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Development of contact allergy and allergic contact dermatitis is on the increase – in spite of preventive measures and increased awareness.

In a study, published in the British Journal of Dermatology1, a team of researchers in Denmark2 looked at the incidence rate and persistence of contact allergy and allergic contact dermatitis in a group of 8th grade school children followed up 15 years later.

The study showed that cases of allergic contact dermatitis to nickel had not only persisted but had increased in number - despite increased awareness and preventative measures having been introduced, such as the EU Nickel Directive.

Contact allergy and allergic contact dermatitis occur when the skin comes into contact with a specific contact allergen in the environment – commonly things like nickel, perfume in cosmetic products, ingredients in hair dye. It is a condition that can have a big impact on sufferers lives and may affect their ability to work, accounting for 70-90% of all occupational skin disorders.3

Deborah Mason, spokesperson for the British Association of Dermatologists, said: “It is interesting that this study found that nickel was still the most common contact allergen, with new cases occurring despite the EU Nickel Directive that limits the amount of nickel released from items of jewellery. The British Society for Cutaneous Allergy has recently publicised its concern that the Royal Mint are producing nickel-plated coins in the UK4. Whilst this may not contravene the EU Directive, the continuing prevalence of nickel as a contact allergen in the general population adds to concerns about nickel in coins and the risk of allergic contact dermatitis especially in people who handle coins at work.”

This study was the first to study both contact allergy and allergic contact dermatitis developing from adolescence to adulthood. To do this the research group had access to the Odense Adolescence Cohort Study which was conducted in 1995-1996. The same researchers from 1995 were able, in 2010, to use the same questionnaires, interviews and clinical examinations in order to conduct the 15 year follow up. In 1995 the cohort was circa. 14 years old, in 2010 the participants were circa. 28-30 years of age.5

The results showed that the prevalence at time of testing of contact allergy increased from 15.1% (of those studied) to 20.1% and that reported past or present allergic contact dermatitis increased from 7.2% to 12.9%.6

In the 15 years between the first observation and the most recent one, several new cases of contact allergy and allergic contact dermatitis had developed. The contact allergen causing the greatest number of new cases was Nickel which the researchers found surprising because in the intervening period the nickel regulations of 1990 would have been fully implemented.

In 2010 the most common sensitisers (found in things like jewellery, sticking plasters, and hair dyes) were nickel sulphate, cobalt chloride, colophony, thimerosal and p-phenylenediamine.7 The researchers noted that the drop in prevalence of sensitivity to Fragrance Mix I might be explained by the replacement of old fragrance chemicals by new ones in cosmetic products.

Charlotte Gotthard Mørtz, one of the researchers said “The results suggest that Fragrance mix 1 is now a poor marker for history of eczematous skin reactions to perfumed products, it seems likely that many of the ingredients have now been superseded in cosmetic products by newer ones.”

Notes to editors:

1. The information in this press release is embargoed until 00:01 on 30th November 2012. If using this information, please ensure you mention that the study is being released in the British Journal of Dermatology, the official publication of the British Association of Dermatologists
For more information please contact: Deborah Mason, British Association of Dermatologists, Phone: 0207 391 6349, Email: comms@bad.org.uk, Website: www.bad.org.uk

2. C. G Mortz, C. Bindslev-Jensen, K. E. Andersen, Department of Dermatology and Allergy Centre, Odense University Hospital, University of Southern Denmark, DK-5000 Odense C, Denmark

3. Nicholson P J & Llewellyn D (Editors). Occupational contact dermatitis & urticaria. British Occupational Health Research Foundation. London. 2010. Research Working Group. Occupational contact dermatitis & urticaria. Systematic review & recommendations. British Occupational Health Research Foundaton. London. 2010. Review date 2015. ISBN 978-0-9564949-0-1
4. Letter from David Gawkrodger & Ian White to The British Medical Journal in April 2012 “Allergy risk from Royal Mint’s new nickel plated steel coins should be publicly assessed.” BMJ 2012;344:e2730 (Published 19 April 2012)

5. The Odense Adolescence Cohort Study is a cohort of 1501 unselected 8th grade schoolchildren established 15 years ago with the aim to follow the course of contact allergy and allergic contact dermatitis from school age to adult life.

6. Contact allergy was defined as a positive patch test using True®Test. Allergic Contact Dermatitis is defined as a the consequence of exposure to a contact allergen exceeding an individual threshold concentration in a contact-sensitised person. The cross sectional study included questionnaires, interviews and clinical examinations, blood samples for IgE measurement and patch tests. Phase two was conducted in 1996-7 as a case-control study in selected groups of school children. Phase three is a 15 year follow up study in the same population and the examination and testing was undertaken by the same investigator who performed the phase one and two studies.

7 Common sensitisers;
Nickel Sulphate (11.8%) – nickel is commonly used in jewellery, metal plating and coinage
Cobalt chloride (2.3%) – used in metal plating
Colophony (2.0%) is a type of plant resin (it is also sometimes called rosin) It has a variety of uses including as the glue in sticking plasters, it can also be found in printing ink, varnishes, glue, soap, paper.
Thimerosal (1.4%) is an organomercury compound used as an anti-fungal and anti-septic
p-phenylenediamine (1.1%) – also known as PPD it is commonly used as a dye and can be found in many hair dyes.


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. The British Journal of Dermatology (BJD) strives to publish the highest quality dermatological research. In so doing, the journal aims to advance understanding, management and treatment of skin disease and improve patient outcomes. BJD is an official organ of the British Association of Dermatologists but attracts contributions from all countries in which sound research is carried out, and its circulation is equally international. The overriding criteria for publication are scientific merit, originality and interest to a multidisciplinary audience. Journal content and further information-including author guidelines and submission details-can be found online at www.brjdermatol.org. The 2011 impact factor is 3.666

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Dopamine, a key neurotransmitter in Parkinson’s disease, may have novel use in fighting unwanted hair growth

Following reports of patients suffering hair loss during treatment for Parkinson’s Disease, scientists have discovered that a neurotransmitter* associated with the disease may have a new use in the fight against unwanted excess hair, new research published the British Journal of Dermatology reveals. 

Researchers at The University of Manchester as well as research centres in Germany and Hungary looked at the role of a chemical called dopamine in relation to hair growth and discovered that, when tested in the laboratory, dopamine increases the number of hair follicles that are in the catagen phase of the hair cycle, the period at which the hair stops growing and prepares to fall out.

Dopamine is a neurotransmitter produced in the brain that has many functions in the body, including in behavioural roles such as reward seeking behaviour. Decreased levels of dopamine are associated with several common disorders, including Parkinson’s Disease and Restless Leg Syndrome. A drug called L-DOPA or levodopa is commonly used in the treatment of Parkinson’s to replace depleted dopamine levels caused by the disease.

Anecdotally, treatment with levodopa or other chemicals that imitate the actions of dopamine have been associated with diffuse hair loss, predominantly in women. Given the widespread use of both dopamine agonists and antagonists (i.e. drugs that either mimic or inhibit dopamine actions) in clinical practice, the researchers examined whether dopamine can directly alter human hair follicle growth.

The scientists found that treating healthy human scalp hair follicles with 1000nM of dopamine, in a laboratory setting rather than on living subjects, more than doubled the percentage of hair follicles in catagen, i.e. of “hair factories” that have stopped producing a hair shaft. Around 19 per cent of hair follicles were in catagen in the control group compared to 53 per cent of hair follicles treated with dopamine 1000nM in the laboratory.

Ralf Paus, Professor of Cutaneous Medicine at The University of Manchester and one of the study’s authors said: “This study provides the first direct evidence that dopamine treatment negatively affects human hair growth, namely that it pushes hair follicles out of their phase of growth and active hair shaft production. This is entirely consistent with case reports of hair loss in women being treated with dopamine agonists.”

Nina Goad of the British Association of Dermatologists said: “This is a perfect example of research confirming the experiences of patients that have been reported but not previously backed up by any hard clinical data. Having this scientific evidence may lead to new treatments for hirsutism - when an individual grows too much body or facial hair, which can cause huge embarrassment and greatly alter their quality of life. In principle, it is conceivable that dopamine could be selectively administered externally to hirsute skin in a cream or lotion.”

Ends

*Neurotransmitters are the molecules that the nervous system uses for communication between cells.

