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New injection promises to stop the itch of eczema

Scientists are developing an injection that could reduce the itch caused by eczema for months at a time, according to research due to be published in the British Journal of Dermatology.

Atopic eczema, a skin disorder linked to allergies, asthma and hayfever, is very common, affecting at least one in five children and often lasting into adulthood. The main symptom is itch, which can be severe, and the scratching in response to the itch worsens the eczema, prevents sleep, causes skin infection and can greatly reduce the patient’s quality of life.

Now scientists have discovered a drug that could be given as a single injection, targeting the mechanisms in the body that cause the itch sensation. 

Patients with eczema produce higher levels of a protein in the blood and in affected skin called interleukin-31 (IL-31), which is thought to be responsible for skin itching, also known as pruritus. IL-31 binds to IL-31 Receptor A (RA) on the cells and then transfers the signals into the cells.

Antibodies are proteins produced by the immune system in response to ‘foreign’ substances which may be harmful to the body. Antibodies bind themselves to the substances so that they can be recognised by cells that seek out and destroy them. In this study, this characteristic feature, specific binding of antibodies to the substances, is utilised as a drug. 

Researchers from Japan tested whether an antibody called CIM331, when injected into the body would bind itself to IL-31 RA, thereby reducing its ability to cause itching.

Volunteers, who were either eczema patients or people without eczema, received either an injection of a placebo or of CIM331. Each person receiving CIM331 received just a single injection but the dosages varied from 0.003mg/kg to 3mg/kg. 

In the eczema patients, scores on a scale used to measure pruritus were reduced by between 24 and 33 per cent (depending on the dose given) one week after treatment with CIM331, compared to a nine per cent reduction in the placebo group. 

After four weeks, the reduction in the pruritus score was between 45 and 50 per cent in the CIM331 group compared to 20 per cent in the placebo group. CIM331 increased sleep and reduced the need for a cream used to treat eczema called hydrocortisone butyrate. 

These positive results were maintained for the full eight weeks that patients were monitored for. None of the volunteers suffered from serious adverse events (side effects).

The authors conclude that a single injection of CIM331 decreased pruritus and sleep disturbance in eczema patients, and that CIM331 may become a novel treatment option for atopic eczema by inhibiting IL-31.

Nina Goad of the British Association of Dermatologists said: “With eczema, if you can break the itch-scratch cycle, then half the battle is won. Itch is not only a deeply unpleasant effect of eczema, but scratching actually makes the disease worse. Reducing the itch will allow the skin to heal, help patients to sleep better and to get back control of their lives. 

“The mainstay of current treatment involves creams applied to the skin, many times a day, which can be messy and impractical. The study showed that patients using the drug did not need to rely so much on topical medications.

“The drug is not ready to go on the market yet, but in terms of first steps, this is a very positive one.” 

Eczema has no single known cause but defects in the body’s immune system (which normally fights off disease) and the skin ‘barrier’ (the protection provided by the skin’s outermost layer) are both thought to play a part. 

Ends 

For more information, please contact: British Association of Dermatologists, Communications Team, 0207 391 6094 (Monday to Friday) or comms@bad.org.uk, Website: www.bad.org.uk

Study details: British Journal of Dermatology: The first trial of CIM331, a humanized anti-human IL-31 receptor A antibody, for healthy volunteers and patients with atopic dermatitis to evaluate safety, tolerability and pharmacokinetics of a single dose in a randomised, double-blind, placebo-controlled study. O. Nemoto,, M. Furue, H. Nakagawa, M. Shiramoto, R. Hanada, S. Matsuki, S. Imayama, M. Kato, I. Hasebe, K. Taira6, M. Yamamoto, R. Mihara, K. Kabashima, T. Ruzicka, J. Hanifin andY. Kumagai. DOI: 10.1111/bjd.14207
The accepted article version in the BJD can be viewed online: http://onlinelibrary.wiley.com/doi/10.1111/bjd.14207/pdf
It will appear in the hard copy version of the journal in February 2016.

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

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

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.

Follow us on Twitter: @HealthySkin4All
 

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1670 per cent mark-up on NHS medicines slammed by health charity

The British Association of Dermatologists is urging the government to revisit a policy that allows certain medicines prescribed by GPs to cost up to 17 times more than the same drugs prescribed in hospitals, needlessly wasting the NHS millions of pounds each year.

Most drugs prescribed by doctors are ‘licensed’ medicines which have been approved for sale in the UK. When suitable licensed medicines are not available, the Medicines Act allows doctors to prescribe unlicensed medicines. For many common skin diseases including psoriasis and eczema, the range of licensed medicines is limited. As a result, doctors rely greatly on unlicensed creams and ointments, known as special-order medicines, or ‘Specials’. Such medicines are commonplace in dermatology - the British Association of Dermatologists (BAD), for example, recommends 39 Specials for use in skin disease treatment.*

However, the BAD has learnt that prices for Specials when prescribed in the community, as opposed to in hospital, are up to 1670 per cent, or 17 times, higher than the same drugs for secondary (hospital) care patients. This huge cost to the NHS is resulting in patients being denied access to treatment, as GPs and the Clinical Commissioning Groups who oversee them are unable to justify such high costs. And the problem is not limited to dermatological Specials, with medicines for other disease areas also being prescribed at greatly inflated prices.

Specials on the Drugs Tariff

In England, when a community pharmacist supplies a patient with a medicine that has been prescribed by a GP, the pharmacist receives a payment from the NHS for this drug. The amount they receive is a set amount, specified in the ‘NHS Drug Tariff’,1 and nine of the dermatology Specials on the BAD’s recommended list of 39 are listed on this Tariff.

The price set out in this Tariff has been decided by the Department of Health, based on an average of costings provided only by members of the Association of Pharmaceutical Specials Manufacturers (APSM), all of whom are private companies, and the Tariff price does not take into account much cheaper quotes from NHS manufacturers. 2

However, the majority of dermatology Specials are made within NHS hospitals, by hospital manufacturing units, who provide Specials to the NHS at prices reflecting lower manufacturing costs. Among the reasons for the lower costs is the fact that these units are able to produce the medicines in large batches. Conversely, APSM members provide the same drugs at far higher prices, in part due to the bespoke, non-batch approach to the manufacturing. 

This system means that in England, Wales and Northern Ireland, a whole-of-market quote has not been obtained for Specials, leading to excessively high prices charged to the NHS for these drugs.

Regardless of where a community pharmacist sources a Special medication from - be it a costly version from a private company or a cheaper version from an NHS manufacturing unit - the pharmacist receives the same reimbursement from the NHS as defined by the Tariff, allowing for large profit margins.

For example, one treatment used for psoriasis, coal tar 10% ointment, is listed in the Tariff3 at £274.27, an item which is available from an NHS Specials manufacturer for £15.49 (a 17-fold increase, or an increase of 1670%). Even allowing for some margin and procurement costs for supplying community pharmacists, a mark-up of £258.78 on an item costing £15.49 is wildly excessive. Salicylic acid 20% ointment (used to treat hard skin build-up in skin disease) is available for £27.25 from NHS manufacturers but has gone on Tariff at £246.93 (806% increase), while another medicine, salicylic acid 2% / sulfur 2% in aqueous cream, is available at £28.68 but has gone on Tariff at £215.85 (652% increase). 

In Scotland, NHS Tariff prices are far lower, for example 5% coal tar ointment, used to treat psoriasis, is on the Scottish Tariff at £26.47 and on the English Tariff at £231.28, while 2% eosin solution (used for skin infections in leg ulcers) is listed at £27.60 versus £229.13 in England. 

Dr Deirdre Buckley, Chairman of the Specials Working Group of the British Association of Dermatologists said: “The tariff-setting system used by the Department of Health in England relies on an arrangement with the APSM, a body representing only private manufacturers, rather than a mixture of NHS and private. An average of prices paid to members of the APSM, which are much higher than NHS manufacturers’ quotes, are used by the DH to decide the NHS Tariff price.

“The margins of over a thousand per cent attached to NHS Dermatology Special medicines during the Department of Health's tariff-setting process seem wildly excessive. It appears to us that the taxpayer is being overcharged for the sole benefit of community pharmacists and some private Specials pharmaceutical manufacturers, or more worryingly, our patients are denied the medications they need because they are too expensive.”

The British Association of Dermatologists acknowledges that the current tariff-setting process, put in place by the Department of Health in 2011, has led to savings for the NHS, but is asking the government to review the process in light of the highlighted issues, and to ensure further cost savings by including NHS manufacturing units in the equation.

Chief Executive of the Psoriasis Association Helen McAteer said: “The inflated cost of special-order medicines has effectively removed them as a much needed treatment option for people with psoriasis. Unfortunately, we have received reports of patients being made to feel guilty about the cost of their requested treatment, which can result in them disengaging from the health service – further isolating people with long-term skin conditions.”

About skin disease

Skin diseases are extremely common. In fact, skin conditions are the most frequent reason for people to consult their GP with a new problem, and around a quarter of the population in England and Wales visit their GP with a skin problem each year. Skin diseases represent 34 per cent of disease in children, with atopic eczema affecting one in five infants. Hand eczema is one of the most common reasons for disablement benefit in the UK. Inflammatory skin diseases are disabling, disfiguring and distressing and reduce quality of life. In the UK, DALYs (Disability Life-Adjusted Years) for skin conditions are as high as those for diabetes, chronic renal disease, gastrointestinal disorders and neonatal abnormalities.4

Ends 

Footnotes:

In dermatology alone over 3819 Dermatology Specials were prescribed in the last quarter (to June 2015). We estimate that the NHS could save around £2million a year if dermatology items listed on Tariff were obtained from NHS manufacturers.

*The British Association of Dermatologists' updated list of preferred unlicensed dermatological preparations ('Specials')

1 Drug tariff link: http://www.drugtariff.nhsbsa.nhs.uk/#/00252860-FA/FA00251910/Part VIIIB - Arrangements for payment for Specials and Imported Unlicensed Medicines 

2 “Part VIIIB of the Drug Tariff (the ‘Specials Tariff’) is a tariff of high volume and high cost unlicensed specials and imports, with set reimbursement prices. The prices are set by analysis of a selection of unlicensed specials manufacturer’s prices, with a margin included for pharmacy purchase profit” (source: Pharmaceutical Services Negotiating Committee). Data on the number of sales and the prices paid by community pharmacies for Specials during the previous quarter are sought from APSM members only, not from NHS pharmacies.

3 At the time of writing. Prices may fluctuate as the Tariff is updated monthly.

4 Skin disease statistics available from ‘Skin Diseases in the UK: a health care needs assessment’: https://www.nottingham.ac.uk/research/groups/cebd/documents/hcnaskinconditionsuk2009.pdf 

Notes to editors:

For more information, please contact: British Association of Dermatologists, Communications Team, 0207 391 6094 (Monday to Friday) or comms@bad.org.uk, Website: www.bad.org.uk 

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. 

Follow us on Twitter: @HealthySkin4All

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Etin Skin Solution found to contain corticosteroid betamethasone

The Medicines and Healthcare products Regulatory Agency (MHRA) and the British Association of Dermatologists are today warning people not to purchase or use Etin Skin Solution, a lotion claiming to treat skin conditions and known to have been supplied from various Asian and African beauty shops.


Etin Skin Solution was brought to the attention of MHRA by a consultant at Birmingham Children’s Hospital who became concerned following a complaint by a patient. Investigations to identify the source of this product are being conducted.


MHRA has recently tested samples of the lotion and found it to contain variable amounts of the corticosteroid betamethasone. Etin Skin Solution is not authorised for use as a medicinal product in the UK.


Corticosteroids are prescribed to treat inflammatory skin conditions, especially eczema and psoriasis. Long-term use can cause skin thinning and can worsen conditions such as eczema. Another listed ingredient is clotrimazole which is used in anti-fungal medications.


There are strict legal requirements in place in the UK relating to the sale, supply, manufacture, distribution and advertising of medicinal products. The legislative controls seek to ensure that products meet certain quality and safety standards; a breach of these legal requirements may constitute a criminal offence. The MHRA investigates any report of suspected illegal activity concerning medicines, or medical devices, and takes appropriate action.


MHRA senior policy advisor, Lynda Scammell said “Our advice to anyone who is using this product, particularly on young children and babies, is to discontinue use immediately. People seeking help for skin conditions should discuss alternative treatments with their healthcare professional. Medicines containing corticosteroids should only be given under the supervision of a doctor or pharmacist.”


Professor Celia Moss, Consultant Dermatologist at Birmingham Children's Hospital and one of the hospital's staff who brought the product to MHRA's attention, said: “We discovered the availability of this product after it had been used on the skin of a baby in our care. A nurse from my team visited the shop where it had been purchased and found it was freely available on more than one occasion. We reported this to MHRA and are pleased it has been investigated and action taken.


