitivity: often presents with pain, redness and

swelling in exposed skin which persists for hours after sun

exposure. It is most commonly caused by tetracyclines,

non-steroidal anti-inflammatories, amiodarone, thiazides or

quinine. Drug photosensitivity is the great mimicker in

photosensitivity. Always take a drug history in photosensitive

patients.

• Erythropoietic Protoporphyria (EPP) (Fig. 2): inherited. Causes

severe pain and swelling of the hands and face within

minutes of summer sun exposure. The reaction is to visible

violet light. Diagnosed on blood test.

Table 1: The common Photoaggravated Dermatoses

Eczema:• atopic • seborrhoeic

Connective tissue: • lupus• Dermatomyositis

Infection: • herpes simplex

Other inflammatory skin diseases• Psoriasis• Rosacea• Actinic lichen planus• Erythema multiforme• Acne

Acantholytic diseases: • pemphigus, Grover’s, Darier’s

Pigmentary: • chloasma

Table 2: The photodermatoses

Immunologically based:• Polymorphic light eruption• Chronic actinic dermatitis• Actinic prurigo• Hydroa vacciniforme• Solar urticaria• Photoallergic contact dernatitis

Chemical photoxicity:• Exogenous: drugs• Endogenous: porphyrias

DNA repair disorders:• Xeroderma pigmentosum

12

• Porphyria Cutanea Tarda (PCT)(Fig.3): a metabolic disease

strongly associated with liver disease and haemochromatosis.

Causes fragile skin and blistering on the hands and face.

Accurate biochemical diagnosis is vital to exclude potentially

life-threatening variegate porphyria.

• Pseudoporphyria: a presentation of drug photosensitivity

which mimics PCT. Can also be caused by haemodialysis.

DNA repair disorders

• Xeroderma pigmentosum (XP): A rare inherited disease in

which the process of repair of UV-induced damage to DNA is

impaired. It causes multiple skin cancers and eye disease

from childhood, and a fatal degenerative neurological disease

in some patients. Early diagnosis is crucial so that absolute

and drastic UV photoprotection can be started as soon as

possible, which prolongs survival. Think of the diagnosis in

any child with exaggerated prolonged sunburn reactions, or

exaggerated early freckling in exposed skin, (rare versions

present in adults).

Managing the patient who complains of asun-induced rash

As every comedian knows, ‘timing is everything’. In patients in

whom there is no rash to see, the history is the key to

diagnosis. If the eruption flares up within seconds or minutes of

first going out in the sun, the diagnosis is most likely to be one

of the three causes of immediate photosensitivity:- drug

photosensitivity, solar urticaria or erythropoietic protoporphyria

(EPP). The other photosensitive eruptions tend to flare up a few

hours after sun exposure.

The classic presentations are:

Immediate photosensitivity (within minutes):

• Drug photosensitivity: pain , redness and swelling in

exposed skin which persists for hours after sun exposure.

Drug photosensitivity is the great mimicker in photosensitivity.

Always take a drug history in photosensitive patients.

• Solar urticaria: itching with redness and swelling in exposed

skin, resolving within an hour once the patient gets away

from the sun

• Erythropoietic protoporphyria: onset in early childhood. Pain

and swelling on the hands and face which lasts 2-3 days.

Delayed photosensitivity (within hours):

• Polymorphic light eruption (PLE): itchy red papules,

sometimes plaques or vesicles, in exposed areas, lasting up

to 10 days

• Lupus: can present like PLE, but tends to last weeks or longer.

• Chronic actinic dermatitis: there may be no history of

photosensitivity, but there can be a history of flaring of

existing eczema which can last for weeks or until topical

steroids are applied.

• Photoallergic contact dermatitis: presents with an acute

eczema starting within a day or two of sun exposure. Since

the allergy (in the UK) is usually to a sunscreen ingredient, it

occurs only where sunscreen has been applied.

• Actinic prurigo: itchy papules appearing within hours of sun,

which persist for months. Commoner in children.