Notes to editors:

1. If using this information, please ensure you mention that the study is being released in the British Journal of Dermatology, the official publication of the British Association of Dermatologists

2. For more information please contact: Nina Goad, British Association of Dermatologists, Phone: 0207 391 6094, Email: nina@bad.org.uk, Website: www.bad.org.uk

3. Articles in the BJD can be viewed online: www.brjdermatol.org
British Journal of Dermatology: Dopamine is a novel, direct inducer of catagen in human scalp hair follicles in vitro.
E.A. Langan,1,2 E. Lisztes,3 T. Bíró,3 W. Funk,4 J.E. Kloepper,2 C.E.M. Griffiths1 and R. Paus1,2
1Dermatology Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Manchester, U.K.
2Experimental Dermatology, Universitätsklinikum Schleswig Holstein, Lübeck, Germany
3DE-MTA ‘Lendulet’ Cellular Physiology Research Group, Department of Physiology, University of Debrecen, H-4032 Debrecen, Hungary
4Clinic Dr Kozlowski, Munich, Germany
DOI REFERENCE: DOI 10.1111/bjd.12113
Accepted for publication, 7th October 2012


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.

Wiley-Blackwell, created in February 2007 by merging Blackwell Publishing with Wiley's Global Scientific, Technical, and Medical business, is now one of the world's foremost academic and professional publishers and the largest society publisher. With a combined list of more than 1,400 scholarly peer-reviewed journals and an extensive collection of books with global appeal, this new business sets the standard for publishing in the life and physical sciences, medicine and allied health, engineering, humanities and social sciences. For more information visit www.wiley.com

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Itching can have a visual trigger, British Journal of Dermatology reveals

Itching is so contagious that just seeing a photo of something we imagine would itch – like ants or an insect bite – can trigger a physical response, new research suggests; the authors say their findings could be of benefit to patients with skin conditions like eczema.

Writing in the British Journal of Dermatology, researchers from Liverpool John Moores University (LJMU) and The University of Manchester tested whether visual cues could generate feelings of itch and provoke a scratch response. A secondary aim was to assess whether the content of some pictures more effectively evoked these sensations. The study also revealed that simply watching someone scratch may trigger feelings of itchiness, just like seeing someone yawn can be contagious.

Thirty participants viewed static images that could either be itch-related (for example ants, fleas or skin conditions) or neutral (butterflies or healthy skin). The itch-evoking images were further split into three sub-categories: ‘skin contact’ (for example ants crawling on the hand or a butterfly on a finger), ‘skin response’ (scratching an insect bite or washing the hands) or ‘context only’, in which itchy or neutral stimuli were seen in the environment but not on the body (for example viewing midges or birds flying, with no reference to skin).

For each picture, the volunteers were asked how itchy they felt looking at the image, and how itchy they thought the person in the picture felt, where relevant. In addition, the researchers recorded the number of times the volunteers scratched themselves while looking at the images.

The scientists discovered that visual cues alone (without application of any irritant to the skin) do indeed elicit sensations of itch in an observer and provoke a scratch response.

Furthermore, watching something that we associate with itchiness causes us to admit to feeling itchy, but in fact it is watching another person scratch themselves (rather than just seeing the cause of the itch) that causes us to subconsciously scratch ourselves also, without necessarily vocalising this or knowing we are doing it.

Professor Francis McGlone, a cognitive neuroscientist at LJMU and the study’s lead author, explained: “The results of the present study confirm that visual cues pertaining to itch-related events are effective in transmitting the sensation of itch from the visual to the somatosensory domain (the body’s system relating to the sensation of touch) and provoking a scratch response. The results suggest that, whereas the sensation of itch may be effectively transmitted by viewing others experiencing itch-related stimuli on the body, the desire to scratch is more effectively provoked by viewing others scratching.
“Our findings may help to improve the efficiency of treatment programmes for people suffering from chronic itch. Knowing the specific triggers of an individual’s chronic itch and how visual stimuli translate to the physical may also provide insight into the mechanisms of ‘psychosomatic itch’, in which there are no physical triggers.”

Nina Goad of the British Association of Dermatologists said: “Itch is often the worst symptom for people with skin disorders, and any research into its causes that may lead to new methods of alleviation will be greatly welcomed by the millions of skin patients. Combining elements of psychology with dermatology is an increasingly important area of research.”

Ends

Notes to editors:

1. If using this information, please ensure you mention that the study is being released in the British Journal of Dermatology, the official publication of the British Association of Dermatologists

2. For more information please contact: Nina Goad, British Association of Dermatologists, Phone: 0207 391 6094, Email: nina@bad.org.uk, Website: www.bad.org.uk

3. Articles in the BJD can be viewed online: www.brjdermatol.org
British Journal of Dermatology: Can itch-related visual stimuli alone provoke a scratch
response in healthy individuals? D. M. Lloyd1, E. Hall1, S. Hall1 and F. P. McGlone2*
1School of Psychological Sciences, University of Manchester, M13 9PL
2School of Natural Sciences & Psychology, Liverpool John Moores University, L3 3AF
 

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.

Wiley-Blackwell, created in February 2007 by merging Blackwell Publishing with Wiley's Global Scientific, Technical, and Medical business, is now one of the world's foremost academic and professional publishers and the largest society publisher. With a combined list of more than 1,400 scholarly peer-reviewed journals and an extensive collection of books with global appeal, this new business sets the standard for publishing in the life and physical sciences, medicine and allied health, engineering, humanities and social sciences. For more information visit www.wiley.com

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Screening for genetic markers in the blood of melanoma patients could improve chances of survival

Scientists have discovered the tumour cells which make melanoma patients more likely to have their cancer spread or come back following treatment, according to a study published in the British Journal of Dermatology.

A team of researchers in Western Australia and Boston in the U.S. looked at the role of melanoma cells circulating in the blood of patients who had already been diagnosed with the disease, and how these cells relate to recurrence of the disease and treatment efficacy. The aim of the research was to identify those subgroups of patients who are more likely to suffer disease recurrence or poor treatment outcomes, in order to provide them with more targeted treatments at an earlier stage, which could improve survival rates.

The study was the first to measure not only the presence of less aggressive cancer cells spread by melanoma tumours into the bloodstream, but also the presence of the destructive minority of cancer ‘stem’ cells, which represent the driving force behind the growth of tumours. To do this, blood was collected from 230 patients with both primary melanoma (where it has not spread) and metastatic melanoma (spreading to other parts of the body), and compared with the blood of 152 healthy controls.

The researchers found that the presence of tumour cells in a person’s blood alone does not necessarily correlate with disease spread or recurrence, as these cells can still be present even when a patient is considered clinically disease free. It is in fact the behaviour and characteristics (phenotype) of these cells that is particularly important.

Therefore, a test for the different genes produced by tumour cells was used to identify those patients more likely to have their cancer spread or come back following treatment. The researchers looked at five different ‘genetic markers’, which are genes or pieces of DNA that allow scientists to tell what different cells are doing. These markers are all found in melanoma tumour cells, of which there are many different types.

The presence and level of different genetic markers in the blood was shown to be useful in assessing a patient’s disease spread, response to treatment, and risk of relapse.

The results revealed increased levels of one gene, called the MCAM marker, correlated with patients whose melanoma had spread to other parts of the body. The link between MCAM genes and a poor response to therapy was also confirmed in the findings, with higher levels of MCAM seen in patients whose treatment had been unsuccessful. 40 of the 62 patients with late stage (IV) melanoma in the study had a negative treatment outcome (progression and/or death); 43% of this subgroup expressed the MCAM marker in their blood.

Lead author of the study, Dr Ziman of the Edith Cowan University, Perth, said: “Patients with metastatic (spreading) melanoma have, to date, shown a poor response rate to conventional treatments. MCAM expression could now be used to monitor treatment resistance, and help to identify a subset of patients who may benefit from an alternative treatment regime.”

The scientists also looked at recurrence of the disease, and were able to identify that two markers called MLANA and ABCB5 were linked with relapse. In the 73 patients who had a relapse, these markers were found to be expressed considerably more frequently (45% and 49% respectively) than in patients without recurrence (23% and 34% respectively). Therefore, the specific detection of ABCB5 and MLANA expressing tumour cells in a patient’s blood could be a valuable predictor of clinical outcome and disease recurrence. The ABCB5 gene marks a subset of rare, chemotherapy-resistant melanoma stem cells.

Another of the study’s authors, Markus Frank, Assistant Professor of Paediatrics and Dermatology at the Harvard Medical School, said: “This has very important implications for melanoma patients. The development of a minimally invasive method of measuring the frequency of melanoma cells, and melanoma stem cells in particular, can be used to follow patient responses to current or novel and emerging melanoma therapies. In turn this will help determine if a particular therapy is capable of eliminating the aggressive cancer stem cell population required for the complete eradication of the cancer, potentially achieving a cure.”

