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Professional societies jointly condemn BBC Apprentice winner's business scheme

The main professional bodies for plastic surgery and dermatology today jointly and unequivocally condemn BBC Apprentice winner Dr Leah Totton’s capacity to set up and run a chain of outlets offering injectable facial treatments such as Botox and fillers. Not only the British Association of Dermatologists (www.bad.org.uk), the British Association of Aesthetic Plastic Surgeons (www.baaps.org.uk) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (www.bapras.org.uk) but a whole host of high-profile clinicians have taken to social media in a Twitter storm denouncing the junior doctor’s dangerously inadequate credentials for the project.

The extensive independent Review of Regulation on Cosmetic Interventions led by Sir Bruce Keogh (which issued its report earlier this year) highlighted problems within the non-surgical cosmetic sector and called for urgent development of an accredited training framework by Health Education England. The recommendations of the Review were welcomed by specialist professional groups who emphasise patient and public safety must be put ahead of commercial interests. They continue to urge rapid Parliamentary approval in order to take the recommendations forward and ensure that proficient implementation and improved patient care is in place – but in the meantime, the public remain at risk.

Mr Graeme Perks, President of the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) says
“At a time when all professionals are collaborating with Sir Bruce Keogh to improve cosmetic surgery practice and protect the vulnerable, it is a concern that a very junior doctor can make claims to be an authority in this field and provide the direction and clinical judgement that only comes with experience. The results of BBC Apprentice provide yet another demonstration of why Parliament must act fast.”

Prof Chris Bunker, President of the British Association of Dermatologists states
“We are seeing more and more complications at the hands of inadequately trained practitioners and counterfeit products. These adverse events can be permanent and life-ruining, and there are even reports of blindness being caused by inappropriate injection of fillers. Many patients require continued treatment and support on the NHS.”

According to Rajiv Grover, consultant plastic surgeon and BAAPS President“
What this debate needs is a strong injection of common sense – if Dr Leah Totton were training to be a GP she would not be able to work unsupervised for another four years after qualifying. Yet in the private sector she is setting herself up to train others. Having a stab at running a business shouldn’t be taken literally.”

According to Dr Tamara Griffiths, dermatology representative on the European Committee for Standardisation (CEN) which has been developing EU-wide standards for cosmetic surgery
“Dr Totton is a very junior doctor and her claim to be an expert in the field of cosmetic procedures may not measure up to the review by the European Committee for Standardisation, where international consensus has been reached regarding the imperative of adequate and accredited training.”


ENDS

About BAD
The British Association of Dermatologists is the central association of practising UK dermatologists. Our aim is to continually improve the treatment and understanding of skin disease. For further information about the charity, visit www.bad.org.uk. For media queries email comms@bad.org.uk or call 0207 391 6094.

About BAAPS
The BAAPS (www.baaps.org.uk), based at the Royal College of Surgeons, is a not-for-profit organisation, established for the advancement of education and practice of Aesthetic Plastic Surgery for public benefit. Members undergo thorough background screening before they can join. Information about specific procedures and surgeons’ contact details can be found on the web site, or by contacting their advice line at 020 7405 2234. Further materials can be posted to members of the public seeking specialised information. BAAPS is also on Twitter: www.twitter.com/BAAPSMedia and Facebook: www.facebook.com/BritishAssociationofAestheticPlasticSurgeons
For all media enquiries, please contact Tingy Simoes on 020 7549 2863 or email tsimoes@wavelengthgroup.com

About BAPRAS
BAPRAS, the British Association of Plastic, Reconstructive and Aesthetic Surgery, is the voice of plastic surgery in the UK. It aims to increase the understanding of the professional specialty and scope of plastic surgery, promoting innovation in teaching, learning and research.
Founded in 1946 (originally as the British Association of Plastic Surgeons), today BAPRAS has over 800 members and is the professional representative body for reconstructive and aesthetic plastic surgeons providing services to patients on the NHS and privately in the UK. www.bapras.org.uk
For more information please contact Luke Guinness or Laura Buller on 020 7403 2230 or 07711 444549, email baprasteam@forster.co.uk 

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Self service phototherapy?

New ways of delivering a well-tried treatment – two studies presented at the British Association of Dermatologists’ Annual Meeting 8-11 July 2013, Liverpool

A lot of time can be used up waiting at the hospital to have regular phototherapy sessions for skin disease. This is a treatment that is often used for common conditions such as psoriasis and eczema. Usually this treatment is given in hospital-based phototherapy units and because travel or regular attendance can be a problem, some people, for whom this would be an ideal approach, cannot get the treatment they need.

Two studies presented at the British Association of Dermatologists Annual Meeting will look at the pros and cons of providing phototherapy in alternative ways or in alternative settings that would help to address that need.

A group from NHS Tayside, who have provided a home ultraviolet B (UVB) phototherapy service for the past 15 years, looked at the feasibility of patients self-administering phototherapy in a hospital outpatient department (1). They underook a pilot project where a group of patients were given a two day training programme. In subsequent monitoring of these patients and comparing the outcomes to a group having the same therapy administered by nurses, similar results were found for efficacy and rate of adverse effects.

Most patients and staff viewed self-administration of phototherapy positively, although it was clear that this approach is only suitable for some patients. The indications from the pilot study suggested that it would be a safe and effective service that would require around 50 per cent less nurse input. The team are now looking at developing this further and hope that it will further increase access and availability of phototherapy for patients whislt freeing up nurse time to provide other patient services.