Figure 2. Oedema during an acute painful attack in achild with erythropoietic protoporphyria (EPP)Reproduced with permission from ref. 3

Figure 3. Porphyria cutanea tarda causes fragility and blistering. It is often the presenting feature ofliver disease or haemochromatosis. Reproduced with permission from ref. 3

• Porphyria Cutanea Tarda (PCT): the patient is usually not

aware of a link to sun exposure. Presents with fragility and

sometimes blistering with scarring and milia formation, on

the hands and face, worse in the summer.

• Hydroa vacciniforme: papules, bullae and pustules within

hours of sun exposure. Can take weeks to resolve and leave

vacciniform scars.

Managing the patient in whom the doctornotices that a rash is distributed in alight-sensitive distribution

In some photodermatoses the doctor will notice that the rash is

in an exposed site distribution. The patient may not be aware

that there is any link to sun exposure. This is often the case in

chronic actinic dermatitis and porphyria cutanea tarda. If a

patient has an exposed site rash, the hallmarks of it being due

to light are sharp cut-off at clothes lines, and sparing in

relatively shaded areas (below the chin, behind the ears, around

the eyes, under watch straps).

In patients where you suspect a connection to sunlight, always

ask whether it is better or worse in the sun and what happens

after bright sun exposure and on hot holidays. If the rash clears

up on the beach in Majorca, it is not a photodermatosis

whatever it may look like!

Exposed site eczema (Fig. 4): Dermatologists often see

patients with eczema which is predominantly in an exposed

site distribution. Although this may be due to photosensitivity

(photoaggravated atopic eczema, chronic actinic dermatitis or

photoallergic contact dermatitis), there are other possibilities.

Contact allergic dermatitis to an airborne allergen affects

exposed sites, and sometimes normal atopic eczema just

happens to be worse on the face and hands (and seborrhoeic

dermatitis tends to be facial). Careful history taking and

relevant investigations (patch tests, photopatch tests,

phototests) are the key to accurate diagnosis and effective

treatment.

Investigating patients with suspectedphotosensitivity

Blood tests:

• Always check the ANA: along with drug photosensitivity,

lupus can present in many ways and is important not to

miss.

• Have a low threshold for checking plasma porphyrins: this is

a good screen for the cutaneous porphyrias. It is essential in

any immediate photosensitivity and any bullous

photodermatosis

• If you suspect actinic prurigo, check the HLA class 2 type:

HLA DR4 and DRB1*0407 are strongly associated with this

disease.

Patch tests: important in any exposed site eczema, (a) to

exclude a non-photosensitive contact allergic dermatitis as the

diagnosis; (b) because Chronic actinic dermatitis, is usually

accompanied by non-photosensitive contact allergies.

Photopatch tests: the diagnostic test for photoallergic contact

dermatitis.

Phototesting: only available in specialist Photodermatology

Units. It is the diagnostic test for chronic actinic dermatitis

and solar urticaria. It can be helpful in other photodermatoses.

It involves challenging small areas of skin on the back with a

series of different doses of each wavelength of UV light in

turn and assessing the response 24 hours later

(‘monochromator test’). Patients’ skin is also exposed to

broader spectrum ‘sun-like’ UV in order to induce the eruption

(‘provocation test’).

Treating the photosensitive patient

Photoprotection

The sunscreen must protect against the wavelength causing

the disease. The SPF (sun protection factor) only measures

protection against short wavelength UV (UVB). For many

photosensitive patients (including most PLE patients), longer

wavelength UV (UVA) is the main problem, so a broad

spectrum sunscreen with high UVA protection (as well as a

high SPF) is needed. UV sunscreens do not protect against

visible light, and for visible light photosensitivity (EPP and

Figure 4 (a, b and c). Exposed site eczema has a wide differential diagnosis ofphotosensitive and non-photosensitive causes. Careful history taking is crucial.The relative sparing here around the eyes and under the chin is a clue that thiscase is photosensitive. This patient had chronic actinic dermatitis.

13

14

some cases of solar urticaria) a visible light sunscreen is

necessary and blocks out blue and violet light.

Photoprotection is not just about sunscreens. Sun avoidance,

broad-brimmed hats, long sleeves and long trousers all play a

vital role. In the most severe photosentivity, transparent

adhesive UV films can be applied to house and car windows.