Melanoma is the deadliest form of skin cancer, which is the most common cancer type in the UK. There are approximately 13,000 new cases of melanoma diagnosed every year in the UK and 2,300 deaths.

Kimberley Carter of the British Association of Dermatologists said: “Melanoma has a high potential to spread and patients who develop distant metastases, where the cancer spreads to remote parts or organs of the body, currently only have a ten year survival rate of 16 per cent. Therefore, studies like this one which look to find methods of detecting melanoma spread at early stages are critical to care of melanoma patients. Research of this kind will hopefully help to deliver more accurate and targeted treatments to melanoma patients in the future, especially those who have not responded well to first-line treatments.”

Five genetic markers in the patients’ blood were examined: MLANA, PAX3d, TGFβ2, MCAM and ABCB5. MLANA and PAX3d are both expressed by melanocyte cells, TGFβ2 and MCAM are both tumour cell markers, and ABCB5 is a stem cell marker. MCAM is a known marker of melanoma tumour progression.

ENDS

 

 

Notes to editors:

1. If using this information, please ensure you mention that the study is being released in the British Journal of Dermatology, the official publication of the British Association of Dermatologists
For more information please contact: Kimberley Carter, British Association of Dermatologists, Phone: 0207 391 6084, Email: kimberleycarter@bad.org.uk, Website: www.bad.org.uk

2. Articles in the BJD can be viewed online: www.brjdermatol.org
British Journal of Dermatology: Markers of circulating tumour cell in the peripheral blood of melanoma patients correlates with disease recurrence and progression.
A.L. Reid1 M. Millward2, R. Pearce1, M.Lee2, M.H. Frank3, A. Ireland2, L. Monshizadeh2, T. Rai1 and M. Ziman14
1. School of Medical Sciences, Edith Cowan University, Perth, WA, Australia
2. Department of Medicine and 4. School of Pathology and Laboratory Medicine, University of Western Australia, Crawley, Australia
3. Transplantation Research Center, Children’s Hospital Boston and Brigham & Women’s Hospital, Harvard Medical School, Boston, MA, U.S.A
Accepted for publication 14 September 2012

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.

Wiley-Blackwell, created in February 2007 by merging Blackwell Publishing with Wiley's Global Scientific, Technical, and Medical business, is now one of the world's foremost academic and professional publishers and the largest society publisher. With a combined list of more than 1,400 scholarly peer-reviewed journals and an extensive collection of books with global appeal, this new business sets the standard for publishing in the life and physical sciences, medicine and allied health, engineering, humanities and social sciences. For more information visit www.wiley.com

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Vitiligo patients three times less likely to get skin cancer, study reveals

People with vitiligo, one of the most common skin diseases, are three times less likely to develop skin cancer, new research due to be published in the British Journal of Dermatology will reveal.

Vitiligo is a condition in which areas of skin lose their normal pigment and so become white. It is common, affecting about one in every hundred people in the world, and as it can be very visible, it is often a psychological burden to patients.

However a study carried out by researchers in The Netherlands has discovered that vitiligo patients have a threefold lower chance of developing both melanoma, the least common but deadliest type of skin cancer, and non-melanoma skin cancers, which are less dangerous but more common.

The scientists compared skin cancer rates in 1307 vitiligo patients, compared to 788 control subjects without vitiligo. They also examined other factors that might influence skin cancer development, such as sun exposure, number of sunburns in childhood, sun protective measures, outdoor work or hobbies and the individual’s number of moles, and these variables were factored into the results.

Of the 1307 patients with vitiligo who answered the survey, seven (0.54%) had been diagnosed with melanoma during their lifetime. All melanomas had occurred in areas of skin not affected by the vitiligo. Of the 788 non-vitiligo controls, 12 individuals (1.53%) had been diagnosed with 14 melanomas. When the results were adjusted for other risk factors, vitiligo remained associated with a threefold decreased likelihood of developing this skin cancer

The results were similar for non-melanoma skin cancers (basal cell carcinoma and squamous cell carcinoma). 30 of the vitiligo patients had been diagnosed with a total of 37 basal cell carcinomas (BCCs) during their lifetimes. In addition, five patients with vitiligo had each been diagnosed with one squamous cell carcinoma (SCC), and one patient had experienced one BCC and one SCC (a total of 44 non-melanoma skin cancers in 36 patients). In the control group, 47 of 788 non-vitiligo volunteers had been diagnosed with a total of 61 BCCs, and four patients had suffered an SCC (a total of 65 non-melanoma skin cancers in 51 patients). When adjusted for all risk factors that were significantly associated with non-melanoma skin cancer development in the analysis, patients with vitiligo had a threefold decreased probability of non-melanoma skin cancer.

Dr Hansje-Eva Teulings in the group of drs Wietze van der Veen and Rosalie Luiten of the Department of Dermatology at the Academic Medical Center of the University of Amsterdam said: “We observed a significant threefold lower odds for melanoma during lifetime in vitiligo patients. The anti-melanocyte immune response in vitiligo, in which melanocytes are destroyed in the skin, may be responsible for the observed decrease in melanoma lifetime prevalence.
We also found that patients with vitiligo have a threefold decreased probability of developing non-melanoma skin cancer during their lifetime. This finding seems to be counterintuitive, as the lack of protective pigmentation is supposed to increase the risk of these cancers. The lower probability may relate to the observed decreased photodamage and increased levels of wild-type p53 expression in keratinocytes (skin cells) in patients with vitiligo. This is a tumour suppressor which may protect against UV damage and the development of keratinocyte cancer.”

Nina Goad of the British Association of Dermatologists said: “A very interesting aspect of this study is that no increased skin cancer prevalence was seen in phototherapy-treated patients compared with patients who had never undergone phototherapy. This differs from patients with another common skin disease, psoriasis, where long-term phototherapy treatment has been linked to an increases risk of some skin cancers. As phototherapy is one of the recommended treatments for vitiligo, this may prove a very positive finding.

“Similarly, vitiligo patients may worry that their paler patches of skin are more likely to develop skin cancer, as it is generally known that people with fairer skin types are more at risk of the disease. However this is not the case for skin that is affected by vitiligo.
“Vitiligo can have a strong psychological and emotional impact as it can be very visible, especially in darker skin types, so any research that eases the burden on these patients is most welcome.”

The pigment that gives skin its normal colour is melanin, which is made by cells called melanocytes. In patches of vitiligo the melanocytes are absent, and the reason for this is not fully understood. However, vitiligo is considered to be an autoimmune condition in which the body’s own immune system rejects some of its own tissues (melanocytes in the case of vitiligo). It affects men and women of all ethnicities equally, but is most obvious in people with dark skin.

Notes to editors:

1. If using this information, please ensure you mention that the study is being released in the British Journal of Dermatology, the official publication of the British Association of Dermatologists

2. For more information please contact: Nina Goad, British Association of Dermatologists, Phone: 0207 391 6094, Email: nina@bad.org.uk, Website: www.bad.org.uk

3. Articles in the BJD can be viewed online: www.brjdermatol.org
British Journal of Dermatology: Decreased risk of melanoma and nonmelanoma skin cancer in patients with vitiligo: a survey among 1307 patients and their partners
H.E. Teulings,1,2 M. Overkamp,1 E. Ceylan,1 L. Nieuweboer-Krobotova,1,2 J.D. Bos,1 T. Nijsten,3 A.W. Wolkerstorfer,1 R.M. Luiten1 and J.P.W. van der Veen1,2
1 Department of Dermatology and the Netherlands Institute for Pigment Disorders (SNIP), Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
2 Skin and Melanoma Center, the Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (NKI-AVL), Amsterdam, the Netherlands
3Department of Dermatology, Erasmus Medical Center, Rotterdam, the Netherlands.
DOI REFERENCE:TBC (request from press office), Accepted for publication, 7.10.12

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.

Wiley-Blackwell, created in February 2007 by merging Blackwell Publishing with Wiley's Global Scientific, Technical, and Medical business, is now one of the world's foremost academic and professional publishers and the largest society publisher. With a combined list of more than 1,400 scholarly peer-reviewed journals and an extensive collection of books with global appeal, this new business sets the standard for publishing in the life and physical sciences, medicine and allied health, engineering, humanities and social sciences. For more information visit www.wiley.com

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Psychological Interventions benefit people with skin conditions report concludes

The symptoms of some of the most common skin diseases could be alleviated through psychological interventions, according to a study released today in the British Journal of Dermatology.