“However this is just one outlet and it is hard to police every supplier. We are therefore warning people not to use Etin and to report its sale to MHRA. Anyone using a steroid lotion such as this is likely to perceive some short-term benefit, because steroids make red skin look paler. This is because steroids constrict blood vessels in the skin. Unfortunately on discontinuing the product the redness may come back, which of course makes people want to continue it. But to do so is unwise, and after a few days the skin will revert to its previous appearance.”


Dr Firouz Mohd Mustapa of the British Association of Dermatologists said: "Milder steroids for short-term, localised use can be purchased over the counter from a pharmacist, but potent steroids such as this must be prescribed by doctors, who follow strict criteria when prescribing them and monitoring patients using them. This is because they can suppress the skin’s response to infection, can thin the skin, and if applied long term over a wide area, particularly in babies and children, can cause other medical problems.


“For babies and children, NICE guidelines set out clear recommendations on when it is appropriate for dermatologists to prescribe these potent or very potent steroids, the appropriate locations of the body on which they can be used and the duration of treatment. Sale of potent steroid creams directly to the public is illegal for good reason."


Ends


Notes to Editor


1. The Medicines and Healthcare products Regulatory Agency (MHRA) is responsible for regulating all medicines and medical devices in the UK by ensuring they work and are acceptably safe. All our work is underpinned by robust and fact-based judgements to ensure that the benefits justify any risks. MHRA is a centre of the Medicines and Healthcare products Regulatory Agency which also includes NIBSC and CPRD. The Medicines and Healthcare products Regulatory Agency is an executive agency of the Department of Health.
www.gov.uk/mhra

2. NICE Guidance available here: https://www.nice.org.uk/guidance/cg57

3. To contact Professor Celia Moss or the British Association of Dermatologists Press Office, please call 0207 391 6094 or email comms@bad.org.uk. 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

 

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British Association of Dermatologists launches psychological support website

Today the British Association of Dermatologists (BAD) launches Skin Support (www.skinsupport.org.uk), a Department of Health funded website providing psychological support for people with skin conditions.

The website brings together, and links to, patient information leaflets, support groups, self-help materials and help-lines.

Prior to the Skin Support website, support materials and services directed specifically at skin disease patients were sporadic and disparate, and those that did exist were not always easy to find or access. While there are both patient support groups, centred on individual skin diseases, and also mental health charities, until now there has been no centralised hub that provides coordinated resources, appropriate to people with problems that go beyond their skin and are psychological or psychiatric – this is role that Skin Support fills.

Skin conditions are the most frequent reason for people to consult their GP. It is not just the physical symptoms that affect sufferers’ lives – diseases that are visible, disfiguring or long-term can carry a multitude of psychological and social effects, including isolation and depression. In the UK, psoriasis alone is linked to 300 suicide attempts annually. A British Association of Dermatologists’ survey in 2011 revealed that 85 per cent of patients indicated to their dermatologist that the psycho-social aspects of their skin disease were a major component of their illness.

Furthermore, stress, as well as being a frequent side effect of skin conditions, is also known to actually cause and exacerbate skin disease. Therefore psychological and self-help interventions can be crucial not only for easing mental distress but also for improving many of the physical symptoms of the skin disorder.

Dr David Eedy, President of the British Association of Dermatologists said: “Skin diseases can have a devastating impact on people’s mental and emotional wellbeing, and the benefits of support on both mental health and physical symptoms are well known in medical circles. However, few dermatology departments have access to local liaison psychiatrists and their associated services, so self-help can be a vital tool for patients. The problem is that finding self-help materials can be difficult – patients don’t know where to look and resources are available across so many different websites. The beauty of the Skin Support website is that it brings together lots of content in one easy to navigate place, and it tailors the materials to people’s individual skin disease and any physical impairment this may involve.

“A report produced by the All Party Parliamentary Group on Skin in 2013 showed that there is under provision of psychodermatology services. Whilst a website can in no way replace this kind of specialist care, it is a good starting point and will be of enormous benefit to clinicians as well as patients.”

Dr Andrew Thompson is Reader in Clinical Psychology at The University of Sheffield and a practising NHS Clinical Psychologist, and he was a member of the advisory panel associated with the development of the website. He said: “Skin conditions can have a significant psychological impact on people and it is well acknowledged that access to psychological intervention and even to good quality evidence based self-help is limited. Consequently the Skin Support project is an important development as it is unique in providing people with skin conditions with information about emotional and social issues associated with dermatological conditions. People visiting the site can also download self-help materials that have been written by qualified clinicians, such as myself, and have been either tested in the NHS or in research. We also hope that the site will encourage people to seek further help from their GP or Dermatologist if needed”

Members of the public with skin conditions have also provided testimonials for the website:

"Enduring skin conditions tend to cause you to be self-conscious, and lack confidence, even when the condition is under control. It is good to know that there are different, recognised methods which can be used to overcome this."
Susan Welch, 62, Surrey

"Emotional support is something that was really missing for me, my condition caused me to have a lot of dark days, it’s good to think beyond just physically managing my skin."
Sally Hooker, 52, Essex

"On particularly tough days, when it’s hard to stay positive, I can really see the benefit of the self-help materials on Skin Support."
Abi*, 28, Berkshire

"The blotchy skin I have with mast cell disease can be embarrassing but being able to share my problems with other sufferers has been a great help."
Gerry Newnham, 68, Hertfordshire

*Abi has asked for her surname not to be used
-ENDS-

Notes to editors:

Contact: Matt Gass, Communications Officer, British Association of Dermatologists. Email: matthew.gass@bad.org.uk, telephone: 020 7391 6084.

The Department of Health Innovation, Excellence & Strategic Development Fund awarded the British Association of Dermatologists (BAD) a three-year grant to enable them to develop an online hub for psychological support specifically targeted at skin disease patients.

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.

Website: www.bad.org.uk
Twitter: @HealthySkin4All
 

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One in five women with a vulval health condition contemplate self-harm or suicide

One in five patients with a condition affecting more than 300,000 women in the UK have considered suicide or self-harm, according to a survey of women with vulval health conditions released today.

Vulval health conditions are common in the UK, with a conservative estimate suggesting that 1 in every 100 women in the UK suffers from Lichen Sclerosus. This is just one of a range of vulval disorders and affects 63 per cent of the respondents to this survey.

The survey conducted by the British Association of Dermatologists (BAD), together with the Association of Lichen Sclerosis and Vulval Health, showed the extent of the social, professional and emotional damage that vulval health conditions can have on lives.

44 per cent of women with a vulval condition surveyed stated that it was difficult to access medical treatment for their condition. Reasons for the difficulties experienced included misdiagnoses, waiting times, not knowing who to speak to and embarrassment at seeking treatment.

Further to this, 89 per cent of those surveyed said that their condition had affected their emotional and mental wellbeing, 42 per cent said that it had affected their social life, 79 per cent said that it had affected personal relationships, and 39 per cent said that it had affected their work life.

The severity of this impact should not be underestimated. 22 per cent had suicidal thoughts or thoughts of self-harm. 17 per cent felt that their condition had been responsible for the break-up of a relationship, partnership, or marriage. 63 per cent felt that their condition had prevented, or made difficult, romantic or sexual relationships. One respondent said her condition made her feel “less of a woman”, another that she felt like “a freak”.

Many of the respondents said their condition made everyday tasks difficult, unpleasant, or impossible, including:

• Walking: 38 per cent
• Urinating: 50 per cent
• Wearing underwear or trousers: 60 per cent
• Engaging in sexual activities: 84 per cent
• Sleeping: 36 per cent

Dr Karen Gibbon of the British Association of Dermatologists said, “Embarrassment, emotional trauma, and physical pain are common themes amongst women with vulval health conditions. It’s important that women are able to talk about vulval conditions without fear of stigma. Greater awareness and education around vulval health will not only help mitigate emotional distress but will also help women get the treatment they need sooner.”

Dr Nevianna Tomson, Consultant Dermatologist said, “Vulval health conditions can be difficult for people to talk about, but it’s important that we overcome that discomfort. It shouldn’t be necessary for women across the country to suffer in silence. For many of these conditions there is no cure, but there are treatments that can help and there is a heavy psychological burden which we can lessen.

“Women should not be trapped inside their own heads thinking that they are less of friend, partner, employee or woman because of a condition. Being able to talk openly about health is the first step to improving the lives of patients and helping them get access to treatment.”

Fabia Brackenbury of the Association of Lichen Sclerosis and Vulval Health said, “I have been living with lichen sclerosus for over 20 years. It was a contributing factor to the loss of my 30 year marriage. The challenges never end. You go into old age with this condition. A woman deserves an Indian Summer, not a Winter of Discontent.

“A much higher profile needs to be established for vulval disease, not only amongst medical professionals but also researchers and the media. My own campaign for awareness started well with media interest but over the years has been dropped in favour of other health issues.

“Those who suffer, long to enjoy the high profile that is seen in other conditions, and none more so than those with vulval cancer. So many women have told me that at least if they had breast cancer, they could talk to people about it.

“If awareness equality was possible, women would feel more able to come forward and seek help. Awareness and education for everyone is essential if we are to improve the lives of the small girls who are diagnosed as young as two years old with lichen sclerosus and who will live a life sentence of shame, despair and uncertainty.

“We live in an unequal world where some people's health issues are more important than others and this is the root of much suffering for those who struggle for recognition.”

-Ends-
Notes to editors:
For more information, please email: john.major@bad.org.uk

Interview opportunities available with Dr Karen Gibbon, Dr Nevianna Tomson and Fabia Brackenbury. For more information contact john.major@bad.org.uk

Vulval health conditions include, but are not limited to, Lichen Sclerosus, Vulval Cancer, Vulvodynia, Lichen Planus, Ulcers, Cysts and Lichen Simplex. None of these are sexually transmitted diseases.

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 Association of Dermatologists’ Vulval Health Survey 2015 was completed by 325 women suffering with vulval health conditions. For details of the full survey contact: John.Major@bad.org.uk

Dr Karen Gibbon is a consultant dermatologist who works both in the NHS for Barts Health NHS Trust and privately in Essex. She runs specialist vulval clinics for girls and women of all ages. She is also a member of the clinical services unit at the BAD.

Dr Nevianna Tomson is a consultant dermatologist who works both in the NHS for West Suffolk Hospital and privately. At NHS West Suffolk she is the lead clinician for vulval disease. More about Nevianna can be found here: www.suffolkskin.co.uk

Fabia Brackenbury is the founder of the Association for Lichen Sclerosus and Vulval Health. She has been living with Lichen Sclerosus since 1994.

Other patient support groups for vulval health include the Vulval Pain Society and the British Society for the Study of Vulval Disease (BSSVD)
 

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Charities and medics call for parliamentary inquiry into NHS staffing crisis

Thirteen national groups representing doctors, nurses and patients are calling for a government inquiry into the chronic lack of doctors working in dermatology, following responses to Freedom of Information data released today that highlight staff shortages and variations in waiting times.

In a letter to Dr Sarah Wollaston MP, Chair of the House of Commons Health Select Committee, the organisations urge the Committee to review a decision by Health Education England not to allow for an increase in the number of trainee doctors in the specialty.

The signatories, which include the All Party Parliamentary Group on Skin, British Association of Dermatologists, Royal College of General Practitioners (RCGP), British Dermatology Nursing Group, as well as charities including DEBRA, Changing Faces, National Eczema Society and Psoriasis Association, cite newly released Freedom of Information (FOI) figures obtained by one of the co-signing groups, Dermatology Council for England.

Two-thirds (66 per cent) of trusts responding to the FOI request reported that they had consultant dermatologist vacancies. However, Health Education England (HEE) is funding just 177 specialty training places in dermatology in 2014/15, a reduction from the previous 178 posts. This means that with fewer trainees coming up through the ranks to replace retiring staff, there will be no scope to increase Consultant numbers.

Steps taken by trusts and CCGs to try to alleviate the void in consultants are themselves problematic, and no substitute for increased consultant numbers achieved through increased training posts.

71 per cent of trusts said they were using locum consultants to maintain services. Furthermore, while locums are meant to be a short-term solution to temporary staff shortages, 52 per cent of trusts employing locum consultants have had them in post for between one and four years, while 19 per cent had employed individual locums for more than four years.1

Recent reports have disclosed that the NHS paid £3.3bn last year for temporary agency staff, compared to £1.8bn in the past three years.
Almost half of trusts employing locums (48 per cent) were employing at least one that was not on the specialist register. In the UK, this register indicates when a doctor has completed training to the standard required to become a consultant.

The data also exposes the detrimental impact on waiting times and patient care For trusts with vacancies, the average waiting time for urgent referrals, but not subject to the two-week waits for cancer, was seven weeks, with urgent waiting lists as long as 19 weeks reported.

Half (104) of the CCGs who responded were commissioning community services staffed by GPs with a Special Interest in Dermatology (GPwSI). GPwSIs are GPs who have additional training and experience in a particular specialty, in this case dermatology. These services are often set up to try to alleviate the pressure on consultant dermatologists and increase the access to dermatological expertise within the community setting.