The other study, undertaken by a team based in Wales (at Cardiff University, Welsh Insitute of Dermatology, Cardiff, Aneurin Bevan Health Board, St Woolos Hospital, Newport) took the findings from the PLUTO study as their starting point . This study found that home phototherapy for psoriasis is safe and as effective as phototherapy administed in hospital, in their own study they aimed to find out what local knowledge and attitudes to home phototherapy might be.

Home phototherapy is widely available in the Netherlands, Germany and the United States and the health economic analysis from the PLUTO study showed that it was cost neutral compared with hospital phototherapy. Using semi-structured interviews the researchers found that 75 per cent of consultants, 100 per cent of registrars, 100 per cent of nurse specialists and 78 per cent of patients thought that home phototherapy was a good idea.

Dermatology professionals gave the main reason for this as ‘less waste of patient time and less travelling’ and the main perceived barrier was ‘cost’. For patients the main reason for supporting home phototherapy was similar being ‘convenience’, ‘less time travelling’ and ‘transport logistics’.

Dr Salako, one of the team said:
“Although there was scepticism about home phototherapy from some of the dermatology professionals we think our findings, in this local sample, are widely representative and they suggest that more should be done to make the case for home phototherapy in the UK.”

-Ends-
Notes to editors:

If using this study, please ensure you mention that the study was released at the British Association of Dermatologists’ Annual Conference.
The conference will be held at ACC Liverpool from July 9th to 11th 2013, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

For more information please contact: Nina Goad, Head of Communications, 0207 391 6094 (or mobile 07825567717 during conference week only) or Deborah Mason, Communications Manager, Phone: 0207 391 6355, Email: comms@bad.org.uk, Website: www.bad.org.uk

Study details:
1. Self-administration of hospital-based narrowband UVB (TL-01) phototherapy: a feasibility study in an
outpatient setting
S. Yule,1 S. Sanyal,1 S. Ibbotson,2 H. Moseley1 and R.S. Dawe1
1NHS Tayside, Dundee, U.K., 2University of Dundee, Dundee, U.K.

2. Evaluation of patients’ and healthcare professionals’ knowledge and views about home phototherapy
S. Lumley,1 K. Salako2 and Alex V. Anstey3
1School of Medicine, Cardiff University, Cardiff, U.K., 2Welsh Institute of Dermatology, Cardiff, U.K. and 3Aneurin Bevan Health Board, Academic Dermatology, St. Woolos Hospital, Newport, U.K.


ABSTRACTS:

1. Self-administration of hospital-based narrowband UVB (TL-01) phototherapy: a feasibility study in an outpatient setting
S. Yule,1 S. Sanyal,1 S. Ibbotson,2 H. Moseley1 and R.S. Dawe1
1NHS Tayside, Dundee, U.K., 2University of Dundee, Dundee, U.K.

Narrowband (TL01 lamp) ultraviolet B (UVB) is used to treat a variety of dermatoses, including the common conditions of psoriasis and atopic eczema. This treatment is most often given in hospital-based phototherapy units; difficulty in
attending such units regularly means that some people, for whom this would otherwise be an ideal approach, cannot easily attend for this effective and safe treatment. There are a variety of approaches to increase availability of this treatment, including supervised home phototherapy. Some patients cannot easily attend hospital phototherapy units when they are open. For some of these, home phototherapy is an appropriate option; for others it is not practicable (for example, some may have inadequate space in their homes for home phototherapy equipment). Self-administration of UVB phototherapy by outpatients might be appropriate for some. We wanted to assess the feasibility of outpatients self-administering UVB phototherapy in a hospital outpatient setting. A pilot project was commenced in November 2011. A total of 27 patients with psoriasis (n = 20) and atopic eczema (n = 7), (17 women, mean age 32 years, range 17–56) were recruited.
Our home phototherapy training programme was adapted. Patients underwent a 2-day training programme, which
included a minimal erythema dose (MED) test and supervised treatment. Patient and staff questionnaires were used to gather feedback. Treatment data were collected for 26 patients. The mean number of exposures was 23 (SD 9), and the mean cumulative dose was 15 J cm_2 (SD 11). Efficacy and rate of adverse effects were found to be similar to those of patients having nurse-administered treatment. Self–administration of treatment by outpatients required ~50% less nursing input than for conventional nurse-administered phototherapy. Most patients and staff viewed this model of care positively. Early indications suggest that this is a safe and effective service development that provides a patient-centred approach to care.
Having a group of patients trained to self–administer treatment empowers them to take a more active role in their treatment as part of their chronic disease management, and could free up nursing time to provide other patient services. We are planning further to develop this service by piloting the use of a dedicated unit on our dermatology ward for self-administration of treatment by outpatients. This service development would further increase access and availability of phototherapy for patients.

2. Evaluation of patients’ and healthcare professionals’ knowledge and views about home phototherapy
S. Lumley,1 K. Salako2 and Alex V. Anstey3
1School of Medicine, Cardiff University, Cardiff, U.K., 2Welsh Institute of Dermatology, Cardiff, U.K. and 3Aneurin Bevan Health Board, Academic Dermatology, St. Woolos Hospital, Newport, U.K.

