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Dermal piercings: Dermatologists raise concerns over unregulated high street surgery

Dermatologists are warning the public about a type of piercing called a dermal anchor, at a presentation given at the British Association of Dermatologists Annual Meeting in Glasgow this week.

Dermal anchors consist of two main components, usually made out of titanium or stainless steel: a flat plate called the ‘anchor’, which sits beneath the skin, and a changeable piece of jewellery that sits on the surface. They are connected by a ‘post’, which is fixed to the plate and protrudes through the skin for attachment of jewellery. These devices are designed to allow greater scope for body decoration, as they enable decoration in areas of the body where traditional piercings wouldn’t be possible, and to have more permanence, as they require professional assistance to remove.

But doctors are raising concerns about how these anchors are inserted into the skin, the safe removal of the anchors, and potential complications. They warn that the procedures involved with inserting and removing these devices are not straightforward, and in the event of something going wrong the NHS is saddled with the burden.

Insertion requires the use of either a scalpel, dermal (skin) punch, or in the case of smaller incisions, a piercing needle. The anchor must be placed deep enough to minimise the risk of the piercing moving, known as migration, but not so deep that the skin begins to grow over the piercing, known as embedding.

 Because local anaesthetic injections can only be administered by those with a medical qualification, those undergoing the procedure have to do without, which has the potential to be very painful. Even once successfully administered, complications can occur. One example raised by the dermatologists is a 29 year old woman referred to a dermatology clinic in Glasgow for repeated inflammation and pain in her hand, caused by a dermal anchor inserted nine months before.

How these devices are removed is less clear, particularly as piercers are not recommended to attempt this procedure themselves. In the above case, it was surgically removed by medical professionals, and it soon became clear that it was embedded into the dermis (the lower layer of skin).

Dr Greg Parkins, one of the doctors issuing the warning, said: “If the popularity of this permanent body art continues to increase then so too will the number of patients seeking removal. This has potential health economic consequences, especially if patients are relying on removal of these implants on the NHS.

“It’s important that the public, medical professionals and those carrying out these piercings are aware of the dangers and difficulties associated with dermal anchors. Although local councils regulate businesses that insert dermal anchors through licencing, there is less clarity when it comes to guidance on how these devices should be removed, and by whom.

“The practice of clinical surgery without medical qualifications is a criminal offence in the UK. With dermal anchors the distinction between piercing and surgery is becoming less clear and I feel there are legitimate concerns over adequate training, hygiene and disease transmission.”

Matthew Gass of the British Association of Dermatologists said: “Dermatologists are not trying to dictate what people should and should not do with their bodies. However, it is important that they understand the long-term consequences of these piercings and the associated risks.”

Other observed complications have included infection, patients requiring Magnetic Resonance Imaging (MRI – a medical imaging technique used to internally examine the body), and pregnant women who have developed acute rejection of abdominal piercings.

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For more information please contact: Matt Gass, Communications Officer, on 020 7391 6084 or atmatthew.gass@bad.org.uk

Study details: 'Dermal piercings: unregulated high street surgery?'

G. Parkins and M. Porter

 

Alan Lyle Centre for Dermatology, Glasgow, U.K.

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Doctors raise safety fears over new on-call plans
 

Trainee dermatologists are warning that any plans to make them work on-call in general medicine will put patient safety at risk, with 82 per cent strongly opposed to such reforms, according to a survey released this week at the British Association of Dermatologists’ Annual Conference in Glasgow.

Specialists in general internal medicine (GIM) care for a wide variety of patients who may be suffering from any number of common disorders, may have multiple conditions or complex needs or may represent a diagnostic conundrum. These doctors have a continuing responsibility for hospital inpatients who are not being cared for in the acute medical unit.

The NHS is faced with a range of problems, including the rising tide of acute admissions, patients with increasingly complex illnesses and a medical workforce crisis. The Future Hospital Commission was established by the Royal College of Physicians to find solutions to the current challenges. In September 2013, the Commission recommended training in general internal medicine to be mandatory for all doctors training in medical specialties.

