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Unanswered questions in the treatment of Eczema – a step forward

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

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

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

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

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

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

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

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


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Notes to editors:

If using this study, please ensure you mention that the study was released at the British Association of Dermatologists’ Annual Conference.
The conference will be held at ICC Birmingham, 3rd to 5th July 2012, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

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

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

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

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Teledermatology – help or hindrance?

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

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

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

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

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

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

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Notes to editors:

If using this study, please ensure you mention that the study was released at the British Association of Dermatologists’ Annual Conference.
The conference will be held at ICC Birmingham, 3rd to 5th July 2012, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

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

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

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

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

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

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

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

The team found that barriers to treatment adherence included:

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

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

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

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

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


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Notes to editors:

If using this study, please ensure you mention that the study was released at the British Association of Dermatologists’ Annual Conference.
The conference will be held at ICC Birmingham, 3rd to 5th July 2012, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

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

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

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Can you screen for skin cancer?

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

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

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

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

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

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

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Notes to editors:

If using this study, please ensure you mention that the study was released at the British Association of Dermatologists’ Annual Conference.
The conference will be held at ICC Birmingham, 3rd to 5th July 2012, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

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

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

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

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Provision of pscyhodermatology services has deteriorated across the UK since 2004

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

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

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

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

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

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

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

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Notes to editors:

If using this study, please ensure you mention that the study was released at the British Association of Dermatologists’ Annual Conference.
The conference will be held at ICC Birmingham, 3rd to 5th July 2012, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

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

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

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

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Genital Psoriasis – the unseen agony

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

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

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

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

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

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Notes to editors:

If using this study, please ensure you mention that the study was released at the British Association of Dermatologists’ Annual Conference.
The conference will be held at ICC Birmingham, 3rd to 5th July 2012, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

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

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

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

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

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Demand for Dermatology

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

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

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

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

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

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

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

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

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

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Notes to editors:

If using this study, please ensure you mention that the study was released at the British Association of Dermatologists’ Annual Conference.
The conference will be held at ICC Birmingham, 3rd to 5th July 2012, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

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

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


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

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

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

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

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How Safe is a Fish Spa?

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

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

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

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

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Notes to editors:

If using this study, please ensure you mention that the study was released at the British Association of Dermatologists’ Annual Conference.
The conference will be held at ICC Birmingham, 3rd to 5th July 2012, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

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

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

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Fashions Change but Tattoos are Forever

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

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

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

-Ends-

Notes to editors: If using this study, please ensure you mention that the study was released at the British Association of Dermatologists’ Annual Conference. The conference will be held at ICC Birmingham, 3rd to 5th July 2012, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

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

Study details: “Fashions change but tattoos are forever: time to regret”; A Aslam and C Owen, Burnley General Hospital, Burnley UK 1. 1,500 tattoo parlours in the UK 2. A recent survey suggested that 1 in 5 British adults has a tattoo The British Association of Dermatologists is the central association of practising UK dermatologists. Our aim is to continually improve the treatment and understanding of skin disease.

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