However, at least 29 per cent of these services were using GPs who did not fully comply with NHS guidance on good clinical practice for the provision of such a service.

The letter to the Health Select Committee, the body responsible for examining the work of the Department of Health, also refers to an independent report last month into the collapse of a dermatology service in Nottingham due to lack of staff and poor commissioning decisions. The report highlighted the need for Health Education England to review the funding available for dermatology training posts - a call to action that the Health Select Committee is being asked to consider, either within the context of dermatology specifically or as part of a larger review of the NHS’ workforce planning capability.

President of the British Association of Dermatologists Dr David Eedy said: “We hope this FOI data will prompt the Health Select Committee to look into the illogical decision by HEE to reduce our trainee numbers. Trusts are struggling to cope and efforts being made to bypass the need for consultants are clearly failing. Relying on locums is not a viable solution, and not just owing to the greatly increased cost to the NHS. Many locums may have trained abroad where clinical standards and guidelines differ widely from those in the UK, but the public are simply being told they are seeing a consultant, which is grossly misleading.”

The Dermatology Council for England is auditing all 209 CCGs and 54 trusts, chosen at random from each of the regions covered by NHS England’s former area teams. This interim report is based on responses received to date, from 204 CCGs and 38 trusts. Figures will be updated when the final responses have been received and processed.

Dr George Moncrieff, GP and Chair of the Dermatology Council for England said: “This report describes a dermatology service in meltdown. There has been an insidious over-dependence on expensive locums, many with foreign qualifications or not even on the specialist register, with alarming consequences.

“Sadly, after years of neglect to their teaching and training in dermatology, we cannot turn to General Practitioners to provide the solution. GPs have had, at most, just one or two weeks teaching in dermatology during their entire time at medical school. The Deaneries responsible for specialist training for these future GPs, provide virtually no further formal dermatology training. That is extraordinary when skin disease is such a large part of the everyday workload of a GP and results in about 15 per cent of the entire workload of a GP.

“Worryingly, the inevitable time lag between making effective changes and establishing a suitably qualified Primary Care workforce and adequate numbers of appropriately qualified dermatologists, will be measured in decades. This report demonstrates a service that has decayed relentlessly over the last ten years. It is imperative that we act now to address this crisis.”

-Ends-

Notes to editors:

For more information please contact: Nina Goad, Head of Communications, British Association of Dermatologists: comms@bad.org.uk
Tel: 0207 391 6094. Website: www.bad.org.uk

*The full results of the FOI requests will been available to view on both the Dermatology Council for England and APPGS websites: http://www.appgs.co.uk/dermatology-council-for-england-releases-foi-report-july-2015/

** The full signatory list for the letter to the Health Select Committee is as follows:
Sir Paul Beresford MP, Chair, All Party Parliamentary Group on Skin
Dr David J Eedy MD, FRCP, President, British Association of Dermatologists
Professor Nigel Mathers, Honorary Secretary, Royal College of General Practitioners
Dr Stephen Kownacki, Chairman, Primary Care Dermatology Society
Karen Stephen, President, British Dermatological Nursing Group
Margaret Cox, Chief Executive, National Eczema Society
Claire Mather, Director Healthcare, Membership, and EB Community Support, DEBRA
Dr George Moncrieff, Chair, Dermatology Council for England
Helen McAteer, Chief Executive, Psoriasis Association
James Partridge, Chief Executive, Changing Faces
Fred Frederiksen, Vitiligo Society
Nigel Scott, Herpes Virus Association
Julie Halford, Hyperhidrosis UK

1 Many trusts employed more than one locum for different lengths of time, as such the percentages given will not total 100%.

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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Increase in hair dye and fragrance allergies in children

A study due to be presented at the British Association of Dermatologists annual meeting in Manchester today has found  a substantial shift in the allergens causing skin reactions in children over the last decade, with some allergies becoming less common and with others, including to hair dye ingredients, on the rise.

The study involved 500 UK children tested for potential contact allergies (skin reactions following contact with a substance*) between 2005 and 2014, and replicated a previous study, also of 500 children, between 1995 and 2004, to see the changes that have occurred in the frequency of contact allergy and the allergens responsible over the past ten years. The study was conducted by dermatologists from Leeds Teaching Hospitals NHS Trust.

In both studies 27 per cent of the children (133 in 1995 to 2004 and 134 in 2005 to 2014) tested positive to one or more contact allergy. However, where they differed in their results most significantly was in regards to the causes of these allergies. In the 1995 to 2004 study 33 per cent of these children had a nickel allergy and 18 per cent presented with an allergy to a fragrance. Between 2005 and 2014 these two allergens remain the most common, however, there was a sharp fall in the number of nickel allergies, down to 18 per cent.

Despite the fall in nickel allergies the total percentage of children with allergies remains static because more children are becoming sensitised to other substances, some of which did not even feature in the original study, including various hair dye ingredients. It is thought this might suggest increasing use of hair dyes in children, and may also be due to black henna tattoos which contain a high concentration of para-phenylenediamine (PPD). Use of these tattoos just once can make people react to PPD in other products at a later date*.

After metals and fragrances, the next most common allergens were:

Allergen                                              Frequency         Common Uses
Para-phenylenediamine (PPD)          16 per cent         Hair dye ingredient
4-aminophenol                                    8 per cent          Hair dye ingredient
Aminoazobenzene                              7 per cent          Dye ingredient
Disperse orange 3                              7 per cent          Textile dye ingredient
Para-toluenediamine sulfate (PTDS)  7 per cent          Hair dye ingredient
Methylchloroisothiazolinone and
methylisothiazolinone
                                                           6 per cent          Preservative commonly used in cosmetics and many everyday household objects.

The authors of the study hypothesised that the reason for the fall in nickel allergies may be down to the European Union Nickel Directive, implemented in December 1994. The Nickel Directive limits the amount of nickel that can be used in products that come into prolonged contact with the skin. This impact of this would not be instantaneous but rather would likely show over time as new generations are less exposed to the metal, as although some people are predisposed to certain allergies others become sensitive to new substances through exposure over time.

In fact, in 2013 dermatologists raised concerns about the UK’s new five pence and ten pence coins which are nickel-plated, rather than being made of a nickel alloy, worried that people would be unnecessarily sensitised to nickel by long-term exposure through these coins.

Dr Vanessa Smith of Leeds Teaching Hospitals NHS Trust and one of the authors of the study, said: “It’s important to track the rates of allergy in children in the UK, and to recognise the underlying allergens, this can help guide policy makers and manufacturers as to potential public health risks.

“Our results suggest that efforts to curb the rates of nickel allergies have been a success and that these policies should continue. However, it’s clear that some of the highest rates of allergy amongst children are due to hair dye ingredients such as PPD. This is perhaps a sign of children using hair dyes and getting black ‘henna’ tattoos at younger ages, both of which can cause sensitivity to PPD.”

Matthew Gass of the British Association of Dermatologists, said: “Contact allergies can be very severe and can have a devastating effect on people’s lives. Nickel has been a common allergy for a long time and so it’s good to see that this study has shown that rates are falling. However, more efforts need to be made to make people aware of the sensitising properties of other common substances.”

-Ends-
Notes to editors:

* The study specifically looked at contact eczema, which is separate to immediate-type allergy, e.g. to foods.

Study details: Allergic contact dermatitis in children: trends in allergens, 10 years on. A retrospective study of 500 children tested between 2005 and 2014 in one U.K. centre
V. Smith, S. Clark and M. Wilkinson
Leeds Teaching Hospitals NHS Trust, Leeds, U.K.

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 Manchester Central from July 7th to 9th and is attended by approximately 1,300 UK and worldwide dermatologists.

For more information please contact:  Matthew Gass, Communications Officer, mobile 07837734620 during conference week, 0r 0207 391 6084 from Friday 10th, or email: comms@bad.org.uk , Website: www.bad.org.uk

*‘Black henna’ temporary tattoos are generally not made from henna but high concentrations of PPD.  This use of PPD is illegal in the EU, however black henna tattoos are often available abroad.

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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Smoking worsens acne scarring, study finds

It is well known that smoking has a negative impact on the health. Now new research, presented this week at the British Association of Dermatologists’ Annual Conference in Manchester, will reveal that it may worsen skin scarring in people with spots.

Smoking is known to cause changes to the skin, such as wrinkles, but this is the first study to suggest there may be a link between smoking and acne scarring.

A team of dermatologists from Harrogate conducted a study of 992 people with acne vulgaris (the most common type of the disorder) referred to a hospital dermatology department over an eight year period.

At the first appointment, each patient’s skin was examined and the severity of their acne and any scarring noted. Lifestyle factors that might affect the skin were also recorded, including smoking.

Scarring was noted in 91 per cent of patients but was not more common in smokers. However, a higher percentage of moderate to severe scarring, rather than mild scarring, was noted in those that smoked. Over half (53.7 per cent) of smokers showed moderate to severe scarring compared to just over a third of non-smokers (35 per cent). This appeared to be independent of acne severity.

Dr Raman Bhutani, one of the study’s authors, said: “The correlation seen between smoking and severity of facial scarring could suggest that smoking can increase the severity of scarring in a susceptible person with acne. Further work is required to confirm this finding and to understand the mechanisms by which this may occur.”

Nina Goad of the British Association of Dermatologists said: “Acne affects a huge proportion of the population, with 80 per cent of teenagers affected at some point. While for most people the disorder will eventually clear, some are left with scarring which can be for life. This can be hard to treat and can make people feel self-conscious and affect their self-esteem. We already know that smoking is bad for our health, so perhaps this latest finding will provide an extra impetus for people to quit.”

Acne occurs when the sebaceous (oil-producing) glands are particularly sensitive to normal blood levels of certain hormones, causing the glands to produce an excess of oil. The build-up of oil creates an ideal environment in which acne bacteria, known as Propionibacterium acnes, can multiply. At the same time, the dead skin cells lining the pores are not shed properly and clog up the follicles, producing blackheads and whiteheads.

The study team are conducting a study to understand how acne is treated across the UK. Please consider answering a short questionnaire via this link https://www.surveymonkey.com/s/Acne_treatment_survey_patient

-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 Manchester Central from July 7th to 9th and is attended by approximately 1,300 UK and worldwide dermatologists.

For more information please contact: British Association of Dermatologists Communications Team, 0207 391 6096 or Nina Goad, Head of Communications, mobile 07825567717 during conference week, or email: nina@bad.org.uk, Website: www.bad.org.uk

Study details: Exhibition poster P56, Smoking and scarring severity in acne, R. Bhutani, P. Kadiyala, E. Fryatt and A.M Layton; Harrogate District Foundation Trust, Harrogate, UK.

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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Sunbed use starts at age 12, study finds

A study due to be presented at the British Association of Dermatologists annual meeting in Manchester this week has found that the average age at which young people start using sunbeds is just 12 years old.

The research, involving 755 secondary school pupils from across Ireland, is the country’s largest study ever undertaken looking at avoidable skin cancer risk factors among the 14-18 age group.

The aim was to assess sunburn history, sun-protection habits (including sunscreen use), sunbed usage rates and attitudes towards sun and sunbed exposure among teenagers.

Eight per cent of respondents had used sunbeds, increasing to 11 per cent in the capital city, Dublin. Worryingly, six per cent had used sunbeds over 25 times in the previous year.

The average age of sunbed use was 16.2 years, with the average age of first sunbed use being 12.9 years. The youngest age of reported use was, shockingly, seven-years-old.

Further to this, only 26 per cent of sunbed users had been given any advice prior to use and 66 per cent of users were left unsupervised.

The study also found that 91 per cent of students had been sunburned. Teenagers were twice as likely to apply sunscreen regularly while abroad on sunshine holidays, than to apply it during the summer months in Ireland, suggesting a lack of understanding that sunburn can occur at home as well as abroad.

42 per cent of sunbed users were male, and most teenagers used sunbeds in beauty salons (29.3%). 20 percent were spending 11 to 30 minutes at a time on sunbeds, a worrying figure since 20 minutes on a sunbed can be equivalent to spending four hours in the sun*.

86 per cent of sunbed users believed that a tan makes you more attractive; 81 per cent believed a tan looked healthy; 61 per cent thought that sunbeds are a good way to create a base tan before going on holiday; and 53 per cent believed sunbeds to be a good treatment for acne. Whereas 72 per cent of non-sunbed users believed a tan makes your more attractive; 70 per cent thought a tan looked healthy; 22 per cent thought it useful to create a base tan; and 18 per cent believed sunbeds to be a good treatment of acne.

Sunbeds are a group 1 carcinogen, with indoor tanning placing users at a 48 per cent higher risk of developing non-melanoma skin cancer. 72 per cent of interviewed sunbeds users were aware that sunbeds were harmful, suggesting that concerns over skin cancer are being outweighed by the desire to be tanned.

