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

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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


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


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


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


www.pcds.org.uk

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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.

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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.


www.pcds.org.uk

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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

[email protected]

07525026476

Thursday 27th August 2015

11


10


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.


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


12


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



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


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


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


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


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


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.

PCDS Bulletin€¦ · PCDS Winter Bulletin 2015 Editorial Winter 2015 Welcome to the Winter PCDS...

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