The PLUTO study (Koek MB, Buskens E, van Weelden H et al. Home versus outpatient ultraviolet B phototherapy for mild to severe psoriasis: pragmatic multicentre randomised controlled non-inferiority trial (PLUTO study). BMJ 2009; 338: 1542) showed that home phototherapy for psoriasis is as safe and effective as phototherapy administered in hospital. Furthermore, health economic analysis from this study showed that home phototherapy is cost-neutral compared with hospital phototherapy. Home phototherapy is now widely available in the Netherlands, Germany and the United States, but provision remains limited in the U.K. Our aim was to explore local knowledge and attitudes about home phototherapy to better understand potential barriers to the introduction of home phototherapy. Semi-structured interviews were carried out on a cross-sectional sample of 18 patients with psoriasis and 18 dermatology healthcare professionals. Awareness by dermatology professionals of the PLUTO study was as follows: 75% of consultants; 57% of registrars; 29% of dermatology specialist nurses. However, just 50% of the dermatology professionals were able to state the conclusions or take-home message from this study. Awareness of the 1998 BAD guidelines on home phototherapy was as follows: 25% of consultants; 57% of registrars; 43% of specialist nurses. When asked for their views on whether or not home phototherapy was a good idea, the rate of positive responses was: 75% of consultants; 100% of registrars; 100% of nurse specialists. When asked to explain why it was a good idea the main reason cited by 83% was ‘less waste of patient time and less travelling’. ‘Cost’ was the main perceived barrier preventing the introduction of home phototherapy on the NHS, cited as follows: 75% of consultants; 86% of registrars; 100% of nurses. Of patients, 78%
preferred the idea of home phototherapy for reasons such as ‘convenience’, ‘less time spent travelling’ and ‘transport logistics’.
In summary, the 18 dermatology professionals had a generally poor understanding of home UVB. Furthermore,
scepticism about home phototherapy was apparent in some. Patients and dermatology nurses were the most positive about the concept of home phototherapy. If our findings in this local sample are widely representative they suggest that more should now be done to make the case for home phototherapy in the U.K. Wider provision of home phototherapy would improve patient choice, widen access to phototherapy and reduce the burden of treatment for our patients. Research is now needed to determine how this innovative model for phototherapy can be integrated into existing frameworks of care.


The British Association of Dermatologists is the central association of practising UK dermatologists. Our aim is to continually improve the treatment and understanding of skin disease. 

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Rise in skin disease due to false nails, dermatologists warn

The fashion for acrylic nails may be behind a rise in allergies being treated by dermatologists, according to research presented at the British Association of Dermatologists’ Annual Conference in Liverpool this week.

A team of researchers from Chapel Allerton Hospital in Leeds, Centre for Occupational and Environmental Health in Manchester and the Hillingdon Hospital in Uxbridge, looked at cases of occupational allergic contact dermatitis (a type of allergic eczema caused in the workplace) suffered by beauticians during a 15-year period from 1996 to 2011.

Acrylate chemicals, used in acrylic nails and eyelash extension glue, was the cause of the disease in 64 per cent of cases over the entire period, which is significantly higher than the second most common allergen, fragrances, at 24 per cent.

The study revealed a steady increase in reactions from 1996 onwards, with a four-fold increase between 1997 and 2010 (no cases in 1996, three in 1997, nine in 2009, 12 in 2010 and eight in 2011). This increase coincides with the rise in popularity of acrylic nails and eyelash extensions, as beauticians experience increased exposure to these chemicals.

This study specifically examined reactions experienced by beauticians, however the same allergies could be experienced by customers receiving these treatments on a regular basis. Acrylic nails are artificial nail enhancements that can add length to the tips and give the nails a harder finish.

The first large-scale study of the psychological impact of hand eczema, carried out by researchers at Barts and the London NHS Trust in London, is also being presented at the same conference and gives a worrying insight into the wider effects of the disease.

Of the 1023 study participants suffering from hand eczema, 89 per cent percent said that they were self-conscious and embarrassed about their hand eczema. Hand eczema also had a major impact on daily activities, with 76 per cent of respondents stating that their eczema affected their social and leisure activities, and 74 per cent their ability to work or study. Interpersonal relationships were also affected: 79 per cent of respondents stated that hand eczema had a negative impact on their mood and 27 per cent that it affected their physical relationship with their partner.

Dr Chung Kwok of Chapel Allerton Hospital, Leeds, and one of the authors of the beautician study said: “This kind of research is important in keeping doctors up to date with potential new allergens and trends in allergy caused by new products. Hand dermatitis (eczema on the hands) is common in beauty professionals because they are exposed to a great variety of chemicals.”

Author of the psychological impact study, Dr Tony Bewley of Barts and the London NHS Trust said: “The impact of hand eczema is greatly underestimated by healthcare professionals and we need to address this. It stops people working, affects their relationships and their social life – it is so much more than a minor irritation.”

Nina Goad of the British Association of Dermatologists said: “If you are either a beautician working with acrylates or a customer regularly using these products and you find you develop an eczema reaction, you will need to see your GP who will refer you to a Dermatologist for patch testing. Hand eczema is debilitating for many people, and for beauticians it can mean an inability to carry out their work, which is of course a significant problem.”

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Notes to editors:

If using this study, please ensure you mention that the study was released at the British Association of Dermatologists’ Annual Conference.
The conference will be held at ACC Liverpool from July 9th to 11th 2013, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

For more information please contact: Nina Goad, Head of Communications, 0207 391 6094 (or mobile 07825567717 during conference week only) or Deborah Mason, Communications Manager, Phone: 0207 391 6355, Email: comms@bad.org.uk, Website: www.bad.org.uk

Study details: 
1. CD03: Occupational disease in beauticians reported to the health and occupation research network from 1996 to 2011; C. Kwok,1 A. Money,2 M. Carder,2 S. Turner,2 R. Agius,2 D. Orton3 and S.M. Wilkinson1
1Dermatology Department, Chapel Allerton Hospital, Leeds, U.K., 2Centre for Occupational and Environmental Health, Manchester, U.K. and 3Dermatology Department, The Hillingdon Hospitals, Uxbridge, U.K.