Treatment of the common photodermatoses

PLE: Short causes of prednisolone (25mg od for 5 days) will

control the bouts. For patients who suffer severe and

frequent bouts of PLE in the spring and summer, TL01 UVB

desensitisation in the early spring can be an effective, though

not always straightforward, option.

Chronic actinic dermatitis: this can be severe, even in winter,

and despite vigorous photoprotection and topical steroids.

Some patients require systemic immunosuppression though

often only in summer.

Actinic prurigo: even with excellent photoprotection this often

requires systemic therapy or UV desensitisation in the early

spring. In some treatment resistant cases, oral thalidomide is

effective.

Solar urticaria: photoprotection can be difficult in cases

caused by visible light. Antihistamines, often in combination

and at high doses, may be effective. Second line treatments

include ciclosporin, IV immune globulin, plasmapheresis and

omalizumab. UV desensitisation is possible but exceptionally

difficult. In some cases,solar urticaria is a very severe,

disabling, treatment-resistant and persistent disease.

Erythropoietic Protoporphyria: in the absence of any more

effective treatment, photoprotection is critical but difficult

because the painful attacks are caused by visible violet light.

Regular monitoring of liver function tests is crucial since

rapidly progressive liver disease requiring liver transplant is an

unpredictable complication in 1% of patients.

Xeroderma pigmentosum (XP): Early diagnosis is crucial so

that absolute and drastic UV photoprotection can be started

as soon as possible. This prolongs survival in this severe

inherited childhood disease in which minimal UV exposure

causes multiple skin cancers from childhood. Think of the

diagnosis in any child with exaggerated prolonged sunburn

reactions, or exaggerated early freckling in exposed skin, (rare

versions present in adults).

Photoallergic contact dermatitis: the diagnosis will not be

made unless it is thought of and photopatch tests carried out.

Avoidance of the relevant sunscreen photoallergen cures the

problem.

Hydroa vacciniforme: affects young children and can be severe

and treatment resistant. Rigorous UV protection and UV

desensitisation are the mainstays of treatment. It usually

resolves after two or three years, but can leave severe

vacciniform facial scarring.

Porphyria Cutanea Tarda: look for an underlying cause

(haemochromatosis, hepatitis C, alcoholism, HRT or the OCP).

Responds to low dose chloroquine or venesection but relapse

once off treatment is common.

Vitamin D in Photosensitive patients

Many photosensitive patients are vitamin D insufficient or

deficient as a result of the necessary photoprotection. Vitamin

D does need to be monitored and supplemented when

necessary.

Learning points

• Ultraviolet in sunlight is a major environmental stress on the

skin

• Careful history taking is vital to diagnose the photodermatoses

• Timing of photosensitive reactions is particularly important

diagnostically

• Drug photosensitivity and lupus can both mimic other

photosensitive diseases.

• Phototesting is the diagnostic test in Chronic Actinic Dermatitis

and Solar Urticaria

• First line treatment in Polymorphic Light Eruption is a broad

spectrum sunscreen, with oral prednisolone for the bouts

• A child with pain on sun exposure usually has Erythropoietic

Protoporphyria.

• Exaggerated freckling, with or without exaggerated sunburn,

is the usual presentation of Xeroderma Pigmentosum.

• Porphyria Cutanea Tarda is often a sign of internal disease.

• The SPF of a sunscreen only tells you about its UVB protection.

Further Reading

1. Photodermatology. Eds. Ferguson J and Dover JS.

Manson Publishing, London (2006)

2. Photodermatology. Eds. Lim HW, Honigsmann H, Hawk

JLM. Informa Healthcare, New York (2007)

3. Sarkany RP.Making sense of the porphyrias. Photodermatol

Photoimmunol Photomed.24:102-8. (2008).

We would like to thank Wiley publishing for allowing us to use

the 2 images used in reference 3.

15

What a year we’ve had for big events

but the biggest has yet to come!

The Queen’s Diamond Jubilee – a mere

bauble!

The European Championships – a mere

footie note!

The Olympics – a mere bagatelle!

The Annual Scottish PCDS meeting

at the Dundee Apex on 10th/11th

November – now you’re talking…..or

if you’re not talking at least you’re

listening to some sparkling speakers

and some great topics.