Now a survey of trainee dermatologists across the UK, conducted by doctors at Norfolk and Norwich University Hospital,reveals that 82 per cent are strongly opposed to the inclusion of general medical on-call for dermatology trainees, and 80 per cent strongly disagree that participation in a general medical on-call rota would be beneficial for the development of dermatology-specific skills. Patient safety was a frequently raised concern. Particular worries included performing unsupervised procedures that are not regularly done by dermatology trainees, including placing central lines, inserting chest drains and temporary cardiac pacing.

Dr Nick Levell, one of the study’s authors, said: “The results of this survey indicate that the majority of dermatology

trainees are opposed to the inclusion of general medical on-call. The General Medical Council states that doctors must put patients’ safety first and make sure that the care they provide is safe and effective. Patient safety must be taken into account when considering the inclusion of general medical on-call for dermatology trainees.”

Professor Chris Bunker, President of the British Association of Dermatologists: “This study highlights a major flaw in the agenda to make participation in general medicine mandatory for those training in all medical specialties. The trainees who would be tasked with the work have stated that they do not feel it is safe for them to do so. We recognise the crisis facing hospital services generally. However a viable solution should not be one that undermines the work of individual departments. Also, it is imperative that training the right number of specialists with the right skills in the right place is a protected priority, and that the effectiveness of this training is not diluted to fight fires in other areas of hospital services.

“In many specialties like ours, trainees provide a large part of the service. Forcing dermatology and other specialty trainees to fill the gaps in general medicine denies specialist patients the care they require. Furthermore, these trainees may not have maintained the required level of skills to serve the needs of general medical patients. This practice is not just harmful to specialty training and patient care in dermatology, but it’s also likely to have minimal impact on the crisis in the acute setting.”

The Future Hospital Commission report (Future Hospital: Caring for medical patients) was released on Thursday September 12th, 2013. The full report can be viewed here: http://www.rcplondon.ac.uk/projects/future-hospital-commission

 

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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: Exhibition poster P24; Dermatology trainee doctor survey: acute general medical on call could endanger patients; R. Coelho and N. Levell; Norfolk and Norwich University Hospital, Norwich, U.K.

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EU fail to ban controversial preservative, as new research shows it is still causing acute contact allergy reactions

A preservative causing an epidemic of skin allergy is to remain in a range of cosmetic products, despite a widespread call for it to be banned, it has emerged today.

According to a decision made by the EU Commission, Methylisothiazolinone (MI) will be removed from products left on the skin, except for those used on the hair and scalp. However it will not be banned from products that are rinsed off the skin, and nor will its permitted concentration in these products be reduced.

It has been a year since dermatologists first warned the public about a contact allergy epidemic in the UK, largely stemming from the use of MI as a chemical preservative in cosmetic products. In addition to this latest EU ruling, new research is being presented from tomorrow at the British Association of Dermatologists’ Annual Meeting in Glasgow tomorrow, warning about the use of the chemical in other products, such as paints and detergents, as well as in the workplace, as the epidemic shows no sign of abating.

This decision not to ban the chemical outright in cosmetic products will further inflame the problem.

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. However, it can also be found in everyday professional and household products such as detergents, paints and glues.

Since last July, when the British Association of Dermatologists first raised the issue, several new studies have been conducted.   At the time, a team at the Leeds Centre for Dermatology showed a sharp rise (up to 6.2 per cent sensitivity) in contact allergy to MCI/MI and MI over the previous three years. This, combined with other studies released by the British Association of Dermatologists, prompted a public outcry about the continued use of the chemical.

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 leading household name cosmetic products containing MI have remained on the shelves during the last six months and are now likely to do so for the foreseeable future. MI continues to feature in a wide range of household and industrial products, often without sufficient labelling.

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.

The Scientific Committee on Consumer Safety of the European Union recommends limiting the concentrations of MI in rinse-off products, such as shower gels, to 15 parts per million (ppm). This has not been upheld in the decision by EU Commission’s decision.

 

MI Research presented at the BAD Annual Conference, 30th June to the 3rd July 2014

MI in paint causing acute facial dermatitis and difficulty breathing:

Dermatologists from University Hospital Lewisham and St John’s Institute of Dermatology have 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 be reactive.