2. CD05: An ethnographic insight into the psychological impact of hand eczema
A.P. Bewley,1 N. Mason,2 J. Rawlins3 and S. Walker3
1Barts and the London NHS Trust, London, U.K., 2Stiefel, GlaxoSmithKline, Uxbridge, U.K. and 3Basilea Pharmaceuticals, Guildford, U.K.

The British Association of Dermatologists is the central association of practising UK dermatologists. Our aim is to continually improve the treatment and understanding of skin disease. 

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Some traditional antiseptics may be ineffective at killing bacteria

Some traditional antiseptics, used in hospitals and clinics, are actually ineffective at killing bacteria, according to research due to be presented at the British Association of Dermatologists’ Annual Conference in Liverpool this week (July 8th-11th).

The study, conducted by researchers from the Department of Dermatology at the Royal Infirmary of Edinburgh and the University of Edinburgh's Centre for Inflammation Research, sought to test the largely anecdotal evidence supporting various antiseptics’ efficacy.

The researchers tested the bactericidal activity against Staphylococcus aureus, a bacterium commonly found on the skin, of four frequently used topical antiseptics. To do this they used a modified version of the European Standard EN 1276 for evaluation of bacteria killing activity. To meet this standard there has to be a very significant reduction in microbial count within five minutes of exposure to the antiseptic.

Two of the four antiseptics chosen met the standard: 0.1% benzalkonium chloride and 6% hydrogen peroxide, but two did not: 2% aqueous eosin and 1 : 10 000 potassium permanganate.

Dr Claire Leitch, one of the study’s authors from the Royal Infirmary of Edinburgh, said: “Although these antiseptics are commonly used in the treatment of skin complaints, there has been a dearth of scientific evidence to support their bactericidal effectiveness. Whilst some of these antiseptics may have desirable astringent properties, these results suggest they lack effective antiseptic activity.

“This is preliminary research, relating specifically to Staphylococcus aureus, and so it is too early to draw wider conclusions. However, this study is an important step for future research to build on”.

Both aqueous eosin and potassium permanganate are used in primary and secondary care, primarily for the treatment of superficial skin infections, atopic dermatitis and chronic leg ulcers. However, their use in atopic dermatitis and chronic leg ulcers is not just for an antiseptic effect but also for their astringent properties.
Hydrogen peroxide and benzalkonium chloride are components of many commercially manufactured antiseptic creams, lotions and washes.

-Ends-
Notes to editors:

If using this study, please ensure you mention that the study was released at the British Association of Dermatologists’ Annual Conference.
The conference will be held at ACC Liverpool from July 9th to 11th 2013, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

For more information please contact: Nina Goad, Head of Communications, 0207 391 6094 (or mobile 07825567717 during conference week only) or Deborah Mason, Communications Manager, Phone: 0207 391 6355, Email: comms@bad.org.uk, Website: www.bad.org.uk

Study details: “Traditional antiseptics show ineffective antistaphylococcal bactericidal activity”; C.S. Leitch, A. Leitch and M.J. Tidman/Department of Dermatology, Royal Infirmary of Edinburgh, Edinburgh, U.K. and Centre for Inflammation Research, Queen’s Medical Research Institute.

Abstract: Topical antiseptics are frequently used in dermatological management, yet evidence for the efficacy of traditional generic formulations is often largely anecdotal. We tested the in vitro bactericidal activity against Staphylococcus aureus of four commonly used topical antiseptics using a modified version of the European Standard, EN 1276, a quantitative suspension test for the evaluation of bactericidal activity of chemical disinfectants and antiseptics. To meet the standard for antiseptic effectiveness of EN 1276, at least a 105-fold reduction in bacteria counts within 5 min of exposure is required. While 0 1% benzalkonium chloride and 6% hydrogen peroxide both achieved this 105-fold reduction in S. aureus counts, neither 2% aqueous eosin nor 1 : 10 000 potassium permanganate showed significant bactericidal activity, when compared with controls, at exposure periods of up to 1 hour. Aqueous eosin and potassium permanganate may have desirable astringent properties, but these results suggest they lack effective antiseptic activity, at least against S. aureus.

The British Association of Dermatologists is the central association of practising UK dermatologists. Our aim is to continually improve the treatment and understanding of skin disease.  

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Dermatologists raise the alarm on a contact allergy epidemic

At a special session of the British Society of Cutaneous Allergy to be held at the British Association of Dermatologists’ Annual Conference in Liverpool next week (July 8th to 11th), leading dermatologists will present research highlighting their fears of a new epidemic of contact allergy (causing eczema) to two chemical preservatives.

The ingredients in question are Methylisothiazolinone (MI) Methylchloroisothiazolinone/Methylisothiazolinone (MCI/MI). It is their presence in personal care products that are causing most concern, for example moist tissue wipes, cleansers, shower gels, deodorants, shaving foam. They can also be found in household products such as washing up liquid.

The preservatives are often used together, and past concerns about MCI/MI in Europe led to reductions in the concentrations allowed in cosmetic products.

Despite this a team at the Leeds Centre for Dermatology show in their research (1) that there was a sharp rise (up to 6.2 per cent sensitivity) in contact allergy to MCI/MI and MI over the past three years.