Book your place now.

Dundee – the city that has more

Premier League Football teams than

Glasgow and Father’s Day causes a lot

of confusion. (Apologies to everyone

from Dundee but I got these from a

St Johnstone fan.)

Other educational events are the

Dermoscopy workshop in Glasgow 5th

September followed by the Essential

Dermatology day in Stirling on the 6th.

One of the key objectives of the PCDS is

to encourage an interest and provide an

arena to promote and establish a clearer

understanding of dermatology in primary

care. So once again I would urge anyone

who hears of anything which looks

interesting in the dermatological

educational field to let me know at

iain.henderson@ntlworld.com and I will

try and disseminate it to appropriate

places.

The Dermatology Council for Scotland

met on 7th June where it was reported

that the update to the melanoma SIGN

Guidelines will probably commence in

2013 and that the initial scoping work

was underway for the guidelines on SCC.

The Council continues to campaign for

inclusion of dermatological conditions

into QoF and it hopes to provide data

from the Psoriasis Integrated Care Clinics

that have been held in Scotland to add

weight to the recommendations of SIGN

121 – “The diagnosis and management

of psoriasis and psoriatic arthritis in

adults.”

News from North of the Border

Skin Care Campaign Scotland continues

to contribute to Cross Party Groups of

the Scottish Parliament on psoriasis, skin

cancer and health inequality.

Dermatology in Practice is now back in

publication and the first hard copy of the

revamped journal has been sent out. If

you didn’t receive one you can register

and log in at

http://www.dermatologyinpractice.co.uk.

One final joke ….

Q. Two Dundee kids in a car without any

music - who is driving?

A. The policeman.

Iain Henderson

October 2012 – December 2012

So, what a summer eh? One or two

special events, a mixed bag of weather

and a few records broken. It’s a good

job that we have the journals to fall

back on to give us a bit of security in

these trying times...

I believe I may have mentioned before

Peace’s first law of human hair – there is

either too much, too little or it is in the

wrong place. A new guideline from the

BAD on the management of alopecia

areata1 is, therefore, a welcome sight to

start this article with. Less welcome is

the paucity of new recommendations for

alopecia is a singularly frustrating disease

to treat. Sadly, although a number of

treatments have been shown to induce

hair growth, none has been shown to

alter the long term course of the disease.

Topical and intralesional steroids remain

the mainstay of treatment options, but

the latter are not appropriate in rapidly

progressive or extensive disease. It is a

sad reflection on our impotence to treat

this distressing condition that no

intervention reaches an evidence level

above concensus and case reports.

I include the next article to demonstrate

the lengths that researchers have to go to

to obtain evidence for our otherwise

accustomed activities. A team from Brazil2

has been looking at the efficacy and

safety of topical antifungal agents. They

looked at a total of 4443 articles and

excluded all but 104 (slightly over 2%!) as

unsuitable for inclusion in this meta-analysis. After all this careful work, their

conclusion is that, although all agents studied were better than placebo, none was

statistically more effective than any other. So now we know.

To continue a slightly depressing theme, oral lichen planus (OLP) is another

common, well, relatively common condition without a recognised treatment

regime. It is 10 years since the last Cochrane review of treatment for OLP was

published, so this was updated by a multinational team3. Sadly, once again, no firm

conclusion was reached. Topical corticosteroids are considered the treatment of

choice and yet there is no trial evidence of their efficacy. The authors reach the

conclusion that, as topical corticosteroids are recognised as a first line treatment,

it would be considered unethical to perform a randomised, controlled trial to prove

their efficacy. Such are the machinations within dermatological research. Of other

treatments studied, topical calcineurin inhibitors, including ciclosporin, could not

be recommended on the balance of evidence, but there was weak evidence to

suggest that Aloe Vera gel could be useful in reducing pain and some clinical signs

of OLP.