While it is accepted that psychological interventions can help with the emotional impact that many skin diseases entail, this study reveals that such services can actually improve physical symptoms also.

In a study, published in the British Journal of Dermatology1 this week, a team from the Department of Psychology at the University of Sheffield2 carried out an analysis of previous studies and concluded that psychological interventions did provide benefit to patients with skin conditions.3

It is accepted that skin conditions can be associated with psychological distress and interventions targeting this, such as habit reversal, relaxation, cognitive behavioural therapy (CBT) and other psychological interventions have been developed to manage this4. However the effectiveness of these interventions has not, until now, been systematically reviewed.

From a meta-analysis of 22 studies involving over 900 participants the team at the University of Sheffield concluded that there was evidence of benefit but also that there was also a need to develop further specific interventions and to conduct more rigorous evaluation of these, including assessments of effects over longer follow-up periods and a wider-range of skin conditions.

From the evaluation they found that psychological interventions had a medium-sized effect on skin conditions but that a number of different factors influenced the effectiveness of the interventions, including: the type of intervention, the time interval between the end of the intervention and follow up, and the type of outcome measure (itch/scratch reduction, psychosocial outcomes)

Psychological interventions had:
• a large size effect on itch/scratch
• a medium size effect on psychological outcomes
• a medium size effect on skin severity

The larger effect on itch/scratch may have occurred because changes in behavioural factors (e.g., the extent of itching) need to take hold first to help facilitate gains elsewhere (e.g., severity of the condition).

The number of skin conditions represented by the study was small but a medium sized effect was seen for interventions treating psoriasis and atopic dermatitis (eczema). The analysis showed that psychological interventions generally had less effect on skin conditions accompanied by pain.

From the studies analysed only four types of intervention were well enough represented for analysis: Habit reversal, CBT, Arousal Reduction and Combined Techniques.

Habit reversal had the largest effect size, followed by CBT (medium to large) and arousal reduction and combined techniques (medium). Although the duration of the intervention did not have a great impact on effectiveness, the length of time between the end of the intervention and the follow up did have a significant impact with longer follow up periods being associated with smaller effects, suggesting that there may be a need to provide ‘booster sessions’. Group therapies appeared to be as effective as one-to-one sessions.

However, the authors also drew attention to the finding that age was negatively associated with effect sizes, such that the older the person was, the less effective the psychological intervention was. They concluded that interventions may require modification so as to be able to better address the needs of older patients.

The authors of the study concluded that there is now evidence that psychological interventions should be made more widely available within dermatology services and that some interventions such as habit reversal could be delivered in nurse-led clinics. Complex cases should still be referred to mental health professionals for consideration with treatment with formal psychotherapies such as CBT. However, the team were also keen to point out that there remain relatively few studies in this area and only a narrow range of interventions have been developed and evaluated. Consequently, further research is needed to develop interventions targeting specific problems. In addition, psychological interventions also require evaluation across a wider range of skin conditions and with the use of more robust methods (e.g., randomized controlled trials).

ENDS
NOTES

Notes to editors:

1. The information in this press release is embargoed until 00:01 on 26 August 2012. If using this information, please ensure you mention that the study is being released in the British Journal of Dermatology, the official publication of the British Association of Dermatologists
 

For more information please contact: Deborah Mason, British Association of Dermatologists, Phone: 0207 391 6355, Email: deborah@bad.org.uk, Website: www.bad.org.uk (Mon-Wed) or Comms Team on 020 7391 6084 email comms@bad.org.uk (Thur-Fri)

2. Department of Psychology, University of Sheffield, Western Bank, Sheffield, S10 2TN
3. Articles in the BJD can be viewed online: www.brjdermatol.org
British Journal of Dermatology: A meta-analysis of the effectiveness of psychological interventions for adults with skin conditions. A.C. Lavda, T.L. Webb, A.R. Thompson. The Department of Psychology, University of Sheffield
4. Interventions include: psychodynamic psychotherapy (targeting underlying psychopathology via exploration of unconscious conflicts); cognitive behavioural therapy (CBT; which aims to modify unhelpful cognitions and behaviours associated with coping or/and treatment adherence); arousal reducing techniques – such as relaxation or meditation; behavioural therapies including habit reversal (which aims at modification of unhelpful behaviours such as scratching); and written emotional disclosure (expression of distress through writing)


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.
The British Journal of Dermatology (BJD) strives to publish the highest quality dermatological research. In so doing, the journal aims to advance understanding, management and treatment of skin disease and improve patient outcomes. BJD is an official organ of the British Association of Dermatologists but attracts contributions from all countries in which sound research is carried out, and its circulation is equally international. The overriding criteria for publication are scientific merit, originality and interest to a multidisciplinary audience. Journal content and further information-including author guidelines and submission details-can be found online at www.brjdermatol.org. The 2011 impact factor is 3.666.
The University of Sheffield:
With nearly 25,000 students from 125 countries, the University of Sheffield is one of the UK’s leading and largest universities. A member of the Russell Group, it has a reputation for world-class teaching and research excellence across a wide range of disciplines.
The University of Sheffield has been named University of the Year in the Times Higher Education Awards for its exceptional performance in research, teaching, access and business performance. In addition, the University has won four Queen’s Anniversary Prizes (1998, 2000, 2002, 2007). These prestigious awards recognise outstanding contributions by universities and colleges to the United Kingdom’s intellectual, economic, cultural and social life. Sheffield also boasts five Nobel Prize winners among former staff and students and many of its alumni have gone on to hold positions of great responsibility and influence around the world.
The University’s research partners and clients include Boeing, Rolls Royce, Unilever, Boots, AstraZeneca, GSK, ICI, Slazenger, and many more household names, as well as UK and overseas government agencies and charitable foundations.
The University has well-established partnerships with a number of universities and major corporations, both in the UK and abroad. Its partnership with Leeds and York Universities in the White Rose Consortium has a combined research power greater than that of either Oxford or Cambridge.
For further information, please visit www.sheffield.ac.uk

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Unanswered questions in the treatment of Eczema – a step forward

The Eczema Priority Setting Partnership is a collaborative partnership of patients, carers, clinicians and researchers set up to identify and prioritise important research questions for the treatment of eczema.

Until now there has been no attempt to identify uncertainties in eczema treatment that are important to both patients and healthcare providers. The Eczema Priority Setting Partnership will report on their work at the British Association of Dermatologists’ Annual Conference in Birmingham this week (July 3rd to 5th).1

The partnership was made possible by the support of the James Lind Alliance 2 which provides a process and infrastructure to help patients and healthcare providers to work together to identify important treatment uncertainties to guide the future research agenda.

The objectives of the Eczema Priority Setting Partnership were to work with patients and clinicians to identify uncertainties; to publicize the results of the Priority Setting Partnership; and to submit the results to research commissioning bodies.

Jonathan Batchelor, one of the dermatologists involved in the project, says “Eczema is a common skin condition and in many cases it can last for years. Sufferers can often feel that things they would most like to see change aren’t being addressed by the research community. A priority setting partnership, such as this one, gives patients a voice. Even more importantly, it allows a dialogue between the clinicians, the researchers and the patients so that no single group has a louder voice than the other, creating a balanced and useful outcome for all.”

“In times of austerity it is particularly important that any funds available for research are spent in the areas that will make the greatest difference – providing these research questions for funders and researchers will help to make that happen.”

Working through a Steering Group (comprising patients, clinicians, researchers and representatives from the James Lind Alliance) input was also drawn from patient groups, health professionals and carers. The project had three phases:
Phase one: A survey to collect treatment uncertainties. This yielded 1071 uncertainties from 493 participants submitting up to five eczema treatment uncertainties.3
Phase two: a ranking exercise which reduced this list to 14 prioritized uncertainties – these included topical treatments (topical steroids, calcineurin inhibitors, emollients and bathing); systemic treatments (including immunosuppressants); allergy testing and diet (role of allergy testing, avoidance of irritants, role of diet) education and habit-reversal interventions.4
Phase three: saw these prioritised uncertainties developed into research questions at a workshop attended by 34 patients, health professionals and researchers.

This press release presents independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research funding scheme (“Setting Priorities and Reducing Uncertainties for the Prevention and Treatment of Skin Disease 2008 – 2013”, RP-PG-0407-10177). The views expressed in this press release are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.