This was also reported by a team of researchers at St John’s Institute for Dermatology at St Thomas’ Hospital in London (2) who had seen a rapid rise in contact allergy to MI in the last two years going from one case in 2010 to 33 cases in 2012 – they also note that reports of high levels of MI allergy are emerging from several European countries. Across the UK other dermatology centres are also noticing rapid rises in numbers of acute allergic contact dermatitis related to MI exposure.

It is suspected that the recent use of MI as a single agent preservative in quantities up to 100 ppm in personal care products may be a major contributor to this outbreak of MI allergy.

David Orton, President of the British Society of Cutaneous Allergy said:

“Across the large patch test centres in the UK, data suggest that rates of allergy to these two preservatives are now nearing 10 per cent – and in some cases higher – this is clearly far too high and is an unacceptable situation.

“The last time a preservative had this type of effect it was banned by the EU. Although the relevant bodies in Europe have set up a review this all takes time – in the meantime the number of people coming to see us with this allergy is only likely to rise.

“We would welcome the opportunity to meet and discuss this issue with representatives of the UK cosmetics industry so as to take immediate steps to protect UK consumers”.

Dr John McFadden, Consultant Dermatologist at St John’s Institute of Dermatology said:
“The time for action is now. We are in the midst of an outbreak of allergy to a preservative (MI) which we have not seen before in terms of scale in our lifetime. Many of our patients have suffered acute dermatitis with redness and swelling of the face. I would ask the cosmetics industry not to wait for legislation but to get on and address the problem of MI allergy before the situation gets worse. If they are already taking action we would urge them to be open and transparent about what steps they are taking”

 

-Ends-
Notes to editors:

If using this study, please ensure you mention that the study was released at the British Association of Dermatologists’ Annual Conference.
The conference will be held at ACC Liverpool from July 9th to 11th 2013, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

For more information please contact: Nina Goad, Head of Communications, 0207 391 6094 (or mobile 07825567717 during conference week only) or Deborah Mason, Communications Manager, Phone: 0207 391 6355, Email: comms@bad.org.uk, Website: www.bad.org.uk

1) Methylchoroisothiazolinone and methylisotiazolinone contact allergy: a new epidemic, R. Urwin and S.M Wilkinson, The Leeds Centre for Dermatology, Leeds. UK
2) Outbreak of contact allergy to cosmetic preservative: history repeats itself (again), J.Mann, I.White, J.White, P.Bannerjee and J. McFadden, St John’s Institute of Dermatology, St Thomas’ Hospital, London, UK

1) Abstract CD01 Methylchloroisothiazolinone and methylisothiazolinone contact allergy: a new epidemic
R. Urwin and S.M. Wilkinson
The Leeds Centre for Dermatology, Leeds, U.K.

Methylchloroisothiazolinone (MCI) and methylisothiazolinone (MI) are commonly used preservatives (biocides) in industrial and household products including cosmetics. Despite a reduction of maximum permissible concentrations of MCI/MI in leave-on and rinse-off products (7_5 p.p.m. and 15 p.p.m., respectively) in 1992 (Cosmetic Ingredient Review Expert Panel of The Cosmetics Toiletry and Fragrance Association. Final report on the Safety Assessment of methylchloroisothiazolinone and methylisothiazolinone. J Am Coll Toxicol 1992; 11: 75–128) due to a European epidemic of MCI/MI contact dermatitis, the incidence of contact allergy remains high at approximately 2% (Lundov MD, Krongaard T, Menn_e TL, Johansen JD. Methylisothiazolinone contact allergy: a review. Br J Dermatol 2011; 165: 1178–82). MI alone was introduced in industrial products in the early 2000s. Case reports of occupational contact allergy from exposure in paints followed. In 2005, MI alone was permitted in cosmetic products (maximum concentration 100 p.p.m.). Concentrations of MI in patch testing have varied, but an approximate prevalence of 1_5% has been estimated, with 0_2% aq. (2000 p.p.m.) considered the optimal test concentration. Over the past 4 years there has been suggestion of an increasing trend for sensitization. A retrospective cohort study was conducted from a database of subjects undergoing standard patch testing to the British Society of Cutaneous
Allergy (BSCA) baseline series from 2008 to June 2012. MCI/MI was tested at concentrations of 0_01% aq. (100
p.p.m.) up to 2008 and at 0_02% aq. from 2008. MI was tested at 0_02% aq. from 2009 onwards and additionally at 0_2% aq. from 2011. An increased prevalence of MCI/MI contact allergy over time was demonstrated in 4_9% of those patch tested, with a measurable increase of MI sensitivity over 3 years to 4_6%. Between January 2011 and June 2012, 6_2% of patch-tested patients had allergy to MCI/MI and/or MI at any concentration. This trend is most likely due to increased use in products, and reassessment of current usage and regulation of MCI/MI should be considered. Increased use of MCI/MI and MI could also be explained by the need for an alternative preservative to methyldibromoglutaronitrile following its prohibition from all cosmetic products in Europe since 2008. Testing MI 0_2% aq. compared with 0_02% aq. resulted in a near doubling of the detection of MI sensitivity, suggesting that future testing should involve 0_2% aq. concentrations.

2) Abstract CD02 Outbreak of contact allergy to cosmetic preservative: history repeats itself (again)
J. Mann, I. White, J. White, P. Banerjee and J. McFadden
St John’s Institute of Dermatology, St Thomas’ Hospital, London, U.K.