Time for a good scratch. Another multinational team has been looking in to the

psychology of scratching4 – the rationale appearing to be that, although it has long

been recognised that scratching an itch is a pleasurable experience, no one has

really looked at why this may be so, and, indeed, if scratching is more pleasurable

at one body site compared to another. A word of caution, however. The

experiment design involved induction of itch using cowhage spicules (individually

counted cowhage spicules, no less) and then scratching was performed by the

investigator using a cervical cytology brush. Nonetheless, conclusions were

reached. The forearm has traditionally been used as the preferred site of itch

investigation, but it was found that itch, itch intensity and pleasurability ratings

were considerably higher on the back and the ankle of test subjects. This also

demonstrated that the more intense the itch, the more pleasure could be obtained

from having it scratched. The next studies suggest the scalp and the anogenital

region as future test sites. I think I may pass on that one, the mental image is not

too pleasant.

We are often reminded of the ‘tsunami’ of skin cancers that are approaching our

troubled dermatological shores. A small, but significant, part of this deluge comes

from non melanoma skin cancers in organ transplant recipients. As these patients

Journal Watch

16

often grow multiple synchronous lesions, a study5 – the first such published –

looking at the use of photodynamic therapy to treat selected basal cell carcinomas

is to be applauded. At first sight, it all appears good – only one recurrence was

reported in the 18 patients studied – but the number of test subjects was small

and the follow up period varied between 2 months and 4 years. A more rigourous

– and standardised - study needs to be performed before this could be considered

a viable treatment option.

This may be the first time that restless leg syndrome (RLS) has been mentioned

in this bulletin, but my magpie eye was caught by an article6 showing that the

incidence of RLS in those suffering from atopic dermatitis is up to four times that

of a healthy control population. Although first described in 1685 as anxietas

tibarium, and more formally classified by Karl-Axem Ekbom in 1945, we have little

or no idea what causes RLS. It is worth, however, considering discussing it with

your atopic patients as their sleep may be disturbed by more than just itch.

A brief mention for the least surprising result of a systematic review7 – no

evidence could be found that homeopathy is an efficacious treatment for eczema.

Fancy!

Whilst I am both an advocate and an enthusiastic practitioner of the dark art of

dermoscopy, there are worrying signs that it is starting to move in to areas for

which it is not really ideally suited. In the first paper8, dermoscopic features of

lichen planus, psoriasis, pityriasis versicolor and dermatitis are delineated and

discussed. This, to me, is like trying to determine the make of car by closely

studying its paintwork. A return to holistic medicine seems timely... The second

paper9 looks at the dermoscopic evolution of melanomas that were identified after

long term monitoring. I’m sorry, but this seems madness – these melanomas

were monitored over the course of a year, and their evolution studied. Although

the study was retrospective and, in most cases, the lesions were only identified

as melanomas after excision, I can’t help feeling this paper sends out the wrong

message. If it’s a melanoma after 12 months, it was a melanoma to start with.

The dermoscope should not be a tool that stops the excision of suspicious

lesions, but a tool to stop the wasteful excision of benign lesions. Rant over.

Another new topic – skin disorders surrounding stomas. These are remarkably

common, representing perhaps a third of all visits to stoma nurse clinics. It is not

unreasonable to consider contact dermatitis as being significant in this group –

occlusive, adhesive appliances applied directly to the skin. This study10, however,

did a load of patch tests on sufferers and found a positive result in only around

5% of ostomates (a new word to me , too). More likely is an irritant dermatitis to

the contents of the bags and the cleansers that it is necessary to use.

Imiquimod cream is licensed for the treatment of superficial basal cell carcinomas,

so a study looking at its use in nodular lesions seems to be of interest. A

randomised, controlled study11 looked at pretreating nodular lesions in preparation

for Mohs surgery. Four weeks of Imiquimod reduced the size of the surgical

defect, reduced the number of stages of Mohs that were necessary and

significantly reduced the reconstruction time. Although the authors recommend

further research to look into cost effectiveness, it is hard to believe that this will

not be seen to be of great interest in future. Watch this space.

As ‘any ful knos’, much of what we perceive to be treatment failure actually

represents poor compliance with the prescribed medication. Methotrexate is a

drug that seems to have both a variable

response and a variable side effect

profile. The reasons for this variability in

toxicity and response are poorly

understood – my reader will remember in

the last bulletin we mentioned genetic

variability in response. A new study12

looks at the presence of Methotrexate

polyglutamates (Methotrexate to which

glutamic acid is sequentially added) in red

blood cells. These were found to be

present early in therapy and then reached

a steady state with continuing therapy. It

was not the scope of the study to

determine if these were a measure of

clinical response, but they do seem to be

a good marker of patient compliance.