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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 ICC Birmingham, 3rd to 5th July 2012, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

For more information please contact: Deborah Mason, British Association of Dermatologists, Communications Manager, Phone: 0207 391 6355 or 07957 145992 (mobile during conference week only), Email: deborah@bad.org.uk, Website: www.bad.org.uk

1. Study details: “The Eczema Priority Setting Partnership: identifying and prioritizing important research questions for the treatment of eczema. A collaborative partnership between patients, carers, clinicians and researchers”; J Batchelor1, M Ridd2, T Clarke1, M Cox3, A Roberts4, M McPhee1, S Crowe5, A Rani1, J Ravenscroft6, A Ahmed1, S Lawton6, M Howard1 and K Thomas1

1. Centre for Evidence-Based Dermatology, Nottingham, 2. NIHR School for Primary Care Research, 3. National Eczema Society, London, 4. Nottingham Support Group for Carers of Children with Eczema, 5. James Lind Alliance, Oxford, 6. Nottingham University Hospitals, Nottingham UK
2. The James Lind Alliance (JLA) is a non-profit making initiative, principally funded by the National Institute of Health Research. It was established in 2004. It brings together patients, carers and clinicians to identify and prioritise the top 10 uncertainties, or ‘unanswered questions about the effects of treatments’ that they agree are most important. This information will help ensure that those who fund health research are aware of what matters to both patients and clinicians.
3. Organizations and individuals were contacted to ensure participation of patients with eczema, their carers, and healthcare professionals caring for patients with eczema. Articles were placed on websites and in relevant newsletters advertising the PSP. The project consisted of three phases: a survey to collect the treatment uncertainties from patients and healthcare professionals; a ranking exercise in which participants voted for their favourite topics from a list of the most frequently asked uncertainties; and finally, a workshop at which the most popular treatment uncertainties were developed into research questions. Using online and paper surveys, 493 participants submitted up to five eczema treatment uncertainties. This yielded 1071 uncertainties, which were refined and collated by the SG. Uncertainties known to have been answered by previous research, and those not relevant to eczema treatment, were removed, giving a short list of 732 uncertainties.
4. In the ranking exercise, 505 participants (399 patients/carers and 106 health professionals) each selected up to 10 ‘favourite’ uncertainties. This yielded a ranking of frequency scores for the uncertainties. The ranking was then subdivided into uncertainties prioritized by all participants, and into those prioritized by patients and health professionals separately, to ensure adequate representation of all participants’ views. This resulting list of 14 prioritized uncertainties included topical treatments (topical steroids, calcineurin inhibitors, emollients and bathing); systemic treatments (including immunosuppressants); allergy testing and diet (role of allergy testing, avoidance of irritants, role of diet); education and habit-reversal interventions. The prioritized uncertainties were then developed into research questions at a workshop attended by 34 patients, health professionals and researchers. These research questions will be publicized and used to guide future research.

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Teledermatology – help or hindrance?

Over 100,000 cases of skin cancer are diagnosed in the UK each year and it is estimated that about half of all dermatology referrals are for assessment of skin lesions. Teledermatology has been welcomed in many areas as a tool that could help triage such referrals, however, debate continues amongst dermatologists as to how safe teledermatology is when used for this purpose. A study1 presented at the at the British Association of Dermatologists’ Annual Conference in Birmingham this week (July 3rd to 5th), hopes to answer that question.

The team from the University of Edinburgh looked at previous studies but concluded that they did not reveal the answer to the critical question which was to understand how many ‘incidental’ skin cancers might be missed by assessing only a single ‘index’ lesion. (In plain English the ‘index lesion’ is the one that you show either to your GP or to the camera (in the case of teledermatology). An ‘incidental lesion’ is one that is picked up during examination or treatment of the ‘index lesion’.)

A study was set up at a UK district general hospital and participants for the study were enrolled from those attending a fortnightly skin lesion clinic2. The study revealed that just over half of the melanomas detected were incidental – i.e. not the referred skin lesion but ones that had been identified during a total body skin examination – which forms a routine part of the index lesion evaluation. Comparing the ratio of incidental to index melanomas the team found that their results were similar to other studies, despite geographical and demographic differences.

The results suggest that isolated single lesion teledermatology triage cannot be considered as an adequate replacement to a total body skin examination performed by a competent practitioner.

Ben Aldridge, Clinical research fellow in Dermatology at the University of Edinburgh and one of the authors of the study, says “Teledermatology could be a useful tool for the referral pathway, but further research is needed to determine the exact practitioner, patient and lesion criteria that will allow it to be incorporated safely, in the meantime if used in isolation, teledermatology triage is likely to miss important skin malignancies.”

The study corroborates the opinions voiced in the annual teledermatology survey of BAD members, which is also presented at the conference3, where 60% of BAD members stated that they did not support teledermatology being used in isolation for the assessment of lesions.

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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 ICC Birmingham, 3rd to 5th July 2012, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

For more information please contact: Deborah Mason, British Association of Dermatologists, Communications Manager, Phone: 0207 391 6355 or 07957 145992 (mobile during conference week only), Email: deborah@bad.org.uk, Website: www.bad.org.uk

1. Study details: “Teledermatology triage of suspicious skin lesions potentially could be missing the majority of melanomas”; R B Aldridge, L Naysmith, E T Ooi, C Murray and J Rees, Department of Dermatology, University of Edinburgh, UK

2. The study was undertaken at a U.K. district general hospital that serves a defined geographical population. All patients who attended a fortnightly skin lesion clinic over a 9-month period between January and October 2010 were prospectively asked to participate, and 336 patients agreed to enrol in the study. This represents 91% (336/370) of the total eligible patients who attended the clinics over this period. The patients (n = 34) who did not participate all had benign index lesions and no incidental malignancies. In addition to recording the details of the index (referral) lesions, further data were collected on all incidental lesions that required a biopsy. These incidental lesions were identified during total body skin examinations (TBSE), which we offer routinely at the time of index lesion evaluation. Most melanomas (5/9; 56%) detected were incidental and not the referred index lesion. In all of these incidental melanomas the index lesion had been benign.

3. “Love it or loathe it? Results of the 2011 British Teledermatology Survey”, N.J. Levell, C.R. Charman* and S.M. Halpern†, Norfolk and Norwich University Hospital, Norwich, *Royal Exeter and Devon Foundation NHS Trust, Exeter and †Medway NHS Foundation Trust, Gillingham, U.K.

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Spare the Cream, Spoil the Child? Challenges for carers of childhood eczema patients

About 20 percent of children in the UK have eczema and non-adherence to treatment is common and a major cause of treatment failure. Researchers from the Universities of Southampton, Hull and Dundee and Ninewells Hospital looked into the reasons for this, and what could be done to make a difference.

Their research “Managing childhood eczema: qualitative study exploring carers’ experiences of barriers and facilitators to treatment adherence’1 is due to be released at the British Association of Dermatologists’ Annual Conference in Birmingham this week (July 3rd to 5th).

The team found that barriers to treatment adherence included:

• Parental beliefs around eczema treatment (e.g. – worries about steroid creams)
• Time-consuming nature of applying various creams
• Child resistance

Exploring the latter the team found that parents and carers had developed a number of strategies to overcome child resistance including:

• Involving the child in the treatment
• Distraction
• Making a game of it
• Using rewards
• Disguising the cream or applying it to the child when asleep

However, these strategies were not always successful and in some cases resulted in reducing the frequency of applications. Some parents and carers also spoke about the negative impact that the conflict over treatment had on their relationship with the child and on the family as a whole.

Miriam Santer one of the authors of the report says: "Treating childhood eczema can be a huge challenge for some parents and carers, particularly if resistance from the child sets in. We hope that by highlighting some of the different strategies used to overcome resistance, these might inform some self-help guidance to support this group and lead to better outcomes for children with eczema.”


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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 ICC Birmingham, 3rd to 5th July 2012, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

For more information please contact: Deborah Mason, British Association of Dermatologists, Communications Manager, Phone: 0207 391 6355 or 07957 145992 (mobile during conference week only), Email: deborah@bad.org.uk, Website: www.bad.org.uk

1. Study details: “Managing childhood eczema: qualitative study exploring carers experiences of barriers and facilitators to treatment adherence.”; M Santer, H Burgess, L Yardely, S Ersser*, S Lewis-Jones¶, I Muller, C Hugh and P Little. University of Southampton, Southampton, *University of Hull, Hull and Ninewells Hospital and ¶University of Dundee, Dundee, UK

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Can you screen for skin cancer?