Miriam Fitzgerald, co-author of the study said: “Studies have shown that first use of a sunbed when aged under 35 years increases the risk of later developing melanoma by 75 per cent, so our findings that eight per cent of teenagers are using sunbeds is a worry. Even more concerning is that those who use sunbeds are starting, on average, at age 12. National legislation banning the use of sunbeds by persons aged under 18 years was introduced in 2014, four months after our study ended. We plan to revisit schools to assess whether the ban, once established, has any effect on the above results.

-Ends-
Notes to editors:

Study details: Ambient and sunbed ultraviolet radiation exposure: exposure rates, protection habits and attitudes of Irish teenagers aged 14–18 years before introduction of national sunbed legislation
M. Fitzgerald,1 S. Daly,2 D. McKenna,2 J. Bourke3 and A. Kelly3
1Mater Misericordiae University Hospital, Dublin, Ireland, 2Sligo Regional Hospital, Sligo, Ireland and 3South Infirmary Victoria University Hospital, Cork, Ireland

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 Manchester Central from July 7th to 9th and is attended by approximately 1,300 UK and worldwide dermatologists.

For more information please contact: Nina Goad, Head of Communications, 0207 391 6094 or mobile 07825567717 during conference week, or email: nina@bad.org.uk, Website: www.bad.org.uk

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.

*http://www.bbc.co.uk/newsbeat/article/21057439/newsbeat-guide-to-sunbeds-and-tanning
 

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Antibiotic usage for acne and skin infections is leading to drug resistant bacteria, doctors warn

Doctors are being warned to limit the use of antibiotics for the treatment of acne, amidst growing rates of antibiotic resistance in patients with the disorder.

For more than 40 years, antibiotic therapy directed against the acne-causing bacterium, Propionibacterium acnes, has been the mainstay of treatment for moderate (rather than mild or severe) acne. Commonly used antibiotics for acne include erythromycin, clindamycin and a group of antibiotics called tetracyclines.

This week, Dermatologists and Microbiologists from Harrogate will present findings at the British Association of Dermatologists’ Annual Conference in Manchester that may challenge this practice, while a study from King’s College Hospital in London will show growing rates of antibiotic resistance among all dermatology patients.

The Harrogate researchers measured the numbers of Propionibacterium acnes colonising the skin of 994 patients referred to the hospital Dermatology department between 2004 and 2013 and assessed what proportion of them were resistant to common antibiotics used to treat acne.

The study, supported by a grant from the British Skin Foundation, revealed that up to 79.5 per cent of patients were colonised by bacteria resistant to erythromycin or clindamycin or both.

The proportion of patients colonised by tetracycline-resistant bacteria was lower (14.2 to 25 per cent), but did rise to 68.2 per cent one year (2011) for reasons that are currently unclear. Most patients were colonised by a mix of both resistant and non-resistant bacteria.

There is evidence to suggest that patients carrying antibiotic resistant Propionibacterium acnes may respond less well to antibiotic therapy used to manage their acne. It has also been shown that these resistant bacteria can be spread by direct contact from one person to the next.

A second study due to be released at the conference looked at the resistance to antibiotics of another bacterium, called Staphylococcus aureus, which is a common cause of skin infections. The researchers, from King’s College Hospital in London, found that 30 per cent of samples taken from general dermatology patients (rather than acne patients specifically) in 2014 were resistant to the antibiotic erythromycin compared to 17 per cent in 2007. 24 per cent of samples in 2014 were resistant to clindamycin, but it is not known if this is an increase from previous years.

Nina Goad of the British Association of Dermatologists said: “The growing resistance to antibiotics among skin patients generally and among acne patients more specifically, as highlighted by these two studies, is of concern. Antibiotics are important for treating skin infections, which are common in many skin diseases like eczema. Acne affects a huge number of people – 80 per cent of teenagers experience acne and while for most people it will disappear with age, for some it continues well into adulthood. If left untreated it can have a big psychosocial impact and cause scarring, so clearly this is a problem that needs to be managed.”

Consultant Dermatologist Dr Alison Layton from Harrogate, one of the acne study’s authors, explained: “Against a background of global concern about rising antibiotic resistance rates in major bacterial pathogens, GPs
may be unaware that resistance rates in skin propionibacteria are so high. These results highlight the need to use antibiotics judiciously when managing acne and to ensure that alternative effective agents are used, such that reliance on antibiotics is reduced whenever possible.”

Acne occurs when the sebaceous (oil-producing) glands are particularly sensitive to normal blood levels of certain hormones, causing the glands to produce an excess of oil. The build-up of oil creates an ideal environment in which Propionibacterium acnes can multiply. At the same time, the dead skin cells lining the pores are not shed properly and clog up the follicles, producing blackheads and whiteheads.

Dr Layton and the team in Harrogate are now conducting a study to understand how acne is being treated and are asking patients (via https://www.surveymonkey.com/s/Acne_treatment_survey_patient) and professionals who prescribe for acne (via https://www.surveymonkey.com/s/Acne_treatment_survey) to complete a survey to confirm this, so they can then provide relevant educational material to support improved treatment outcomes.

-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 Manchester Central from July 7th to 9th and is attended by approximately 1,300 UK and worldwide dermatologists.

For more information please contact: Nina Goad, Head of Communications, 0207 391 6094 or mobile 07825567717 during conference week, or email: nina@bad.org.uk, Website: www.bad.org.uk

Study details:
1. A decade later, has the prevalence of skin colonization by resistant propionibacteria increased in our patients with acne? K.H. Kuet,1 C. Finch,1 E. Fryatt,1 A. Eady1 and A. Layton1,2
1Sheffield Teaching Hospitals NHS Trust, Sheffield, U.K. and 2Harrogate and District NHS Foundation Trust, Harrogate, U.K.
This study was supported by a grant from the British Skin Foundation: www.britishskinfoundation.org.uk

2. Trends in antibiotic resistance patterns of Staphylococcus aureus isolates from dermatology patients in the U.K. over 12 years. A. Sears, M. Rossabi, N. Desai, J. Wade, R. Hay and R. Morris-Jones
King’s College Hospital, London, 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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BAD response to independent report confirming "unmitigated disaster" at Nottingham Hospitals

We welcome the report which we feel summarises the series of errors that led to the collapse of key dermatology services in Nottingham. We agree that all involved parties must now work together to improve patient care and to rebuild services in the region. However, it is also crucial that the failures outlined in the report are accepted and learnt from. The CCGs claim that the health of Nottingham’s citizens has been improved by the Circle service but it is hard to see how this is the case, given the destruction of what was previously a world renowned centre of excellence, the critical comments from patients in the report, and the current lack of key dermatology services. The commissioners have also claimed that the NUH service collapse was down to an employment issue rather than a commissioning issue, suggesting a failure to acknowledge the role of their own questionable commissioning decisions – such as preventing NUH setting up a separate specialist service that would have helped to retain specialists in Nottingham - that triggered the ‘employment’ problems they refer to. If CCGs deny accountability when services fail, our fear is that devastating contracting decisions will continue to be made, and it cannot be claimed that lessons have been learnt.

Circle admits that now they are saddled with the high costs of employing locums, it is likely that their service is not financially sustainable. This is a depressing indicator of things to come. The consultants who left Nottingham have not been asked to contribute to the report and it is important to establish why dermatologists have felt driven to move their families and jobs away.

 The problems in Nottingham are compounded by decisions taken at a national level. Despite a deficit of more than 200 Consultant Dermatologists across the UK, Health Education England has refused to allocate further training posts for dermatology. This means that we do not have enough trainees coming up through the ranks to replace retiring Consultant Dermatologists. While we appreciate that the time-lag involved in training does not provide a quick fix for the current crisis, the fact that training numbers are not increasing suggests that the Consultant workforce deficit will be plaguing patients with skin problems in many parts of the UK for years to come.

It is also worrying that doctors who do not possess the same certification required of consultants on the Specialist Register, can legally be appointed locum consultants. For the NHS, these locums come at a hugely increased cost, as demonstrated in Nottingham. For the patient, this means that many posts in dermatology are held for long periods by someone not possessing the same qualifications as a substantive UK accredited Consultant. They may have trained abroad where clinical standards and guidelines differ widely from those in the UK. The use of the word ‘Consultant’ dupes patients into believing that these locums have been trained to the level required to enter the Specialist Register, which may not be the case.

The report makes for grim reading but, provided all involved can take responsibility for their errors, it may help to prevent spurious commissioning decisions decimating dermatology services elsewhere.

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Legal levels of common preservative are ‘not safe for consumers’

Legal limits of a preservative causing an epidemic of skin allergy are not safe for use in everyday products, according to new research in the British Journal of Dermatology.

Methylisothiazolinone (MI) is a preservative that is widely used in cosmetics, toiletries and other household items including paints. At present, the maximum concentration at which it is allowed to be used in cosmetics, known as the ‘permitted usage’, is 100 parts per million (100ppm, or 0.01%), both in ‘leave on’ products which are designed to remain on the skin (such as moisturisers and sunscreens) or ‘rinse off’ products which are washed off (such as liquid hand soap, shampoo and shower gel).

Allergic reactions to skin contact with MI have increased by 93 per cent in just three years*, prompting warnings from dermatologists across Europe and a public outcry at a failure to ban the chemical from everyday consumer products.

Studies have found that MI used at the permitted level in leave-on products is what is most likely to have caused the epidemic of MI allergy. This study, which will appear in the July edition of the journal, examines reactions to MI from rinse-off products, and whether individuals already allergic to MI will react to levels that are permitted in rinse-off products.

The study tested rinse-off liquid hand soaps, containing two permitted concentrations of MI, on 19 people with a MI allergy, to see if these concentrations have the potential to trigger allergic contact dermatitis (eczema caused by allergy). 10 of these people received a soap containing 100 ppm MI, and nine received half that concentration, 50 ppm. 19 people with no MI allergy, acting as a control group, also used the products. The soaps were applied to test areas of skin five times a day for up to 21 days, and rinsed off shortly after application, as would be usual with soap use.

All of the test subjects with an MI allergy had reactions to the rinse-off product containing 100 ppm MI. When reducing the concentration to 50 ppm, 78 per cent (7 out of the 9) MI-allergic subjects reacted. None of the control group suffered a reaction, and none of the MI patients suffered a reaction to a control product that did not contain MI.

Given the widespread rates of MI allergy in the general population, with MI allergy affecting at least 11 per cent of people attending UK patch test clinics, the authors conclude: “Rinse-off products preserved with 50 ppm MI or more are not safe for consumers. No safe level has yet been identified.”

This latest research coincides with an editorial written by the Executive Committee of the European Society of Contact Dermatitis in next month’s edition of the journal Contact Dermatitis1, in which the group outlines how the European Commission has ignored the recommendations of its own Scientific Committee on Consumer Safety (SCCS), which in 2013 advised that MI should be banned from all leave-on cosmetic products, and that the legal limit in rinse-off products should be reduced to 15 parts per million (15 ppm) instead of the current 100 ppm.

Nina Goad of the British Association of Dermatologists said: “It has been two years since dermatologists first warned the public about a contact allergy epidemic in the UK stemming from the use of MI in cosmetic products. We now know it is a problem in many other products also, such as paints and detergents, as well as in the workplace. The epidemic shows no sign of waning, and is unlikely to do so without action on a legislative level.”

Dr David Orton, President of the British Society of Cutaneous Allergy and Secretary of the European Society of Contact Dermatitis, said: “Dermatologists from the UK and indeed many other parts of Europe have been vocal over the past two years about the unprecedented rise in allergy to MI and the many sources of exposure to this widely used preservative. As far back as 2013, the European regulatory body was advised by their own safety committee (the SCCS) and also by Cosmetics Europe who represent the major European cosmetic manufacturers, on what should be done.

“Cosmetic Europe’s advice to their members stressed that action should not be dependent upon regulatory intervention – yet it seems to have fallen on deaf ears. We continue to see unacceptable levels of allergy and patients, both adults and children, experiencing debilitating allergic responses. There has been no expedient action taken either by regulators or the manufacturers – UK and other European citizens’ health continues to be put at risk. One can only wonder what it takes for these bodies to act. Many manufacturers have cynically let stocks of their products remain on the shelves whilst they are busy re-formulating behind the scenes. In my view, consumers need to be made aware of these failures of regulation and the inertia of the manufacturers.”

Ben Smith’s two-year-old son, Tennyson, was recently diagnosed with MI allergy, believed to have been triggered by use of baby wipes. He said: “To find out that the allergy was actually caused by the use of this chemical in baby products was very upsetting. What made it even more shocking is to learn that the problem was known by the manufacturers because they had already been notified and lobbied yet they chose to continue to include the chemicals and not warn parents.

“Having the allergy has caused lots of upset and confusion over the last 14 months. My son has suffered severe itching and painful inflammations during multiple flare-ups lasting approximately five days each. These always mean very disturbed sleep with crying in the night, which had a knock-on effect on daily life.