Methylisothiazolinone has been used in combination of 1 : 3 with methylchloroisothiazolinone as a preservative in toiletries and household products since the 1980s and is currently regulated in this combination to a level of 3_75 p.p.m. It has also been used in wall paints and in industry. This combination has represented a common cause of preservative allergy since then but usually at a reported prevalence rate of < 1_5% from patch test clinics. On the basis of in vivo reports suggesting that methylisothiazolinone is only a moderate sensitizer, it has been allowed in toiletries and household products up to a reported safe limit of 100 p.p.m. Since July 2010, methylisothiazolinone has been included in our cosmetic series. Over the last 2 years there has been a rapid rise in contact allergy to methylisothiazolinone. There were 33 cases (5_7%) in 2012, up from 18 (3_5%) in 2011 and 1 (0_5%) in 2010 (2010 vs. 2011, P < 0_05; 2010 vs. 2012, P = 0_0015). The majority of cases were women over 40 years of age: 17 (8_8%) in 2012 and 15 (7_4%) in 2011, there having been no cases in 2010 in this group. In most cases contact allergy was relevant to the presenting dermatitis (definite relevance 69%; possible relevance 31%) with onset/exacerbation of rash within the previous 2 years (71%). Sources of exposure were diverse, including moist
tissue wipes, cleansers, toners, shower gel, shave foam, mascara, hair products and washing-up liquid. Reports of high levels of methylisothiazolinone allergy are emerging from several European countries. Outbreaks of preservative allergy have been regularly observed in Europe every 5–10 years, perhaps from too high a concentration of preservative being permitted after toxicological data, which, in retrospect, did not reveal the potential hazard. That human and animal data were available for the analysis of the sensitizing potential of
methylisothiazolinone and the failure to identify the risk of sensitization when used in cosmetics at 100 p.p.m. is of considerable concern. In future, animal and human data will not be available for risk assessment when new preservatives are brought into use in Europe. This outbreak also highlights the lack of a formal reporting system at present, although cosmetovigilance is being introduced.

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A dermatology smear campaign

Certain drugs used to treat severe psoriasis in women may be associated with an increased risk of cervical cancer and patients and doctors need more awareness of this, suggests research from Glan Clwyd Hospital in Rhyl.

The research, due to be released at the British Association of Dermatologists’ Annual Conference in Liverpool next week (July 8th to 11th), retrospectively audited case notes for cervical smear documentation in female patients who had started taking the drug Ciclosporin as a treatment for psoriasis.

Ciclosporin is an immunosuppressant drug which is commonly used in the treatment of severe psoriasis (and a number of other conditions). Because it functions by suppressing the patient’s immune system it can also increase the risk of cervical abnormalities, of the type caused by the HPV virus, which are usually picked up by routine cervical screening (smear tests).

Because of the known link between immunosuppression and cervical abnormalities there is guidance in the British National Formulary that advises that when Ciclosporin is prescribed ‘exclusion of malignancies, including those of the skin and cervix’ should be undertaken prior to the medicine being given. The audit of medical notes undertaken by the researchers revealed that only 21 per cent of them had any documentation relating to this, and that only 26 per cent of patients had gynaecological records that were relevant.

Although cervical cancer is the second most common cancer in women under 35 years, the cervical screening programme, which aims to detect changes early – often when there are no symptoms – means that death rates are low compared to other cancer types, with about 1,000 women dying from the disease each year.

Many of the patients in this study would have been either too young or too old to be included in the regular cervical screening programme, which may explain the low numbers in the audit; however the authors suggest that in the immunosuppressed population, an increased frequency of cervical screening should be considered, perhaps every six months or every year.

Alison Devine, one of the research team says: “Our audit suggests that more rigorous documentation of cervical smears and history is needed when women are prescribed immunosuppressive agents such as Ciclosporin and that more information should be available to both doctors and patients about this risk. This is particularly the case as a number of patients will either be too young, or too old, to be part of the national cervical screening programme.”

Psoriasis is a common skin problem affecting about two per cent of the population. It occurs equally in men and women. The outer layer of skin (the epidermis) contains cells which are formed at the bottom and then move up towards the surface, gradually changing as they go, finally dying before they are shed from the surface. This process normally takes between three and four weeks. In psoriasis, the rate of turnover is dramatically increased within the affected skin, so that cells are formed and shed in as little as 3 or 4 days. There is also inflammation and blood vessel proliferation on the affected skin; the reasons for these are still not fully understood. Lesions of psoriasis (often known as plaques) are pink or red, and covered with silvery-white scales. They can form a variety of shapes and sizes, and have well-defined boundaries with the surrounding skin.

-Ends-

Notes to editors:

If using this study, please ensure you mention that the study was released at the British Association of Dermatologists’ Annual Conference.
The conference will be held at ACC Liverpool from July 9th to 11th 2013, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

For more information please contact: Nina Goad, Head of Communications, 0207 391 6094 (or mobile 07825567717 during conference week only) or Deborah Mason, Communications Manager, Phone: 0207 391 6355, Email: comms@bad.org.uk, Website: www.bad.org.uk

Study details: “A dermatology smear campaign” A. Devine, P.D. Yesudian and K.S. Chen Glan Clwyd Hospital, Bodelwyddan, Rhyl, U.K.