Skin Cancer is the most frequent type of cancer in the UK, but of the 100,000+ cases only ten percent will be the most deadly kind – melanoma – and of those affected only around 2,000 will die. If detected early melanoma has a good prognosis and the British Association of Dermatologists has been working to educate the public on the importance of early detection for some years. In research due to be released at the British Association of Dermatologists’ Annual Conference in Birmingham this week (July 3rd to 5th), the question is raised as to whether there are effective screening tools for those most at risk.

In a UK study based at King’s College Hospital in London a group of researchers investigated whether the two week wait system could be considered as a type of ‘filtered screening’ for skin cancer.1

The 2-week wait (2ww) referral was introduced by the New Labour government in 2000 to tackle the problem of patients with symptoms indicative of cancer who waited too long to be seen and treated in secondary care. Unlike other cancers there is no reliable ‘screening test' for skin cancer at the disposal of the general practitioner (GP), and therefore the researchers suggest that the two-week-wait system could be viewed as ‘filtered screening'.

Taking this as a starting point the group studied local GP referrals under the two week wait system. They found that, the majority of GPs adhered to the referral guidelines and that 12.5 per cent of those referred under the two week wait system were diagnosed with skin cancer, of which 6.75 per cent had Malignant Melanoma or Squamous Cell Carcinoma.2

Klara Balogh, one of the authors of the paper says: “These percentages may seem low, but in well-established screening programmes for cervical and breast cancer the actual detection rates are only 0.02 and 0.8 per cent respectively. A 6.75 per cent skin cancer detection rate through this ‘filtered screening' process is effective in comparison.

“Our study shows that, when the guidelines are adhered to, the two week wait system can be effective and leads to rapid diagnosis of skin cancer in the minority and rapid reassurance for the majority: a satisfactory outcome for patients.”
 

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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 ICC Birmingham, 3rd to 5th July 2012, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

For more information please contact: Deborah Mason, British Association of Dermatologists, Communications Manager, Phone: 0207 391 6355 or 07957 145992 (mobile during conference week only), Email: deborah@bad.org.uk, Website: www.bad.org.uk

1. Study details: Skin cancer ‘filtered screening’ by dermatologists: the 2-week wait system. K. Balogh, P. Trehan, S. Bashir, E. Higgins and R. Morris-Jones, Dermatology Department, King's College Hospital, London, U.K.

2. To see how the two-week-wait system was being used locally they examined 400 consecutive two-week-wait referrals to dermatology received during 2011: 239 women (60 per cent) and 161 men (40 per cent; mean age 51 years (range 20–98). Ninety per cent (n = 360) of patients were seen within two weeks; the remaining 10 per cent waited longer due to patient choice/not attending the initial appointment. Eighty-one per cent (n = 323) of two-week-wait forms specified a suspected clinical diagnosis (2/3 ?MM, 1/3 ?SCC). However, the GP diagnosis cited on 17 (11 per cent) of the two-week-wait forms did not fall within the guidelines [seborrhoeic or actinic keratosis, basal cell carcinoma (BCC), ‘general check']. Fifty (12.5 per cent) histology-proven cancers were identified from the 400 two-week-wait patients: 12 MM, 15 SCC, 22 BCC and one porocarcinoma. Twenty-seven (6.75%) of the two-week-wait referrals were SCC or MM. Seven new patients referred routinely by their GP during the same period were diagnosed with SCC (n = 3) or MM (n = 4); these patients waited an average of 21 days (range 6–34). In conclusion, the majority of GPs adhered to the referral guidelines; 12.5 per cent of two-week-wait patients were diagnosed with skin cancer; 6.75 per cent had MM or SCC. These percentages may seem low and there is clear dissatisfaction in the literature in general with the low rates of cancer diagnosed as a result of two-week-wait referrals (colorectal 4.3–25 per cent, brain 9 per cent etc.) with the exception of lung (48.8 per cent) and prostate cancer (30 per cent) where screening tests are available. Published evidence shows no increased rates of skin cancer detection with enhanced GP education or stricter guidelines. None the less, no target detection rates have been set. Well-established U.K. screening programmes for cervical and breast cancer have detection rates of 0.02 and 0.8 per cent, respectively.

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Provision of pscyhodermatology services has deteriorated across the UK since 2004

Despite recommendations in 2004 that provision of psychodermatology services should be developed a new study shows that they have in fact deteriorated across the UK.

The research, “Psychocutaneous medicine and its provision in the UK”1 is due to be released at the British Association of Dermatologists’ Annual Conference in Birmingham this week (July 3rd to 5th).

The results of a survey sent out by the research group showed the following need for pscyhodermatology services:
• 17 per cent of patients needed psychological support to help them cope with psychological conditions secondary to their skin condition
• 14 per cent of patients had psychological conditions exacerbating their skin condition
• 3 per cent of patients presented with primary psychiatric disorders
• 8 per cent had worsening psychiatric problems due to concomitant skin disorders

Of the 127 hospitals taking part 45 hospitals treat in dermatology and 95 refer to a psychiatric department. Only seven of the hospitals have a dedicated pscyhodermatology department and a further three have a joint clinic with a dermatologist and psychologist/psychiatrist.

Only 17% of these hospitals had at least one person who had had specific psychocutaneous medicine training.

A comparison of their results with a survey undertaken in 20042 showed that rather than the development called for at that time, deterioration had taken place.

Anthony Bewley one of the authors of the study says “Despite the clear recommendations of the 2004 study as well as a clear demand from the Joint Royal Colleges of Physicians Training Board for SpRs to engage in psychocutaneous medicine and the recent work of the BAD in this area, there is still both insufficient provision of services and low exposure of trainees to appropriate training. If this deterioration continues many patients will not get the specialised care they need.”

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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 ICC Birmingham, 3rd to 5th July 2012, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

For more information please contact: Deborah Mason, British Association of Dermatologists, Communications Manager, Phone: 0207 391 6355 or 07957 145992 (mobile during conference week only), Email: deborah@bad.org.uk, Website: www.bad.org.uk

1. Study details: “Psychocutaneous medicine and its provision in the UK”; A P Bewley, C Fleming and R Taylor, Barts and the London Trust, London, UK

2. Riaz S, Staughton R, Bridgett C, Mapping Psychodermatology in the United Kingdom, poster presented at the British Association of Dermatologists Annual Meeting 2004

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Genital Psoriasis – the unseen agony

Flaky, scaly, red and itchy, psoriasis can occur on any part of the skin, including the genitals. In fact it is estimated that around 32 per cent to 57 per cent of people with psoriasis have some genital involvement.

In research, due to be released at the British Association of Dermatologists’ Annual Conference in Birmingham this week (July 3rd to 5th), a team from St Vincent’s University Hospital, Dublin and the Baylor Institute in Texas, looked at how genital psoriasis affected sexual function and psychological status amongst a group of patients.1

The results of their study showed that nearly 40 per cent of those with genital psoriasis reported reduced sexual activity and 46 per cent reported discomfort following sexual intercourse. Not unsurprisingly those patients with active genital psoriasis had a worse Dermatology Quality of Life Index2 score than those who didn’t and also were more likely to have depressive symptoms3.

Despite the fairly high prevalence of genital involvement there has been little emphasis on identification and treatment of this specifically and the Muriel Sadlier, one of the authors of the study says

“It isn’t surprising to find that active genital psoriasis is associated with greater depression, reduced sexual function and reduced quality of life and as such it is really important that physicians are aware of the presence of genital disease and its psychosexual implications and that they are able to provide both treatment and appropriate psychological support for these patients”.

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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 ICC Birmingham, 3rd to 5th July 2012, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

For more information please contact: Deborah Mason, British Association of Dermatologists, Communications Manager, Phone: 0207 391 6355 or 07957 145992 (mobile during conference week only), Email: deborah@bad.org.uk, Website: www.bad.org.uk

1. Study details: “Sexual function and psychological status among patients with genital psoriais.”; M Sadlier, C Ryan*, L Edwards*, A Lally, A Menter* and B Kirby. St Vincent’s University Hospital, Dublin, Ireland and *Baylor Institute, Dallas, TX, USA.