“Whenever your child is upset, the immediate reaction is to find a way to soothe them and fix whatever the situation is. Not knowing what the allergy was and how to avoid it permanently lead to many feelings of guilt and upset. I am thankful that we got through it and now know what the allergy is to, and we have the ability to isolate and avoid it. However, I am very angry that this is something that could have been avoided from the start and am keen to help ensure that other children and parents do not suffer from it.”

MI is widely used, either on its own or in combination with methylchloroisothiazolinone (MCI), as a preservative in personal care products such as moist tissue wipes, cleansers, shower gels, deodorants and shaving foam, as well as in everyday professional and household products such as detergents, paints and glues.

In December 2013, in response to pressure from dermatologists, Cosmetics Europe, the European cosmetics trade association, recommended to all its members that MI should be immediately removed from all leave-on skin products and personal care products, including cosmetic wet wipes, without waiting for action from regulators. In practice, however, many leave on cosmetic products containing MI have remained on the shelves. Furthermore, safe levels of MI in rinse-off cosmetics have not yet been determined, either for induction of allergy in the first place, or for elicitation of responses such as eczema in people who are already allergic, yet industry continues to use it at levels of up to 100ppm.

Prior to 2005, MI had to be mixed with MCI and was generally found in concentrations of around four parts per million (ppm) in personal care products. However, from 2005 MI was permitted for use on its own in far higher concentrations - up to 100 ppm – which is a 25-fold increase on the previous levels of the preservative and widely thought to be responsible for the disease increase. MI/MCI mix has been banned from leave-on products and reduced in rinse-off products but this has not been the case for use of MI on its own, despite the recent increase in MI allergy being largely attributed to its use in higher concentrations without the addition of MCI.

Dermatologists have also raised concerns that for non-cosmetic products, there is no legal requirement to show the presence of MI on product labelling, and there is no restriction on what concentration it can be used at. Last year, doctors from University Hospital Lewisham and St John’s Institute of Dermatology identified MI in paint as a serious potential public health concern. Exposure to paints with MI can trigger reactions in those already sensitised to the allergen, as well as causing those with no history of allergy to MI to react.2

At the same time, scientists from the Leeds, Manchester and Bath warned that MI can be an occupational health risk, after treating workers who developed MI reactions in the course of their employment due to use of industrial products including glue.2

The British Association of Dermatologists has endorsed the opinion of the SCCS and called on EU Regulators to:
• Ban MI in all leave-on cosmetic products / toiletries
• Reduced the permitted level of MI to 15 ppm in rinse-off products
• Classify MI as an allergen according to CLP Regulation (Classification, Labelling and Packaging of substances and mixtures), to ensure it is listed as an ingredient in non cosmetic / household detergent products, to allow the public to identify its use within these products.

-Ends-

Notes to editors:

For more information please contact the media team: comms@bad.org.uk, 0207 391 6094. Website: www.bad.org.uk. Case studies available on request.

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. Study details: British Journal of Dermatology: Methylisothiazolinone in rinse-off products causes allergic contact dermatitis: a Repeated Open Application study; K. Yazar, M.D. Lundov, A. Faurschou, M. Matura, A. Boman, J.D. Johansen and C. Lidén; DOI: 10.1111/bjd.13751. Articles in the BJD can be viewed online: www.brjdermatol.org

References:

*UK data shows a rise in MI allergy among patch tested individuals at 11.1%: http://onlinelibrary.wiley.com/doi/10.1111/cod.12185/abstract
Data from Europe and elsewhere also shows prevalence as high as 10%: e.g. http://www.abc.net.au/news/2014-03-03/one-in-10-allergic-to-chemical-in-baby-wipes/5294140

1 Contact Dermatitis (/journal/10.1111/(ISSN)1600-0536) Volume 72, Issue 6 (/doi/10.1111/cod.2015.72.issue-6/issuetoc), Article first published online: 11 MAY 2015

2 http://www.bad.org.uk/News.aspx?sitesectionid=154&itemid=1157 

About us:
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

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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Brits burying their heads in the sand over UK’s most common cancer, survey finds

96 per cent of Brits fail to check their skin the recommended once a month for skin cancer, and more than 77 per cent would not recognise signs of the disease, according to a survey of over a thousand people, carried out by the British Association of Dermatologists and being released in time for Sun Awareness Week 2015 (4th-10th May).

Worryingly, 72 per cent of people admitted that they had been sunburned in the last year. This is of concern given that the risk of developing melanoma – the deadliest form of skin cancer - is more than doubled in people with a history of sunburn compared with people who have never been sunburned.

Skin cancer is the most common cancer in the UK and rates have been climbing since the 1960s. Every year over 250,000 new cases of non-melanoma skin cancer – the most common type – are diagnosed, in addition to over 13,000 new cases of melanoma, resulting in around 2,148 deaths annually.

Johnathon Major of the British Association of Dermatologists said: “Almost three-quarters of people we surveyed admitted that they had been sunburned in the last year, which is shocking. With sunny days already making an appearance in parts of the UK, it is likely that this figure will remain high this year. This is a reflection of poor sun protection habits – people underestimate the damage that sunburn can do to their skin, and many think that skin reddening is just a harmless part of the tanning process, rather than a sure sign that you have damaged your skin irreparably.”

Sun Awareness Week 2015, in partnership with sponsor La Roche-Posay, will culminate in an event at the Westfield shopping centre in Shepherd’s Bush, London. Consultant Dermatologists from the British Association of Dermatologists and nurse volunteers will be on hand to speak to the public, educate them on how to check their skin for skin cancer and provide information on sun protection techniques. There will also be a UV photo-booth to demonstrate the effect of sun damage on the skin, giving the public the opportunity to upload their pictures to social media websites during the event.

Charlotte Proby, Professor of Dermatology at Ninewells Hospital and Medical School in Dundee, and Chair of the British Association of Dermatologists’ Skin Cancer Prevention Committee said, “Rising skin cancer rates are a major health concern for the UK, and some dermatology departments are stretched to capacity trying to keep up with cases.

“Many people in the UK are aware of the dangers; however, this has yet to translate into a culture of sun protection and skin checking which would do a lot to curb the incidence and deaths from this disease. As summer comes around again we want people to consider the message that you can enjoy the warm weather whilst staying safe.”

Tessa Tysome of La Roche-Posay said, “This year we are very proud to be the sole sponsors of the British Association of Dermatologists’ Sun Awareness roadshow. UV sun damage is a serious issue that many people underestimate and Sun Awareness Week is a fantastic opportunity for La Roche-Posay and Anthelios to show our commitment to promoting healthy skin care.”

The British Association of Dermatologists surveyed 1,018 people over the summer of 2014 at national events across the country. The results are as follows:

  • 84% are worried about skin cancer in the UK climate
  • 88% don’t think skin cancer is any easier to remove than other cancers
  • 95% know skin cancer rates in the UK are still rising
  • 40% never check their skin for signs of skin cancer; 36% check their skin infrequently; 6% once a year; 4% once a month and 6% four times a year.
  • 77% do not feel confident that they could recognise signs of a melanoma.
  • 81% do not feel confident that they could recognise signs of a non-melanoma skin cancer.
  • 72% of people have been sunburned in the past year.

Over the summer the British Association of Dermatologists, with sponsor La Roche-Posay, will be visiting the following events with the “Be Sun Aware” roadshow:

·         Westfield, Shepherd’s Bush, 9th-10th May

·         BBC Gardeners’ World Live 2015, NEC Birmingham, 11th-14th June

·         New Forest County Show, Hampshire, 28th-30th July

 

-Ends-

 

Notes to Editors:

For media queries please contact the British Association of Dermatologists’ communications team: email comms@bad.org.ukor phone 0207 391 6094 / 6355 or 07825567717.

For expert comment on either Saturday or Sunday please call Professor Charlotte Proby of the British Association of Dermatologists on 07788741338. On Sunday (until mid-afternoon) or Monday please call Dr Bav Shergill of the British Association of Dermatologists on 07958600135

Sun Awareness Week takes place 4th-10th May 2015 and is owned by and trademarked to the British Association of Dermatologists. La Roche-Posay is the sole sun protection brand partner of the 2015 campaign and has been a sponsor of the British Association of Dermatologist’s Sun Awareness Campaigns since 2011.

The hashtag for Sun Awareness Week 2015 is #SunAwarenessWeek.

For more information of this year’s campaign and to learn more about sun protection and skin cancer please visit: http://www.besunaware.com/

Sun protection tips:

 

1.      Spend time in the shade during the sunniest part of the day when the sun is at its strongest, which is usually between 11am and 3pm in the summer months.

 

2.      Avoid direct sun exposure for babies and very young children.

 

3.      When it is not possible to stay out of the sun, keeping yourself well covered, with a hat, T-shirt, and sunglasses can give you additional protection.

 

4.      Apply sunscreen liberally to exposed areas of skin. Re-apply every two hours and straight after swimming or towelling in order to maintain protection.

 

Checking for skin cancer:

There are two main types of skin cancer: non-melanoma, the most common, and melanoma, which is less common but more dangerous.

The following ABCD-Easy rules show you a few changes that might indicate a 'melanoma', which is the deadliest form of skin cancer.

As skin cancers vary, you should tell your doctor about any changes to your skin, even if they are not similar to those mentioned here.

If your GP is concerned about your skin, make sure you see a Consultant Dermatologist, the most expert person to diagnose a skin cancer. Your GP can refer you via the NHS.

 

Asymmetry - the two halves of the area may differ in shape

Border - the edges of the area may be irregular or blurred, and sometimes show notches

Colour - this may be uneven. Different shades of black, brown and pink may be seen

Diameter - most melanomas are at least 6mm in diameter. Report any change in size, shape or diameter to your doctor

Expert - if in doubt, check it out! If your GP is concerned about your skin, make sure you see a Consultant Dermatologist, the most expert person to diagnose a skin cancer. Your GP can refer you via the NHS

The following are some suggestions about what to look for in potential non-melanoma skin cancers.

Non-melanoma skin cancers can occur on any part of the body, but are most common on areas of skin that most often exposed to the sun such as your head and neck (including lips and ears) and the backs of your hands. They can also appear where the skin has been damaged by X-rays, and on old scars, ulcers, burns and persistent wounds.

Non-melanoma skin cancers vary greatly in what they look like. They tend to appear gradually on the skin, and slowly get bigger over time. They will not go away on their own without treatment. Some possible signs include:

-          A scab or sore that won’t heal. It may also bleed occasionally

-          A scaly or crusty patch of skin that looks red or inflamed

-          A flesh coloured, pearly lump that won’t go away and appears to be growing in size

-          A lump on the skin which is getting bigger and that may be scabby

-          A growth with a pearly rim surrounding a central crater, a bit like an upturned volcano

The British Association of Dermatologists (BAD) is the central association of practising UK dermatologists. Our aim is to continually improve the treatment and understanding of skin disease. The BAD provides free patient information on skin diseases and runs a number of high profile campaigns, including Sun Awareness, which runs from May to September annually and includes national Sun Awareness Week in May.

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Independent King’s Fund report finds major failings in NHS services for people with skin diseases

A report by the King’s Fund into a major NHS specialty - dermatology - has identified staff shortages, poor training, inconsistent quality in diagnosis and treatment and large variations in access to specialist care, affecting millions of patients across the UK each year.

Dermatology represents an important part of NHS provision. Each year, approximately 24 per cent of the population will visit their GP with a skin complaint, making skin conditions the most frequent reason for people to consult their doctor with a new problem.

The independent report by the King’s Fund, commissioned by the British Association of Dermatologists and released today, reveals a number of worrying challenges facing dermatology services and identifies opportunities for improvement, which may also be applied to other health specialties. The report looked at a range of issues, including workforce (staffing), training, use of temporary or locum staff, technology and the role of pharmacy, making a number of observations and recommendations.

The authors Nigel Edwards and Candace Imison summarise: “Dermatology represents an important part of NHS provision. There are approximately 13 million GP consultations for skin conditions a year and 716,830 new referrals and yet this important area is poorly understood and has received comparatively little attention. Commissioning has often been poor. Inadequate planning has left gaps in the workforce. The 40,000 GPs managing this workload have received little training in dermatology and there are only 650 consultants to advise them and provide the more specialist care.

These include the following two key recommended objectives:

1. To urgently improve quality of dermatology knowledge in primary care.
The report outlines: “GP dermatology teaching averages approximately only six days and most GP training schemes have no dermatology attachment…. Dermatology undergraduate training averages a couple of weeks at most, is variable in terms of quality as well as syllabus, and it is not compulsory.” As well as improved education and training and targeted continuing professional development, other solutions might include the development of experts in larger GP practices, and the use of peer review and decision-support.

2. To improve commissioning
The report states: “Our work exposed major concerns about the current quality of commissioning for dermatology services and the lack of specialist knowledge among commissioners… Commissioning should not be driven by short-term tactical decisions designed to minimise the price paid rather than to improve value for patients; there is a danger of service fragmentation and of models of care that make false economies … or in the worst case threaten the quality of care. We saw a number of examples of this.”