So there you have it. It always feels like

an Olympian task to summarize these

August journals. This summer, that has

been more apt than ever. Enjoy!Julian Peace

References1. Messenger et al – British Association ofDermatologists’ guidelines for the management ofalopecia areata 2012. BJD2012:166;916-926.

2. Rotta et al – Efficacy and safety of topicalantifungals in the treatment of dermatomycosis: asystematic review. BJD2012:166;927-933.

3. Lodi et al – Interventions for treating oral lichenplanus: a systematic review. BJD2012:166;938-947.

4. Bin Saif et al – The pleasurability of scratching anitch: a psychological and topographical assessment.BJD2012:166;981-985.

5. Guleng and Helsing – Photodynamic therapy forbasal cell carcinomas in organ transplant recipientsCED2012:37;367-369.

6. Cicek et al – Increased frequency of restless legsyndrome in atopic dermatitis. CED2012:37;469-476.

7. Ernst – Homeopathy for eczema: a systematicreview of controlled clinical trials.BJD2012:166;1170-1172

8. Lallas et al – Accuracy of dermoscopic criteria forthe diagnosis of psoriasis, dermatitis, lichen planusand pityriasis rosea. BJD2012:166;1198-1205

9. Terushkin et al – Changes observed in slowgrowing melanomas during long term dermoscopicmonitoring.BJD2012:166;1213-1220.

10. Al-Niaimi et al – The relevance of patch testing inperistomal dermatitis. BJD2012:167;103-109.

11. Van der Geer et al – Imiquimod 5% cream aspretreatment of Mohs micrographic surgery fornodular basal cell carcinoma in the face: aprospective randomised controlled study.BJD2012:167;110-115.

12. Woolf et al – Methotrexate polyglutamates as amarker of patient compliance and clinical response inpsoriasis: a single centre prospective studyBJD2012:167;165-173.

17

18

Dermatology in Pigmented SkinA Rwandan Sojourn

When my practice found that we had to

entertain 3 GP registrars for the month

of February 2012 and that consulting

rooms were at a premium I unselfishly

gave mine up to go on a 3 week

sabbatical to Gahini Hospital in rural

eastern Rwanda.

My connections to Rwanda go back to

both my sons. In 2008 my elder son

was working for the International

Justice Mission in the capital, Kigali and

we visited him while he was there. With

the connections we made at that time,

my younger son then went on his senior

medical election in 2010 to Gahini

hospital.

Within clinical practice as a GP in an

increasingly multicultural practice and as

a hospital practitioner in dermatology I

have become aware of the challenges of

being presented with dermatological

conditions in pigmented skin. These

include the diagnosis of common skin

conditions as well as conditions more

peculiar to pigmented skin. There are

also specific challenges in the

biopsychosocial aspects that can

influence the management and

concordance of them.

I contacted Wim Schonbee the senior

doctor who my son shadowed while at

Gahini and he kindly agreed to host my

Gahini Hospital, rural eastern Rwanda Podoconiosis

wife who is a physiotherapist and me

during our stay. He informed me that

there is no specific dermatology service

in the hospital and dermatological

conditions are treated at the open access

daily general medical clinics.

The hospital had no mains water supply

but it did have internet connection!

This sabbatical, therefore, was an

opportunity to help at the hospital and set

up a teledermatology service.

I applied and was successful in receiving

the Alastair Short Memorial Travel

Fellowship ,which funded my airfare and

equipment for the service. This included

a compact SLR digital camera with a

macro attachment, illuminated

magnifying glasses and a battery

operated angle poise lamp. All the

batteries were rechargeable.

I contacted five Dermatology

Consultants who all agreed to receive

and give advice on pictures sent to

them by email and to whom I am

eternally grateful.

We also took out scalpels, blades,

sutures, crutches, aircast boots,

footballs and football jerseys.