2. Dermatology Life Quality Index and Child Dermatology Life Quality Index. The Dermatology Life Quality Index or DLQI, developed in 1994, was the first dermatology-specific Quality of Life instrument. It is a simple 10-question validated questionnaire which has been used in over 33 different skin conditions in over 33 countries and is available in 85 languages. Its use has been described in over 800 publications including many multinational studies. The DLQI is the most frequently used instrument in studies of randomised controlled trials in dermatology. Further information can be found at: http://www.dermatology.org.uk/quality/dlqi/quality-dlqi.html

3. Measured using the Centre for Epidemiological Studies Depression Scale (CES-D).

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Demand for Dermatology

It is estimated that 1 in 2 people in the UK each year, will suffer from some type of skin disease or condition. Skin cancer has the highest number of cases of any cancer in the UK. 20 per cent of children and 10 per cent of adults will suffer from eczema. There is a clear demand for services to meet this need, but for a health service that is currently facing unprecedented challenges both economic and structural, it is vitally important to find out how that need can best be met; in primary, secondary and tertiary settings.

At the British Association of Dermatologists’ Annual Conference in Birmingham this week (July 3rd to 5th) a number of presentations are being made which seek to address these questions.
At primary level General practitioners (GPs) are under considerable pressure to ensure that all referrals to specialist dermatology services are necessary. Commissioners of services are keen to manage demand for these services in order to get best value for money in a cash-limited National Health Service, a study in Hertfordshire sought to understand dermatology referrals and, using this information, identify ways to reduce referrals from an individual GP practice. The study, which took place over a six month period revealed that where referrals were made for long term skin conditions they tended to be highly appropriate, but those for skin lesions were less so, also that the average for a practice could be strongly skewed by a single high volume referrer. The study revealed that skin cancer referrals made up about two thirds of the total number, but that the accuracy and appropriateness of the referrals was low.1
Julia Schofield, one of the authors of the study says “This study demonstrates the challenges for GPs in trying to reduce dermatology referrals. Most GPs see 42 patients per day, and with that level of activity, reducing referral rates from 2–3 per month is likely to be difficult, particularly across the breadth of dermatology conditions. However, we did see that in some cases a single GP might be referring far more than colleagues and that targeting education to high referrers within a practice is important, also some referrals might be reduced by improving GP skin lesion diagnostic skills and perhaps using digital images with referrals.”

A number of presentations were made on the need for local acute dermatology services, including on-call services.

A study by a team in Manchester looked at the usage of ‘urgency clinics’ (a three times a week clinic into which patients can be booked following urgent referral) and compared them with usage of general dermatology clinics.2 As anticipated the largest groups of patients in both clinics came from the two local PCTs, however the urgency clinics also saw a higher than proportionate number from 6 more distant PCTs which the team suspect to reflect the lack of acute dermatology clinic appointments in those areas, putting pressure onto central services and extending journey times for patients.

Sarah Felton, one of the authors of the study says ‘It is clear that when commissioning dermatology services within a community it is important to assess the need for acute dermatology services in order to be able to deal appropriately with urgent referrals as close to home as possible”.

Another study, this time in Leeds, focussed specifically on the on-call service.3 The hospital provides a 24 hour, seven days per week non-resident on-call service and not only provides a service to patients but also allows dermatology trainees the opportunity of gaining sufficient experience in emergency dermatological presentations to become competent in managing acute serious skin disease. Looking at the number and type of cases referred to the service over a two month period the data showed a significant demand for an out-of-hours service.

Sangeetha Shanmugam, one of the authors of the study says “Over 15 per cent of the cases we referred out of hours, and at least half required assessment on the day of referral, our data shows that there is a real need for this service providing essential specialist care for patients with a variety of serious skin diseases.”

Many people suffering with a chronic skin condition may not need urgent care, but do require specialist referral. A team in Dewsbury looked at whether specialist multi-professional clinics were necessary for patients with complex skin problems.4 The aim of the clinic was to provide a multi-professional review of patients with complex and rare skin conditions, especially where the diagnosis was in doubt or there were problems with management. Facing criticism that this one hour a month clinic was a ‘luxury’ the team sought to analyse it’s exact benefits. The most important benefit was shown to be that 95% of the patients seen could be offered a new diagnosis or treatment and that improved patient care would also have beneficial cost-implications.

Manu Shah, the author of the study says “A regular specialist multi-professional clinical meeting is a good use of clinician time and produces great benefits to patient care. In the economic climate, dermatologists must strive to maintain quality care for their patients, despite pressures from medical and non-medical managers.”
 

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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 ICC Birmingham, 3rd to 5th July 2012, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

For more information please contact: Deborah Mason, British Association of Dermatologists, Communications Manager, Phone: 0207 391 6355 or 07957 145992 (mobile during conference week only), Email: deborah@bad.org.uk, Website: www.bad.org.uk

1. The challenge of demand management and dermatology referrals: the general practitioner’s view
M.A. Syed, J.K. Schofield* and A. Kanji, Chequers Surgery, Prestwood, Great Missenden and *University of Hertfordshire, Hatfield, U.K.
The aim of this study was to look at dermatology referrals and, using this information, identify ways to reduce referrals from an individual GP practice. All referrals from a practice population of 12,800 with eight GPs (six whole-time equivalents) were counted and reviewed during a 6-month period. The referrals were categorized into skin lesions and other skin conditions. Information was obtained about the GP and hospital diagnosis and based on this, an attempt was made to assess whether the referral was appropriate. For four of the six months, detailed information was obtained about the number of referrals from the individual GPs. Over the six-month period there were 117 referrals to the dermatology service, an average of about 19 per month. This represented a relatively high referral rate compared with other local practices (top third). The average referral rate among the eight doctors over the six-month period was 2.38 per month. More detailed analysis of the individual GPs’ referral activity, following adjustment to allow for their clinical commitment, showed the average monthly rate of referrals for seven of the eight GPs to be between 1.25 and 2.75. The eighth GP had a referral rate of 9.4 per month. With respect to the type of referrals, 74 (63 per cent) were skin lesions and of these 45 were for suspected skin cancer. Pick-up rates were as follows: 4/10 suspected squamous cell carcinomas, 7/26 suspected basal cell carcinomas and 0/9 malignant melanomas. Appropriateness of referrals was highest in the long-term skin conditions (approaching 100 per cent). This study demonstrates the challenges for GPs in trying to reduce dermatology referrals. Most GPs see 42 patients per day, and in the context of this level of activity, reducing referral rates from 2-3 per month is likely to be difficult, particularly across the breadth of dermatology conditions. Some referrals might be reduced by improving GP skin lesion diagnostic skills and offering a digital image with referral service. Targeting education to high referrers within a practice is also important.


2. Regional approach to dealing with demand for acute dermatology services
S. Felton, J. Newsham and J. Williams, Dermatology Centre, Salford Royal NHS Foundation Trust, Manchester, U.K.
Significant demand is placed on acute dermatology services across the country. Within the region of the study, on-call Registrars cover a large catchment area. In addition to urgent out-of-hours review where required, on-call Registrars have access to Registrar-led ‘Urgency clinics' three times a week, into which they may book patients following urgent referral. The objective of the study was to examine the pressure on the Urgency clinics at the local hospital, in terms of patient population distribution. The postcode of each new patient attending an Urgency clinic appointment over the 3-month period, July–October 2011 (n = 132) was recorded and then mapped according to their local Primary Care Trust (PCT). Data were compared with the PCTs of newly referred patients attending general dermatology clinics at the same hospital over the same time period (n = 2412). Results demonstrated significantly different population distributions between patients attending Urgency clinics and those in the general clinics (P < 0.0001): in the general clinics, patients from the two local PCT areas formed the largest patient subgroups (41% and 24%, respectively). While the commonest sources of referral to the Urgency clinics were the same two PCTs, the proportions of patients from these areas were lower than would be predicted from the general clinic population data, at 22% and 23%, respectively. In contrast, a greater than anticipated number of patients from six more distant PCTs was seen in the Urgency clinics. The relative lack of patients in Urgency clinics from those PCTs in the immediate vicinity of the study hospital may be a result of patients attending Accident & Emergency and Walk-in centres where they are seen on the same day as an ‘emergency', rather than waiting for an urgent appointment. However, it is more likely that capacity meets demand locally. The data demonstrate that patients from distant PCTs are over-represented in the Urgency clinics, so placing extra pressure on the study hospital’s services. The team suspect that this is a reflection of the relative lack of acute dermatology clinic appointments in patients' local areas, so forcing them to travel further afield for urgent problems. This pressure is likely to increase if PCTs commission services from alternative providers without also commissioning ‘acute' care services. Such pressures could destabilize services. Given the increasing pressure on dermatology services at a national level, the data also emphasizes the overall need for commissioning of acute dermatology services, particularly where local provision for urgent review is limited.