The British Association of Dermatologists (BAD) asked The King’s Fund to explore the current challenges facing dermatology services and identify opportunities for the future. The King’s Fund engaged a wide range of stakeholders from within and outside dermatology to help address this question. This engagement activity included a survey, stakeholder interviews with patients and with clinicians from both primary and secondary care, interviews with the independent sector and commissioners, visits to specialist dermatology services, and stakeholder workshops.

“There are opportunities to improve these services but also an increasingly urgent need to respond to: growing demand and expectations; rising costs of new treatments; inconsistent quality in diagnosis and treatment (particularly within primary care); large variations in access to specialist care; issues with patient experience; and shortages, and an uneven distribution, of senior medical and nursing staff. There is a challenge for primary care where there are some of the greatest opportunities for improving the quality of care for people with skin conditions. This report looks at these issues and the options for addressing them.

“Dermatology is a useful case study that can shed light on thinking for other outpatient-based services and how these can develop new delivery models that make better use of limited specialist skills.”

Dr David Eedy, President of the British Association of Dermatologists said: “This independent report confirms our suspicions about many of the problems currently facing dermatology, while suggesting some interesting solutions. Workforce and GP education are already top of our agenda, yet seem to be ignored by the powers that be. Given that as much as 20 to 25 per cent of GP workload involves skin disease, the added pressure on GPs will not be alleviated by cutting further Consultant Dermatologists who help them with some of their most numerous, time consuming clinical problems. And yet the shortfall in Consultant numbers is not being addressed by creating further trainee posts in dermatology, which would seem like a logical step. Furthermore, it is widely acknowledged that there is a lack of knowledge about skin disease in general practice as a result of poor undergraduate and postgraduate teaching which leaves most GPs lacking the skills to manage dermatology and results in more patients being referred to Consultants. This is not the fault of the GPs but of the education they are offered.”

The report will be disseminated to a range of stakeholders to whom it is relevant, including medical professionals, commissioners and skin disease charities and patient groups.

Key facts about skin disease from the British Association of Dermatologists:

• Dermatology comprises a vast proportion of the total UK health burden. Dermatologists manage over 2,000 diseases of the skin, hair and nails in adults and children.
• Each year 54% of the population is affected by skin disease, and 23 to 33% of the population at any one time has a disease that would benefit from medical care.
• Approximately 13,000 melanomas and around 500,000* non-melanoma skin cancers are diagnosed a year. The number of just one type of skin cancer, basal cell carcinoma, equals all other cancers combined, and increased by 133% between 1980 and 2000. Melanoma incidence increased by 50% over just 13 years. *Actually the true figure is not known because the government does not collect the numbers!
• Approximately 4,000 deaths occur in the UK annually due to skin disease, most often from malignant melanoma.
• Skin diseases represent 34% of disease in children, with atopic eczema affecting 20% of infants.
• Skin cancer is the most common cancer and the second most common cancer causing death in young adults.
• Hand eczema is one of the most common reasons for disablement benefit in the UK.

-Ends-

Notes to editors:

For more information, please email: Nina Goad, Head of Communications, nina@bad.org.uk
Interview opportunities available with Dr David Eedy, President of the British Association of Dermatologists.


The report can be found on the British Association of Dermatologists’ website here: http://www.bad.org.uk/official-responses/kings-fund-report-into-dermatology-services-in-the-uk  

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 King's Fund is an independent charity working to improve health and health care in England. We help to shape policy and practice through research and analysis; develop individuals, teams and organisations; promote understanding of the health and social care system; and bring people together to learn, share knowledge and debate. Our vision is that the best possible care is available to all.

 

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Parliamentary Questions regarding dermatology Jan-Feb 2015

Parliamentary questions relating to the dermatology crisis in Nottingham, HEE training numbers, lack of National Clinical Director of Dermatology, reveiew of strategic clinical networks, prescribing specials and more...

Dermatology Questions & Answers January – February 2015

 

Most recent first:

Lilian Greenwood MP:

To ask the Secretary of State for Health, how many commissioning fact sheets have been produced by NHS England since 2013; and what plans NHS England has to produce a commissioning fact sheet for dermatology services.

To ask the Secretary of State for Health, what assessment he has made of the potential merits of introducing a National Clinical Director for Dermatology.

To ask the Secretary of State for Health, when the next review of strategic clinical networks will be undertaken; and if he will consider the merits of creating a dermatology-focused strategic clinical network.

Answered 23rd February

Norman Lamb MP:

Since 1 April 2013, NHS England has published information factsheets for a range of purposes. The main factsheet resource for commissioners has been produced to provide the costs and benefits of 25 specific interventions to reduce premature deaths:

www.england.nhs.uk/ourwork/forward-view/sop/red-prem-mort/factsheets/

Although there are currently no plans to produce a commissioning factsheet for dermatology, National Institute for Health and Care Excellence guidance in areas such as eczema and psoriasis continues to help commissioners to deliver high quality dermatological care.

With regard to strategic clinical networks (SCNs), the first SCNs were chosen by NHS England using criteria developed with input from a broad range of stakeholders. These are initial groupings and it is expected that they will be expanded in the future. NHS England is undertaking a review of the role, purpose and function of the sub-regional infrastructure that it funds, which is focussed on supporting commissioners and providers to improve the quality of services including SCNs. This review is ongoing and is expected to reach its conclusions by the end of March.

NHS England currently has no plans to introduce a National Clinical Director for Dermatology. However, NHS England has established a clinical reference group for specialised dermatology to bring together clinical experts, patients and carers to share best practice and improve services for patients.

Lord Turnberg:

To ask Her Majesty’s Government what assessment they have made of the recent closing of the acute dermatological services at Nottingham University Hospital Trust and the impact it has had on the dermatology services to in-patients with acute medical and surgical conditions and on training capacity in the East Midlands.

The provision of services, including dermatology services, is a matter for the local National Health Service.

We are advised by the NHS Trust Development Authority that Nottingham University Hospitals NHS Trust has worked with commissioners to ensure a satisfactory service is available to local people from alternative providers and the Trust will continue to provide an out of hours service for its inpatients and those patients requiring emergency treatment.

Rushcliffe Clinical Commissioning Group has commissioned a review to assess what is needed to meet the needs of the population in the future.

This Government established Health Education England to co-ordinate education and training activity across the NHS, including the management of training programmes for junior doctors. Health Education England and the Local Education and Training Board in the East Midlands are best placed to work with local employers in Nottingham to understand and manage the impact of changes.

Answered 20th February

Earl Howe:

The provision of services, including dermatology services, is a matter for the local National Health Service.

We are advised by the NHS Trust Development Authority that Nottingham University Hospitals NHS Trust has worked with commissioners to ensure a satisfactory service is available to local people from alternative providers and the Trust will continue to provide an out of hours service for its inpatients and those patients requiring emergency treatment.

Rushcliffe Clinical Commissioning Group has commissioned a review to assess what is needed to meet the needs of the population in the future.

This Government established Health Education England to co-ordinate education and training activity across the NHS, including the management of training programmes for junior doctors. Health Education England and the Local Education and Training Board in the East Midlands are best placed to work with local employers in Nottingham to understand and manage the impact of changes.

Lord Walton of Detchant:

To ask Her Majesty’s Government why the acute adult dermatology service at Nottingham University Hospital is to be closed; and whether they have assessed the effect that that decision will have upon patients in the area affected by skin diseases.

Answered 16th February

Earl Howe:

The provision of services, including dermatology services, is a matter for the local National Health Service.

The NHS Trust Development Authority advises that since 2 February 2015 Nottingham University Hospital NHS Trust has not been able to provide a comprehensive adult dermatology service. It no longer has sufficient consultant dermatologist capacity to sustain such a service.

The Trust has worked with commissioners to ensure a satisfactory service is available to local people from alternative providers.

Rushcliffe Clinical Commissioning Group has commissioned a review to assess what is needed to meet the needs of the population in the future.

Baroness Finlay of Llandaff:

To ask Her Majesty’s Government how Health Education England calculates the number of trainees in dermatology; and how those numbers are matched to future specialist consultant requirements for England.

Answered 13th February

Earl Howe:

The Government has mandated Health Education England (HEE) to provide national leadership on education, training and workforce development.

HEE sets out its commissioning intentions based upon the needs of local employers, providers, commissioners and other stakeholders who come together as members of HEE’s Local Education Training Boards (LETBs).

HEE’s national workforce plan for England is an aggregate of local LETBs’ plans, but the advice and input of clinical advisors and patient representatives, as well as the Royal Colleges and other stakeholders, is also listened to and considered. It is this discussion and involvement locally and nationally that makes this a plan for the whole of the National Health Service in England.

HEE is in the process of reviewing investment in medical education in the context of current and forecast supply and demand, competing priorities, the NHS Five Year Forward View, and HEE’s Strategic Framework.

Cheryl Gillan MP:

To ask the Secretary of State for Health, what his Department's policy is on the long-term use of locum consultants to run dermatology services in England.

Answered 16th January

Daniel Poulter MP:

The Department expects National Health Service organisations to have a strong grip on their workforce planning and management across all their specialties including dermatology, making permanent appointments to consultant posts wherever possible. Via Monitor, the NHS Trust Development Authority and the Care Quality Commission, the Department is working with the NHS to reduce trusts’ reliance on temporary staffing including the long term use of locum consultants.

Cheryl Gillan MP:

To ask the Secretary of State for Health, how many consultant dermatologists with (a) permanent contracts, (b) agency contracts and (c) other contractual or financial arrangements worked in the NHS on 13 January 2015.

To ask the Secretary of State for Health, how many vacant consultant dermatologist posts there were in the NHS on 13 January 2015.

Answered 16th January

Daniel Poulter MP:

Information on vacancies is not collected by the Department. The last annual National Health Service vacancy survey in England was undertaken by the Health and Social Care Information Centre in 2010.

The survey was suspended in 2011 and then discontinued in 2013 following the publication of the Fundamental Review of Data Returns, which aimed to reduce the burden of the collection of data from NHS organisations.

Information on the number of consultant dermatologists who hold agency contracts and other contractual or financial arrangements is not held by the Department

The latest annual workforce census data, published by the Health and Social Care Information Centre (HSCIC), shows there were 486 directly employed consultant dermatologists working in the NHS in England as at 30 September 2013.

The next census will be published by the HSCIC on the 25 March 2015 and will provide data for September 2014.

Cheryl Gillan MP:

To ask the Secretary of State for Health, how many consultant dermatologist training posts have been funded in each financial year since 2010; and what assessment he has made of the sufficiency of that number.

Answered 16th January

Daniel Poulter MP:

Health Education England (HEE) has commissioned 177 specialty training places in dermatology in 2014/15 and intends to maintain this number in 2015/16.

Data on the volume of training places commissioned by strategic health authorities in the period before 2014/15 is not available.

HEE is responsible for workforce planning and education commissioning activity to ensure that the National Health Service in England has available a future workforce in the right numbers, with the right skills, values and behaviours this includes dermatologists.

HEE has recently published its second national workforce plan for England for the period 2015/16 which is built upon the needs of local employers, commissioners and other stakeholders who, as members of Local Education Training Boards have shaped the 13 local plans that are the foundation of the national plan for England. The priorities in the plan are the priorities of the NHS, identified locally and nationally by employers, colleges and other stakeholders.

Sir Paul Beresford MP:

To ask the Secretary of State for Health, what steps his Department is taking to curb excessive disparities in the cost of dispensing (a) dermatology and (b) non-dermatology preferred unlicensed dermatological preparations; and what steps he is taking to ensure that all pharmacies in England obtain a whole-of-market quote from manufacturers of such preparations, as is the case in Scotland.

Answered 12th January

Daniel Poulter MP:

The Drug Tariff sets out what National Health Service dispensing contractors will be paid for the products supplied as part of providing pharmaceutical services and the fees for providing those services in primary care.

The current arrangements for paying for unlicensed medicines were introduced in 2011. These arrangements, unlike the ones for Scotland, do not require pharmacy contractors to obtain a whole-of-market quote from manufacturers. However, the Drug Tariff sets the price that the NHS pays to dispensing contractors for dispensing many of the most popular specials. Setting a reimbursement price, applied to all contractors, stops disparity of payment for these products and encourages dispensing contractors to obtain best value for the NHS, while also ensuring patients receive the medicines they need, when they need them. Due to the number of unlicensed medicines that can potentially be prescribed, it is not possible to list a reimbursement price for all available specials.

Where the reimbursement price of a product has not been set, dispensing contractors are paid according to how the product is sourced. Where a dispensing contractor buys the product from a specials manufacturer or an importing company, they must claim the invoice price of the pack size used to dispense the product minus any discounts or rebates received.

NHS England is responsible for commissioning pharmaceutical services in primary care and it is for NHS England to consider whether dispensing contractors have acted appropriately, including excessive claims for payment made by contractors. In addition, the General Pharmaceutical Council is responsible for regulating the pharmacy professions should there be any concerns of professional misconduct.