Our first night in Rwanda was in Hotel

de Milles Collines, which is the Hotel

Rwanda and had our last mains supply

hot shower for 3 weeks.

For the next 3 weeks I shadowed the

inspirational Wim, a South African who

had worked as a GP in a township

practice in his home country. He first

entered Rwanda one month after the

genocide in 1994. He kept going back

and has been at Gahini hospital

permanently except for holidays for the

last 10 years. He upskilled as an

ophthalmologist but also had training in

obstetrics.

The first patient I saw was a

dermatological one on the way to the

hospital and we invited him to the clinic.

He had podoconiosis, a non-filarial

for malarial prophylaxis but there were

no topical treatments for acne. The

nearest equivalent of an emollient cream

was udder cream they used for milking

goats and cows.

While I was there Wim came up with

other uses for the camera such as

monitoring cervical dysplasia treatment

as the focal length of the macro lens

was the length of a speculum. He was

going to buy some small LED strip lights

to stick to inside the speculum for

illumination.

He was also going to use it to

photograph theatre packs for various

operations as the instruments were

often all piled into one pack and when

opened only 2 or 3 instruments may be

used and the rest had to be resterilised

again.

His wife Bertha helped at the local blind

school and disabled centre and was

using it to photograph hand made cards

for the centre’s website catalogue.

Over the next few bulletins I will present

a few of the conditions I encountered.

We may complain about the NHS and all

its faults but having worked for a short

period in rural Rwanda we should be

very grateful for it.

Iain Henderson

elephantiasis caused by walking barefoot

in volcanic dust. I took a picture of this on

my compact digital camera and sent it to

the consultants for comment on delivery,

picture quality etc.

I then sent them other photographs

during my stay taken on the SLR camera.

The size of these photographs was much

bigger at 5-6 Mb compared to around

1Mb on the compact camera but

although slower, managed to get through

to the consultants. Consent was verbal

through translation and the patient was

always shown the photograph to confirm

they were happy with it.

My first operation was a curettage and

cautery of a pyogenic granuloma on a

thumb. The next was a debridement of

what we thought was a soft tissue

infection of the foot from a snake bite.

I also helped out with hernia repairs,

deliveries including Caesarian sections

mainly at the wound closure stage.

During my stay I felt challenged

especially with the language barrier, lack

of resources and slowing to African time

but I admired the Rwandans’ patience

and fortitude.

Dermatological products were sparse.

Liquid paraffin was frequently used

making follicular conditions common.

Doxycycline was plentiful as it was used

PCDS 2012:

Skin Surgery13th & 14th OctoberCopthorne Hotel Newcastle

Scottish Meeting10th & 11th NovemberApex Hotel Dundee

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

Forthcoming Meetings 2012

Members of the corporate membership scheme

Essential Dermatology2012:l 27th September PRESTON

l 11th October LEEDS

l 1st November MAIDSTONE

Essential DermatologyLevel 2 2012:l 4th October LONDON

l 22nd November MANCHESTER

PCDS 2013:

Spring meeting16th & 17th MarchManchester

Summer Meeting6th JuneLondon

Autumn Meeting12th SeptemberNottingham

Scottish Meeting9th & 10th NovemberEdinburgh

The New PCDS Website

At long last the new PCDS website is nearly upon us. It is due to be re-launched on Ist October2013. The domain address will remain unchanged.

The advantages of the new website are many and include the following:

n The clinical chapters

n The clinical contents have all been updated

n Each chapter is written in the same format

n Clinical images can be enlarged and / or downloaded

n Improved linkage between different chapters

n Events

n An easy guide to our various dermatological, dermoscopic and surgical meetings

n On-line payments for subscriptions and events

n An online ‘self-examination of moles’ toolkit that can be used by GPs to teach patients

Some features have been removed such as the forum, as these were not used except for spam!

The website is still in its evolution and there are some 20 new clinical chapters waiting to be added,and more after that.

I would like to take this opportunity to thank Neil Evans who is the technical wizard behind thewebsite and the PCDS committee, all of who work equally hard in their different capacities for thesociety, and who have supported me in the development of the new website over the past twoyears.

Dr Tim Cunliffe