3. Demand for dermatology on-call service: an audit in a large teaching hospital
S. Shanmugam and V. Goulden, Leeds General Infirmary, Leeds, U.K.
The 2010 Dermatology curriculum requires trainees to have sufficient experience of emergency dermatological presentations to become competent in managing acute serious skin disease, both assessing severity accurately by telephone and making decisions to come in from home to see patients urgently. This requires a regular out-of-hours on-call commitment for trainees but the future of on-call in dermatology is uncertain. For the last few years and particularly in the present financial climate, the cost of on-call is under close scrutiny in many trusts. The department at Leeds General Infirmary currently provides 24 h, 7 days per week nonresident on-call service. The team carried out an audit to assess the demand and clinical cases referred to the service. Data were collected prospectively over a period of 2 months between 1 November and 31 December 2011. The total number of referrals for the period was 228. The age range of patients varied from 8 weeks to 90 years. Of 228 patients, 188 (82.5%) were referred within normal working hours, 18 (7.9%) out-of-hours on weekdays and 22 (9.6%) at weekends. Nearly half of the referrals were from hospital wards (109), 67 from general practitioners, 39 from the Accident & Emergency department and 13 from other specialty clinics. One hundred and fourteen (50%) patients required assessment on the day of the referral. Among the patients seen by the on-call registrars, 46 (20.2%) were assessed between 17:00 and 09:00 h. Twenty-one patients needed biopsy and 45 patients required subsequent follow-up. A wide variety of conditions was seen including Stevens–Johnson syndrome, pustular psoriasis, eczema herpeticum, acute graft-versus-host disease, immunobullous disease, drug rashes, viral rashes, cellulitis as well as Sweet syndrome, pyoderma gangrenosum, lichen planus, psoriasis, eczema, pityriasis lichenoides, leg ulcers and tinea infections. In summary, the data show a significant demand for an out-of-hours dermatology service with 17.5 per cent of patients referred outside of normal working hours. The study also demonstrated that the service provides essential specialist care for patients with a wide variety of serious skin disease as well as invaluable experience for trainees.

4. Are specialist clinics for patients with complex skin problems necessary?
M. Shah, Dewsbury & District Hospital, Dewsbury, U.K.
Dewsbury & District Hospital started a specialist clinic in 2010, made up of four consultant dermatologists, one with a special interest in paediatrics and genetics. The aim was to provide a multiprofessional review of patients with complex and rare skin conditions especially where the diagnosis was in doubt or there were problems in management. The clinic time is 1 h per month and was described by a (nondermatological) clinical manager as a ‘luxury’. The clinic was audited to assess any benefits or drawbacks. Twenty patients were seen over five clinics (15 min each). Twenty per cent were children (mean age 4.25 years). Six patients had been under follow-up for 10 years or more (mean duration of follow-up for the entire group 54.2 months). In 12 patients (60%) the clinical diagnosis was certain prior to the clinic but there were problems in management. In the other eight patients the diagnosis was uncertain but a new diagnosis was offered from the clinic in six. New treatment suggestions were offered from the clinic in 16 patients (80%) and further investigations were suggested in 11 (55%). Reviewing patients with complex and difficult problems is essential. Benefits of this clinic include receiving a higher tariff per patient and valuable learning experience for clinicians which can be used as part of medical education. However, the most important aspect was being able to offer a new diagnosis or treatment in 19 of 20 patients (95%). This improved patient care should also have cost-improvement implications. A regular specialist multiprofessional clinical meeting is a good use of clinician time and produces great benefits to patient care. In the current economic climate, dermatologists must strive to maintain quality care for their patients, despite pressures from medical and nonmedical managers.

Salford Royal NHS Foundation Trust is an integrated provider of hospital, community and primary care services, including the University Teaching Hospital. The Trust employs 6,000 staff and provides local services to the City of Salford and specialist services to Greater Manchester and beyond. The Trust also offers specialist care to people from all over the UK who need expert help with brain, neuroscience, kidney, bone, intestine or skin conditions. The Trust has an excellent track record; having the highest consistent rating for service quality coupled with one of the highest sets of patient and staff satisfaction scores. www.srft.nhs.uk / @salfordroyalnhs

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How Safe is a Fish Spa?

Fish spa pedicures have gained increasing publicity and media exposure but are they safe? Angela Steen, of Glan Clwyd Hospital, will present her research on ‘The Little Dermatologist’ at the British Association of Dermatologists’ Annual Conference in Birmingham this week (July 3rd to 5th).

She says: “Healthcare professionals are often asked to comment on the use of alternative therapies for patients with skin disease, and can be placed in a difficult position if evidence is limited. I hope that this research goes some way to answering these questions.”

Known by the people of Southern Turkey as ‘The Little Dermatologist’ the Garra Rufa fish will gently lick and suck the skin, removing any dead skin scales. Discovered by Turkish shepherds as a means of helping wound healing the process became commercialised in the 1960s in combination with thermal springs and many people with psoriasis flocked to try the new treatment. This combination of hot spring with fish as a treatment for psoriasis was shown to be effective in a research paper in 20001. However this is not directly comparable with the ‘Fish spa’ offered in salons and clinics around the world today.

Introduced in Japan in 2006 and the UK in 2010 the modern fish spa sees customers put their feet (or whole body) into a long tank of warm water where they are then enveloped in hundreds of Garra Rufa fish. Risks arise when tanks are not cleaned between customers and where open cuts are prime targets for infection and also risk of fish tuberculosis from the fish themselves. As a result of this the Health Protection Agency investigated and in 2011 suggested that although the risk of infection was low immune-compromised patients should not use fish spas. Unfortunately this would include many people with psoriasis who are undergoing conventional treatments alongside alternative therapies such as the fish spa.

-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 ICC Birmingham, 3rd to 5th July 2012, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

For more information please contact: Deborah Mason, British Association of Dermatologists, Communications Manager, Phone: 0207 391 6355 or 07957 145992 (mobile during conference week only), Email: deborah@bad.org.uk, Website: www.bad.org.uk

Study details: “The Little Dermatologist.”; A Steen, Glan Clwyd Hospital, Rhyl, UK
1. Ozçelik S, Polat HH, Akyol M et al. Kangal hot spring with fish and psoriasis treatment. J Dermatol 2000; 27:386-90

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Fashions Change but Tattoos are Forever

A significant number of people regret having a tattoo, and the longer they have had one the more likely this becomes. With a tattoo parlour popping up on every high street1 and the popularity of tattoos increasing2, a study, due to be released at the British Association of Dermatologists’ Annual Conference in Birmingham this week (July 3rd to 5th), seems timely.

Author of the study Arif Aslam says, “We feel that it is important for people to know that it’s very likely that one day they will regret their tattoo. They are not that easy to remove and unwanted tattoos can affect people’s life chances and cause them upset and unhappiness”. The study used a questionnaire and took place over a six month period in a dermatology department in a large district general hospital in England. Patients (aged 16 or over) who had a visible tattoo during general skin examination were asked to complete the questionnaire which looked at age, the age at which the tattoo was acquired, whether it was done by an amateur or a professional, how long they had had it, whether they had other tattoos, the site of the tattoo, whether they still liked it and whether they would have it removed if they could.

• 580 responses were analysed (from a total sample of 615) with a split of 53 per cent men and 47 per cent women. The responses revealed:
• Most tattoos were done by a professional • Half of the patients were over 40 • 45% of the patients had their first tattoo done aged between 18 and 25 years old
• Almost half had between two and five tattoos
• Almost one third regretted their tattoo
• Men were more likely to regret their tattoo than women
• Men were three times more likely to regret their tattoo if it was done when they were under 16 years of age
• Women over the age of 21 at the time of their first tattoo were the least likely to regret it.
• Most patients who regretted getting a tattoo had them on their upper body.
• Fewer than half those who regretted their tattoos would have them removed.

-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 ICC Birmingham, 3rd to 5th July 2012, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

For more information please contact: Deborah Mason, British Association of Dermatologists, Communications Manager, Phone: 0207 391 6355 or 07957 145992 (mobile during conference week only), Email: deborah@bad.org.uk, Website: www.bad.org.uk

Study details: “Fashions change but tattoos are forever: time to regret”; A Aslam and C Owen, Burnley General Hospital, Burnley UK 1. 1,500 tattoo parlours in the UK 2. A recent survey suggested that 1 in 5 British adults has a tattoo 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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