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BAD response to draft NICE guidance on Sunlight Exposure: Benefits and Risks

Below you will find the BAD's response, and suggested ammendments, to NICE's draft guidance on Sunlight Exposure: Benefits and Risks

Following this consultation stage, the BAD will have the opportunity to review the revised guidelines before publication.

The draft guidance can be found here: http://www.nice.org.uk/guidance/indevelopment/gid-phg77/consultation

National Institute for Health and Care Excellence

 

PUBLIC HEALTH GUIDELINES – SUNLIGHT EXPOSURE: BENEFITS AND RISKS

 

Stakeholder Comments

 

Section Number Page Comments

General

 

·         Our principal comment is that the remit of this guidance, and what it actually delivers, are inconsistent, limiting its usefulness for those tasked with delivery of the ‘message’ to the public. The guidance does not offer evidence-based guidance on the risks and benefits of sunlight exposure, but focuses almost entirely on communication delivery without any advice on the content of the messages. Communication delivery we understood would be only a part of the intended guidance.

·         The evidence-based messages need to be defined before the channels of communications are agreed, rather than the other way around.

·         The timing of this guidance when the SACN review has not been completed is questionable, as the SACN review findings may be pivotal to this guidance’s messages.

·         The limited messaging around UVR and vitamin D (rather than around delivery of messaging) does not seem to be adequately evidence-based. This may not be the case but we would be keen to learn more about which evidence sources were used, and how the messages were then extrapolated from this evidence.

·         The evidence commissioned to form part of the guidance does not address the gaps in evidence around the role of UVR and vitamin D synthesis.

·         Rather than forming new guidance that seems to insinuate that the risks and benefits of sunlight are somehow equitable, would it perhaps be preferable to use existing sun safety guidance and caveat this with advice on vitamin D intake through diet and supplements?

·         The order of benefits and risks should be changed to risks and benefits throughout the document. The risks are well understood, the benefits less so.

·         The assumption seems to be that the only way to counter the risk of low vitamin D status is to increase exposure to sunlight. Except for a small number of people who cannot absorb oral vitamin D, this is just not true. The document should state clearly that when there is a risk of low vitamin D status, then oral supplementation is an effective way of improving vitamin D status for most people.

·         The document consistently discusses the need to protect the public from under- or overexposure to sunlight. This is the wrong way round.

 

0

1

“malignant non-melanoma” – Malignant non-melanoma is not a commonly used term and is confusing – please refer just to non-melanoma

 

0

1

The statement at the foot of page 1 that research suggests there may be other benefits, for example, protection against chronic diseases such as cancer, heart disease and diabetes is very misleading. Consensus does not support this statement and the brief background should reflect consensus and not add this as an afterthought.

0

2

This consensus statement represents the unified views of the British Association of Dermatologists, Cancer Research UK, Diabetes UK, the Multiple Sclerosis Society, the National Heart Forum, the National Osteoporosis Society and the Primary Care Dermatology Society. As such all authors should be referred to.

 

Please note that this consensus statement also dates back to 2010 and is subject to review following the publication of new evidence (e.g. SACN, and ‘Limited exposure to ambient ultraviolet radiation and 25-hydroxyvitamin D levels: a systematic review’, British Journal of Dermatology).

 

 

0

2

The link to the consensus statement is to a press release rather than the statement, and the link within that page to the PDF is defunct. The statement is available at  http://www.bad.org.uk/for-the-public/skin-cancer/vitamin-d?q=Vitamin%20D or please insert a working link to a PDF.

 


1: 3

6

‘people who put themselves at risk of UV overexposure, for example by

Sunbathing’ – insert ‘or using sunbeds’. This section should be expanded to include those who put themselves at risk of incidental exposure – such as gardeners, water sportsmen etc.

 

Other occupational exposure should also be covered here as a high-risk group, not just outdoor workers – for example truck drivers (UVA penetrates glass).

 

1.5

8

"Ensure messages are simple, succinct and in line with recommendations 6-9."  This is an oxymoron as recommendations 6-9 are not simple and succinct. We feel too much onus is being placed on the people delivering the messages at a local level, to decide what the messages should be and how best to deliver them. However, the guidance also shows that there is no available evidence to guide them on best practice. The statements “There is a lack of evidence on how health and social care practitioners and policy makers should convey messages about the benefits and risks of sun exposure, particularly in the UK” and

“There is a lack of evidence on how messages about the benefits and risks of sun exposure can be effectively tailored for different groups” in the Gaps in Evidence section (p. 43-44) reveal the limited utility of this guidance.

 

Despite the lack of evidence, could more advice be given to render this guidance useful ‘on the ground’, possibly including an algorithm that factors in population type / local demographics, target audience, mode of communication etc, to provide clear examples of campaign options. If not, perhaps the guidance should be postponed until such evidence is available?

 

1:5

8

Page 8 states that a skin cancer prevention campaign should also mention the risk of under-exposure. Our current knowledge suggests there is little risk of under-exposure for the majority of fair-skinned people targeted in skin cancer prevention campaigns. The prevention message will be confused by this approach which needs to be nuanced to those at risk of under-exposure due to cultural or religious reasons or dark skin colour.

1: 5

9

‘Develop resources that are downloadable from a central website and easy

to adapt for local use by a range of agencies, to ensure a consistent

message and to minimise duplication of effort.’

 

What message do you refer to here? There is as of yet no uniform message – and with the lack of evidence (as mentioned above) this creates a conundrum for those trying to put a campaign into practice.

 

1 : 6

9

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

‘advise people to go out in the sunlight for short periods (less than the

time it takes for skin to redden or burn) between 11am and 3pm from the

beginning of April to mid-October in the UK’

 

This is the crux of the guidance and yet what evidence is this based on? A review of all available evidence, or isolated studies / statements?

 

The latest review of available literature (January 2015*) that we are aware of states: “Interventional studies demonstrate that UVR can increase vitamin D levels in humans, but extrapolating from them to suggest that UVR is necessary for adequate vitamin D levels may be erroneous...

 

“This study demonstrates that many healthy adults in different populations across the world can maintain adequate serum vitamin D levels despite negligible UVR exposure for several months of the year. Public health campaigns promoting a high vitamin D diet or supplements to healthy adults could positively impact the burden to the individual and the health service of inadequate vitamin D levels and could avoid the negative sequelae of UVR exposure...

 

“While the findings of this review provide useful information for evidence based public health recommendations at the present time, more research is required in the form of prospective clinical trials that accurately record vitamin D intake, its UVR-related synthesis and its storage in the participants throughout the year, in particular in situations of negligible UVR exposure.”

 

*Limited exposure to ambient ultraviolet radiation and 25-hydroxyvitamin D levels: a systematic review, British Journal of Dermatology, DOI TBC.

 

We are aware that the committee received the above mentioned study, yet its core findings are not reflected in the guidance’s recommendations. Please could you inform us as to whether or not the study was used in the committee’s review of evidence?

 

All of the research commissioned by NICE appears to be around the economics and impact of public messaging, not around what the messages should actually contain, i.e. a systematic review of existing evidence around the role of UVR in vitamin D synthesis, or commissioning new research to breach gaps in this clinical evidence.

 

For example, we cannot see reference to the recent modelling study mentioned in the systematic review that reported that 10–20 min of sun exposure (often advocated by public health statements) is inadequate to boost serum vitamin D levels significantly, and that sufficient sun exposure to achieve worthwhile benefit would compromise skin health.

 

Please can more information be provided on how the messages contained within this guidance were formed, and more clearly detailing the evidence base for each message.

 

1.6

9

Current skin cancer prevention advice is to ‘spend time in the shade between 11am and 3pm when the sun is at its strongest.’ While this is not the same as telling people to stay in the shade (the whole time) as was advocated in previous decades, we need to ensure the wording is very carefully balanced. Fair skinned individuals can burn in less than 10 minutes in the summer between 11am and 3pm. The message regarding the perceived benefits of sunlight – to spend time in the sun – must never be given independently of the skin cancer message as this will be interpreted as two conflicting messages about whether or not to go outside between 11 and 3. Therefore a message that encompasses both issues must be used.

 

1 : 6

10

‘Being aware that skin that has less previous sunlight exposure (for

example, the back) is more likely to burn so extra care should be taken.’

It may be sensible to caveat this with a warning that a base tan does not provide adequate sun protection (less than SPF 6) and therefore use of sunbeds or pre-holiday tanning as a way of preventing sun damage is not advised.

 

1:6

10

‘ Make people aware that tanned skin is an indicator of possible skin

damage.’

 

A sun tan is damaged skin so the word ‘possible’ is erroneous. It is the body’s protective reaction to skin which has already been damaged by UVR. This message should be made clear.

 

1:6

10

The UV 400 label is not recognised in the BS EN 1836:2005 standard. Anyone can use the label and take it to mean whatever they wish. Secondly the concept of 100% UV protection is not recognised in the standard and is not achievable.

1 : 7

10 and 11

 

 

 

 

 

 

 

 

 

 

 

 

‘Apply sunscreen (at least sun protection factor [SPF] 15)’

In light of recent research (post the Feb 2012 review), the recommended SPF must be raised from 15 to 30. There is a volume of evidence to support this view.

 

In fact, this very guidance from NICE states in section 5.12: “The Committee was aware of concerns that sunscreen prohibits vitamin D synthesis. Expert testimony clarified that this may be the case when sunscreen is tested in laboratory conditions. But it is unlikely to be the case in reality, because people tend to apply much less sunscreen than the manufacturers recommend and in a patchy fashion”, acknowledging that people do not apply enough sunscreen to receive SPF15.

 

The latest research** that “While either sunscreen [15 or 30], if delivering the nominal SPF over the entire exposed skin, would be sufficient to prevent any erythema, the simulation indicates that the combination of the average quantity applied with the variability in thickness over the skin surface will lead to erythema, especially in SPF15 sunscreen users. People who intend spending long periods outside in strong sunshine would be better advised to use SPF30 labelled sunscreens than SPF15 sunscreens”.

 

Further conclusions are: “Sunscreen products carry a sun protection factor (SPF) number (relating to UVB radiation) and (often) a star rating (relating to UVA radiation), both of which indicate the potential protection offered. However, the actual protection gained depends heavily on exactly how people use sunscreen, and typically sunscreens are applied too thinly. Using a product with a high SPF (30) is a practical way of addressing this issue” and “Failure to prevent sunburn is usually due to the way sunscreen products are applied rather than the technical inadequacy of the product. However, one can argue that if the majority of consumers do not use the product in accordance with the recommendation, then this is a technical inadequacy in itself. Low cosmetic acceptance and the high cost of sunscreen products may result in insufficient use.” Furthermore, the article in the Journal Photochemistry & Photobiology (April 2011***) by De Villa et al describes research into the effectiveness of reapplication (two coats) to achieve coverage closer to the recommended amount.  Their research showed that even with two applications the amount of product on the skin was still lower than the recommended amount.

 

It is the role of this guidance to reflect new and emerging scientific evidence, not to ensure consistency with what is currently being recommended by external stakeholders (i.e. the guidance should determine the advice delivered by external stakeholders, not the other way around). Therefore we feel it imperative that the higher SPF30 is recommended to address this issue.

 

The wording ‘if applied properly and regularly, SPF15 should be enough’ cannot be conveyed to the public and is not sufficient (e.g. what is properly?). For this reason this statement should be deleted.

 

Evidence references:

**Pissavini M, Diffey B. The likelihood of sunburn in sunscreen users is disproportionate to the SPF. Photodermatol Photoimmunol Photomed. 2013

Jun;29(3):111-5. doi: 10.1111/phpp.12033. PubMed PMID: 23651270.

 

***Lodén, M., Beitner, H., Gonzalez, H., Edström, D.W., Åkerström, U., Austad, J., Buraczewska-Norin, I., Matsson, M. and Wulf, H.C. (2011), Sunscreen use: controversies, challenges and regulatory aspects. British Journal of Dermatology, 165: 255–262. doi: 10.1111/j.1365-2133.2011.10298.x

 

Iheanacho, I, Sunscreen SPFs: clear as daylight? DTB Vol 49 DTB2011;49:61, doi:10.1136/dtb.2011.02.0033

 

Iheanacho, I, Evidence review: Do sunscreens have a role in preventing skin cancer? DTB June 2011

DTB2011;49:69-72, doi:10.1136/dtb.2011.02.0036

 

De Villa D, Nagatomi AR, Paese K, Guterres S, Cestari TF. Reapplication improves the amount of sunscreen, not its regularity, under real life conditions. Photochem Photobiol. 2011 Mar-Apr;87(2):457-60. doi: 10.1111/j.1751-1097.2010.00856.x.

 

Petersen B, Datta P, Philipsen PA, Wulf HC. Sunscreen use and failures--on site observations on a sun-holiday. Photochem Photobiol Sci. 2013 Jan;12(1):190-6. doi: 10.1039/c2pp25127b.