Abstract:
In the U.K., cervical cancer is the second most common malignancy in women aged under 35 years. In its early stages it may be completely asymptomatic. Screening is therefore vital and has led to a reduction in deaths from cervical cancer, although about 1000 women still die each year in the U.K. from the disease. The British National Formulary advises ‘exclusion of malignancies, including those of the skin and cervix’ prior to commencement of ciclosporin for psoriasis (British National Formulary, December 2012, 13 5 3). We retrospectively audited case notes for cervical smear documentation in female patients commenced on ciclosporin in the last 3 years in the dermatology department of our district general hospital. Cases were identified by a computer search for ciclosporin
by the hospital pharmacy. We identified 62 patients and 42 sets of notes were available for audit. Patients were
aged 15–74 years, with 17 between 16 and 40 years old (40%). Conditions treated included psoriasis (22, 52%), eczema (12, 29%), and others including urticaria, lichen planus and nodular prurigo (eight, 19%). Previous systemic immunosuppression had been taken by 26 (62%). Only nine patients (21%) had any documentation of smear history in their clinical notes prior to the commencement of ciclosporin therapy. Of note, 11 patients (26%) had gynaecological records relevant to this audit, including one patient with a history of previous severe cervical dyskaryosis requiring electrosurgical excision under general anaesthetic. We also examined whether patients had received the British Association of Dermatologists (BAD) patient information leaflet (PIL) on ciclosporin. There was documentary evidence in the notes of 14 (33%) patients that they were given this information, whereas those of 28 (66%) did not show this. Interestingly, this PIL does not mention the importance of a previous abnormal smear history. Literature review confirms an increased risk of cervical cytological abnormalities in the immunocompromised (Sasadeusz J, Kelly H, Szer J et al. Abnormal cervical cytology in bone marrow transplant recipients. Bone Marrow Transplant 2001; 28: 393–7; Ozsaran AA, Ates T, Dikmen Y et al. Evaluation of the risk of cervical intraepithelial neoplasia and human papilloma virus infection in renal transplant patients receiving immunosuppressive therapy. Eur J Gynaecol Oncol 1999; 20: 127–30). In the immunosuppressed, an increased frequency of cervical screening has been suggested, perhaps every 6 months or every year. This audit highlights the need for more rigorous documentation of cervical smears in women prescribed immunosuppressive agents. The BAD PIL for ciclosporin could perhaps be amended to mention the importance of abnormal cervical smears, highlighting this to both female patients and clinicians.

The British Association of Dermatologists is the central association of practising UK dermatologists. Our aim is to continually improve the treatment and understanding of skin disease.

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Was ‘Sex and the City’ the beginning of the end for pubic lice?

It is estimated that 10,000 species go extinct every year, however, the loss of some are mourned more than others. One species unlikely to be greatly missed is Pthirus pubis, otherwise known as the pubic louse. Much like the panda, pubic lice are being threatened with extinction due to the disappearance of their natural habitat. However this is due to deforestation of another kind - the increased popularity of ‘Brazilian waxing’.

In a presentation due to be given at the British Association of Dermatologists’ Annual Conference in Liverpool next week (8-11 July), researchers will hypothesise that the impetus behind this comprehensive approach to hair removal stems from an episode of the hit US TV show ‘Sex and the City’, first aired in 2000, which introduced an international audience to the practice.

The pubic louse has infested humans for thousands of years, with archaeologists discovering specimens in the UK as far back as the 1st century AD. The pubic louse evolved from its ancestor, the gorilla louse, about 3.3 million years ago and adapted to live in areas on the human body with a similar density of hair to that of the gorilla. Unfortunately this was a costly mistake, as a mere 3.3 million years later the international success of ‘Sex and the City’ has led to an unprecedented removal of this very hair.

A UK study showed a fourfold increase in its incidence, from 0.8% in 1954 to 3.2% in 1964, which may have been due to increased sexual freedom. However, from 1997 to 2003 a further UK study revealed a steep reduction in prevalence from about 0.41% to 0.17%. Similar observations have also been reported from sexual health specialists in Australia. A decrease in sexual activity could not have accounted for this, as the prevalence of other sexually transmitted diseases has increased.

Dr Kun Sen Chen, one of the authors of the presentation, said: ”Pubic hair removal has been practised by humans for thousands of years, by cultures from all over the world, including the Ancient Egyptians. However, until recently, with the rise of truly global mass media, pubic lice have been able to weather changing cultural attitudes to body hair.

“What we have seen at work is the law of unintended consequences, in popularising hair removal Carrie Bradshaw and co. have contributed to ridding humanity of pest that had plagued humans for millions of years. Sadly there isn’t an Emmy for that”.

Before giving all the plaudits to the writers of ‘Sex in the City’ it’s worth considering that other factors for the decline in pubic lice numbers could include the reluctance of patients to seek medical attention leading to self-treatment with over-the-counter insecticidal treatments, therefore causing a decline in recorded numbers.

The research is due to be released at the British Association of Dermatologists’ Annual Conference in Liverpool this week (July 8th - 11th).

-Ends-
Notes to editors:

If using this presentation, please ensure you mention that it was given at the British Association of Dermatologists’ Annual Conference.
The conference will be held at ACC Liverpool from July 9th to 11th 2013, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

For more information please contact: Nina Goad, Head of Communications, 0207 391 6094 (or mobile 07825567717 during conference week only) or Deborah Mason, Communications Manager, Phone: 0207 391 6355, Email: comms@bad.org.uk, Website: www.bad.org.uk

Study details: “Why Pthirus pubis don’t watch Sex and the City”; K.S. Chen and P.D. Yesudian, Glan Clwyd Hospital, Bodelwyddan, U.K.