 

1 : 7

10

‘…a hat is far better and more convenient’

This should specify ‘a wide-brimmed hat’ as a cap or similar would not protect the neck and ears.

 

1 : 7

And

5.1

10

And

21

‘sun screen…’

Sunscreen is one word, not two

1 : 7

11

‘4-star UVA protection’

 

Not all sunscreens use the star system as this was created for use within Boots, so please also refer to the UVA circle logo which is the European standard.

 

An explanation might also be included of the UVA:UVB protection ratio algorithm that is used to determine satisfactory UVA protection offered by products.

 

1:7

General

A point should be added regarding ‘one-application-a-day’ sunscreens, noting the potential dangers arising from improper application and accidental removal.

 

1:8

11

‘Older people should: be encouraged to go out in sunlight for short periods (less than the time it takes for skin to redden or burn) between 11am and 3pm, from the beginning of April to mid-October in the UK’

See previous comment. Actively encouraging people to go outside in the middle of the day in the height of summer will be misinterpreted. The two messages (skin cancer and vitamin D) must be combined and used in tandem. Focus should be given to dietary sources of vitamin D and supplementation – again, it is not sufficient for this to simply be addressed in a separate piece of NICE guidance.

 

1.8

11

‘expose at least the forearms and hands (or similar amounts of skin)’

What is this calculation based on?

 

1:11

13

‘Encourage children and young people to spend time in the shade and to wear wide-brimmed hats, protective clothing and sunscreen to protect themselves when UV levels are high (above 3 on the UV index)’

 

Given that many people are unaware of the UV index and its associated forecasts, might any health promotion work incorporate information on these and where they can be found?

 

Also, the UV index needs to be used in conjunction with info on skin type – e.g. a UV rating of 4 has very different implications for fair versus dark skin.

 

The BAD and Met Office produce a free-of-charge, non-commercial app (world UV app) which shows the UV index anywhere in the world, automatically geo-located to where you are, or you can select another location. It then provides sun safety information tailored to the UV index that day, and based on your own skin type. We would be happy for this to be used freely.

Information about the UV index is also available on the Met Office and BBC websites, although this does not cross reference with advice based on skin type.

 

1.11

13

‘Encourage parents of children at higher risk of skin cancer to provide their

child with protective clothing as well as sunscreen’

 

From the current wording it is unclear what you define as ‘children at higher risk’. Also, all children’s and adults’ first line of defence is protective clothing, not just those who are at higher risk of skin cancer.

 

3

16

NICE correctly identifies the challenges in maintaining balance between sun safety and vitamin D promotion messages. As above, a useful tool to promote is the UV index, which can be added to weather bulletins.

 

3

17

An issue at the centre of the consistent messaging difficulty is that various organisations do not agree on some of the core pillars of sun safety advice, for example recommended SPF, vitamin D acquirement practices, time spent out of the sun etc, and as we have shown, this guidance does not clarify these issues.

 

It is vital that this issue is addressed if we are to produce one clear, concise message to communicate to the public.

 

In order to unite these conflicting views, and the lack of evidence-base for the messages contained within this guidance, NICE may wish to conduct an independent audit of the supporting evidence upon which these views are based and construct consistent messages through those means, before issuing this guidance.

 

3

18

The major issue with mass media campaigns for smaller organisations is funding. Whilst commercial funding opportunities do exist, they can be limited in number available and resource that is provided. Smaller organisations rely on health campaigns to increase their profile and fundraising capacity, so will continue to run individual campaigns in tandem to any national, mass media campaign.

 

4

18

‘People at risk of overexposure include outdoor workers and anyone else who generally spends a long time outdoors, for example, because of outdoor leisure pursuits such as sailing or gardening or because they like to sunbathe.’

The guidance here is confusing cumulative sun exposure with intense, episodic sun exposure, which are different and carry different risks.

 

Overexposure is certainly not limited to people who ‘generally spend a long time outdoors’, which in fact relates to chronic but not intermittent exposure. It is intermittent exposure that is linked to sunburn and melanoma (chronic sun exposure is linked more to squamous cell carcinoma) and this does not usually mean people who spend a lot of time outdoors, indeed it is usually people who spend little time outdoors and then sunburn during occasional holidays or weekend leisure time. This is different to people who are in the sun for long periods on a daily basis and who have cumulative sun damage.

 

It is vital that we do not imply that it is people who spend much of their time outside who are at the greatest risk, as this is not the case.

 

See National Cancer Institute (http://www.cancer.gov/cancertopics/pdq/genetics/skin/HealthProfessional/page2):

 

While there is no standard measure, sun exposure can be generally classified as intermittent or chronic, and the effects may be considered acute or cumulative. Intermittent sun exposure is obtained sporadically, usually during recreational activities, and particularly by indoor workers who have only weekends or vacations to be outdoors and whose skin has not adapted to the sun. Chronic sun exposure is incurred by consistent, repetitive sun exposure, during outdoor work or recreation. Acute sun exposure is obtained over a short time period on skin that has not adapted to the sun. Depending on the time of day and a person's skin type, acute sun exposure may result in sunburn. Intense intermittent recreational sun exposure has been associated with melanoma and BCC, while chronic occupational sun exposure has been associated with SCC.

 

 

4

20

‘In 2011, 13,348 cases of melanoma and 102,628 cases of non-melanoma skin cancer were diagnosed in the UK.’

 

The NMSC figure used here is based on incomplete data. The actual figure is that 200,000 patients have 247,000 BCCs removed in the UK in 2010* (though this only counts those who had BCC surgically removed, not those treated with topical preparations). And this does not include SCC. So the commonly cited figure is more than 250,000 cases of NMSC per year.

*Clin Exp Dermatol. 2013 Jun;38(4):367-9. doi: 10.1111/ced.12016. Epub 2013 Mar 18. Basal cell carcinoma epidemiology in the UK: the elephant in the room.

Levell NJ1, Igali L, Wright KA, Greenberg DC.

 

 

5.1

21

“The contribution sunlight makes to vitamin D status …was beyond the remit of this guideline.”

We appreciate that this guidance will feature the findings of the SACN review, possibly as an update, and  is designed to be read in conjunction with the NICE guidance on increasing vitamin D supplement use. However, how can sunlight’s contribution to vitamin D be beyond the remit of this guidance, if this guidance gives the key messages about the sunlight and vitamin D balance?

 

5.2

AND

5.15

 

21

AND

24

“The Committee acknowledged that the people at risk of overexposure to sunlight and those at risk of not having enough vitamin D are usually in different groups, so messages can be adapted accordingly.”

AND

“The Committee recognised the importance of persuading children of the benefits and risks of sunlight. This is partly because of the higher risks they face from both low vitamin D status (for example, the development of rickets) and skin cancer (often associated with sunburn in childhood).”

 

These two statements are contradictory. One says those at risk of vitamin D deficiency are not the same as those at risk of overexposure to the sun, while the second statement says that children are at risk of both.

 

Also these statements do not take into account varying risk levels within groups of children.

 

5.3

21

“The only consistent message is that the risks can be reduced if people never expose their skin long enough for it to redden or burn.”

 

This message is echoed within the recommendations, and provides advice which is retrospective. Different skin types burn faster and more slowly in different conditions, with the only way of knowing how long an individual took to burn in a certain condition being for the individual to be exposed to that situation and to burn.

 

Advice should focus more on making protective precautions a habit as opposed to experimentation on how long skin takes to burn before protective measures are taken.

 

5.3

21

“One reason why it is difficult to provide a simple message is that the amount of UV someone gets from sunlight depends on a range of biological, environmental and behavioural factors”.

 

For this reason, would it not be more sensible to use the dietary / supplementation messages instead, rather than encouraging people to spend time in the sun which may either place detrimental, increasing skin cancer risk, or ineffective (according to aforementioned modelling study)?

 

5.6

22

‘The Committee noted that once the body has synthesised vitamin D, more time in the sun is harmful and can also break surplus vitamin D down.’

This is a bit misleading – in terms of skin damage, the sun is harmful even before the level that causes skin to redden or burn, but this implies that skin damage only occurs after this point, rather than this being the point when the worst damage occurs. Also, it is not just the ‘surplus’ vitamin D that is broken down after the point of reddening. So perhaps change to:

 

‘The Committee noted that once the body has synthesised vitamin D, more time in the sun will actually reduce vitamin D levels, while also increasing skin damage’.

 

5.8

22/23

“The Committee questioned the usefulness of referring to ‘skin

types’ (I–VI) to help people assess how to benefit more from, and

reduce their level of risk from, sunlight exposure. It noted that both

practitioners and the public find it difficult to judge skin types. They

opted instead to refer to lighter and darker skin types.”

 

While we are aware of studies examining public understanding of the Fitzpatrick scale, in our experience, the referencing of Skin Types I-VI, has both been an engaging and useful tool in communication to the public the risks of sun exposure, when supported with appropriate, public-friendly information. Whilst lighter and dark skin permit for an instant understanding, using these terms runs the risk of over-generalisation and lack of detailed reference and meaning.

 

General

 

We would prefer to see discussion of the "Risks and Benefits" of sunlight exposure rather than the repeated mention of "Benefits and Risks", to reflect where the weight of evidence lies.  Skin cancer in the UK is by far the most common cancer and is a rising epidemic, under the pressure of which dermatology services are struggling to cope. The impact of vitamin D deficiency is arguably not of this magnitude, and much of the evidence is emerging, unlike the proven impact of UV damage. While we support guidance that incorporates both the risks and benefits, emphasis on vitamin D benefits must not be at the expense of reducing potentially deadly cancers, and the wording must carefully reflect this. Greater emphasis should be put on the role of dietary vitamin D intake and supplementation, which cannot reasonably be excluded from this guidance as they are the ‘safe’ alternatives to UVR exposure.

UVR and diet / supplements as sources of vitamin D cannot be considered in isolation of one another.

 

5.11

23

“Members were also aware that some people use sunscreen because they want a tan and believe that its use means they can stay in the sun for longer without burning.”

Is there evidence available to support the first part of this statement, i.e. that people use sunscreen because they want a tan? Sunscreen, when used correctly, prevents tanning so we would be keen to see the evidence behind this as it may help guide our campaign work, and could form an important message about sunscreen application.

 

5.12

23

“The Committee was aware of concerns that sunscreen prohibits vitamin D synthesis. Expert testimony clarified that this may be the case when sunscreen is tested in laboratory conditions. But it is unlikely to be the case in reality, because people tend to apply much less sunscreen than the manufacturers recommend and in a patchy fashion.”

 

The notion of relying on poor sunscreen application as a source of Vitamin D in contrast to attempting to advocate proper sunscreen application is unhelpful.

 

5.2.9

28

“This section will be completed in the final document.”

What will this include and will this be circulated, to form part of the stakeholder consultation?

 

6

28

The section ‘Recommendations for Research’ should include research around the health risk / benefit ratio, rather than just research around delivery of messages. The development of more instructive and definitive advice should be a priority, as this guidance fails to add any real clarity to a confusing topic, due to lack of available evidence.

 

10

General

Within the key questions, which outline the scope of this guidance, no mention is made as to what the current messages regarding sunlight exposure risks and benefits are, where they come from, or how can these messages be reviewed and amalgamated into one set of concise messages.

 

12

43-44

The gaps in the evidence section is striking, and raises the question of the utility and purpose of this guidance.

 

Close
BAD response to ‘Weighing the benefits and risks of sunlight exposure’ by NICE

The guidance is still very much a draft and it is likely that several groups may advocate important changes to the document. Its release at this stage may lead to confusion if the messages are then changed when it is finalised later in the year, which we hope they will be. As it stands, it seems to offer very little clarity and we question its evidence-base. 

We know that skin cancer is caused by sunlight, that it is by far our most common cancer, and that it can kill people. Much of the evidence around vitamin D is still emerging.  

Furthermore, you can get vitamin D from your diet and supplements. For that reason, we would have preferred for the guidance to consider all the means of obtaining vitamin D rather than just sunlight in isolation.  While we agree that it is important to communicate both the risks and benefits of sunlight exposure, we feel that the emphasis which has been placed upon the benefits of obtaining vitamin D from sunlight are misleading.

The guidance advises people to go out in the sun for short periods. However, it also acknowledges that skin type, location, UV index, altitude and weather type all play essential roles in determining an individual’s response to sunlight. Therefore, actively encouraging people to go outside to obtain vitamin D, while being unable to specify how long this should be for, is unhelpful.

Protective practices are vital to ensuring individual safety in terms of limiting skin cancer risks from UV radiation. Whilst it is important to appreciate that vitamin D is an essential part of good health, it is vital to emphasise safer channels in which vitamin D can be obtained – such as diet and supplements. What is clear, and what is starkly highlighted by the 'gaps in evidence' section of the guidance, is that  more research is needed in this area, before we should add to public confusion by repeatedly changing the messages.

You can find the original announcement by NICE here: https://www.nice.org.uk/news/press-and-media/weighing-the-benefits-and-risks-of-sunlight-exposure

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