The British Association of Dermatologists is the central association of practising UK dermatologists. Our aim is to continually improve the treatment and understanding of skin disease.

Close
Dermatologists urge hospitals not to cut on-call services

Research due to be presented at the British Association of Dermatologists’ Annual Conference in Liverpool next week (July 8th - 11th) will highlight the importance of on-call dermatology services and the need to protect these services from NHS cuts.

On-call dermatology services are regularly used by other hospital specialists and GPs and are highly valued, not least because non-dermatology specialists and generalists have little confidence in correctly identifying and managing dermatological emergencies.

Three studies will highlight the importance of out-of-hours and emergency dermatology provision in hospitals and the risks to patients inherent in cutting these services.

One study, by researchers at St George’s Hospital in London, showed a worrying lack of knowledge and confidence in the management of acute dermatological emergencies by non-dermatology professionals.

The researchers asked a group made up of GPs, non dermatology specialists and trainees to identify a dermatological condition from a case vignette and image. 23 per cent of hospital respondents (non-dermatology) correctly identified the dermatology emergency compared with 85 per cent of dermatology trainees and 43 per cent of GPs. These results by specialty were: paediatrics 52 per cent, general medicine 22 per cent, emergency medicine 22 per cent, intensive care 15 per cent and obstetrics and gynaecology five per cent.

Respondents were asked to rate their confidence in managing each condition. Overall, only one per cent of non-dermatology hospital specialists strongly agreed with the statement “I would feel confident initiating treatment, instructing nursing staff and managing” patients with acute skin conditions, and 44 per cent strongly disagreed with this statement. In contrast 39 per cent of dermatology trainees strongly agreed with the statement and two per cent strongly disagreed.

Regarding support for out-of-hours dermatology provision, 82 per cent of GPs and hospital specialists valued the service. The remaining eight per cent thought this was service was “possibly helpful” and no respondents chose the option “cannot see the need”.

Dr Vanessa Pinder, one of the St George’s study’s authors, said: “Our study shows that general medicine is not well equipped to manage dermatology emergencies. There was poor recognition of emergency dermatological presentations, with a lack of confidence in managing potentially life-threatening conditions. Despite this, on-call dermatology is under threat, with an increasing number of hospitals no longer providing emergency cover. These changes have been made with scant regard for how dermatological emergencies will be managed. With the increasing financial pressure on the National Health Service this trend is likely to continue, and dermatology is particularly vulnerable as the potential for skin disease to cause life-threatening and serious illness is not well recognized.”

Two further studies involved audits of all urgent, on-call referrals to Dermatologists and found that, despite pressure to cut on-call care, it offers a crucial service for patients, as well as invaluable training experience for junior doctors.

The first study was carried out at Northampton General Hospital over a four-month period (September to December 2012). Referrals here are made to a dermatology registrar in a district general hospital, with no out-of-hours, on-call service.

The total number of referrals was 63, with the vast majority from other hospital specialties requesting an inpatient review (medical specialties 59%, surgical specialties 21%, paediatrics 5% and intensive treatment unit 3%), followed by the emergency department (9%) and other specialty clinics (rheumatology and haematology: 3%).

68% of patients were seen on the same day, 24% within 24 hours and 6% within 72 hours, the remaining 2% were seen within one week of referral. In 63% of cases the referral asked for identification of a rash, 10% queried diagnosis of a lesion, 10% requested a review of an existing dermatological condition and 16% requested support with the diagnosis and management of leg ulcers.

The second study looked at 90 on-call referrals over a 10-week period (September 2012 to November 2012) at Portsmouth Hospitals NHS Trust. They found an even distribution between referrals from secondary care (53%) and primary care (47%). Of the inpatient referrals received, the majority were from medical departments (77%), followed by paediatrics (7%), intensive care (7%), surgical departments (3%), emergency department (3%) and obstetrics and gynaecology (3%). Of all the referrals received, 49% required an urgent outpatient appointment, 33% required inpatient review and 18% telephone advice.

Nina Goad of the British Association of Dermatologists said: “Hopefully these audits will help to demonstrate to commissioners and managers that on-call dermatology services are greatly valued, by clinicians and patients alike. They are also a vital training tool for registrars. There is a misapprehension that dermatology does not warrant emergency or out-of-hours provision, but this fails to recognise the severity of many skin issues, such as drug reactions. To limit on-call services would be to the detriment of other hospital departments and most importantly to patient care.”

-Ends-
Notes to editors:

If using this study, please ensure you mention that the study was released at the British Association of Dermatologists’ Annual Conference.
The conference will be held at ACC Liverpool from July 9th to 11th 2013, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

For more information please contact: Nina Goad, Head of Communications, 0207 391 6094 (or mobile 07825567717 during conference week only) or Deborah Mason, Communications Manager, Phone: 0207 391 6355, Email: comms@bad.org.uk, Website: www.bad.org.uk

Study details:
P33: An audit of acute dermatology referrals at a district general hospital, B. Shaheen and C. Soon, Northampton General Hospital, Northampton, U.K.
P34: Dermatology on-call service: is it really necessary? N. Anjum, L.H. Lee, A. Haworth and B. Hughes, Portsmouth Hospitals NHS Trust, Portsmouth, U.K.
P37: An audit to support the need for emergency dermatology training, V. Pinder, F. Worsnop, J. Wee and L. Ostlere, St George’s Hospital, Tooting, U.K.

The British Association of Dermatologists is the central association of practising UK dermatologists. Our aim is to continually improve the treatment and understanding of skin disease.  

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