To illustrate the problem, the researchers used the case of a 52-year-old woman who presented with severe facial eczema and difficulty breathing, caused when she repainted her living room. She had no past medical history of asthma or other respiratory conditions. The symptoms started with an itchy rash over the cheeks, which progressed to involve the entire face, eyelids, upper chest and dominant hand.

After initial treatment, the patient then suffered a further flare-up of her symptoms when she tried to continue painting her living room, not knowing this was the trigger for her reaction, and her breathing difficulties became so serious that she required emergency treatment. The use of MI in the paint was eventually identified as the cause of the reaction; however, the patient had to avoid her living room for the next two months.

Dermatologist Dr Wisam Alwan, one of the authors of the study, said: “Lack of necessary regulation regarding the use of MI in paint means there is no current maximum permitted concentration and no requirement to label MI as an ingredient.

 

“As with its use in cosmetics, urgent action is required to assess and manage the risk of including MI in paints and other non-cosmetic products. At the very least, MI should immediately be classified as an allergen with the potential to cause serious harm to human health and it needs to be regulated. It also needs to be identified in all product labelling. Given the serious reactions seen with MI exposure from paints, its use should be restricted and alternative, safer preservatives should be considered.”

 

MI an occupational health hazard:

Scientists from the Leeds Centre for Dermatology and the Faculty of Medical and Human Sciences at the University of Manchester are presenting research identifying MI and MCI as an occupational health risk. This research is backed-up by a case presented by dermatologists from The Royal United Hospital, Bath, of two workers from the same furniture factory who presented with allergic contact dermatitis (eczema) caused by MI in glue.

In the Leeds study, an analysis of the data from 1996 to 2012 regarding occupational skin disease caused by MCI and MI, across a range of professions, showed a 4.1% annual increase in the number of cases. This included a 3.8% increase in workers exposed to personal care products, with the greatest increases in healthcare workers (8.1%) and beauty workers (6.6%). There was also a 6.3% increase among manufacturing workers.

In the second study, two men, working at the same furniture factory under identical conditions, both suffered for almost two years from severe allergic contact dermatitis due to MI in the glue they used to assemble the furniture.

Dr Rachel Urwin, of the Leeds Centre for Dermatology and one of the authors of the first study, said: “This research shows that a review of regulations in an industrial setting is needed. There is currently little guidance and an improvement in labelling would allow workers to protect themselves against contact allergy from MI.”

Dr Deirdre Buckley, Consultant Dermatologist at The Royal United Hospital, Bath, said: “These cases add to the evidence that MI can be a significant occupational allergen, and suggest that limitation of the exposure concentration in industrial products may be advisable. It is reasonable for workers to expect to work in conditions which are not detrimental to their health.”

 

Speaking of the latest EU ruling, Dr David Orton of the British Association of Dermatologists said: “I am extremely disappointed at this decision and remain concerned for all UK consumers, both adults and children. The ban on the use of MI in leave on cosmetics was requested over a year ago and even industry's own representative body, Cosmetics Europe, suggested this six months ago. Yet these products remain on the shelves even today. There is no argument that these sorts of products sensitise people, so every day more people will be sensitised and have the capacity to react to MI. Dermatologists unequivocally know such sensitised people will react to MI at concentrations of only 50 parts per million (ppm) so it is not joined-up thinking to continue to allow rinse-off products to be sold at concentrations of 100 ppm. It allows continued severe allergic reactions to highstreet cosmetics to occur.

The data supplied by the cosmetics industry lobby to the European Parliament is a predictive tool which is not uniformly accepted  and it is being used in a retrospective fashion. UK and European citizens continue to be industry's guinea pigs. I urge them to put the health of their consumers first.”

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The conference will be held at SECC in Glasgow from July 1st to 3rd 2014, and is attended by approximately 1,300 UK and worldwide dermatologists and dermatology nurses.

 

For more information please contact: Matt Gass, Communications Officer, on 020 7391 6084 or atmatthew.gass@bad.org.uk

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“Thou art a boil, a plague sore, an embossed carbuncle” – is Shakespeare’s enduring popularity to blame for continuing stigmatization of skin disease?

There is no doubt that people suffering from skin diseases and conditions that cause visible difference still face, and fear, stigmatization, which can lead to social anxiety and depression.  Research, due to be presented at the British Association of Dermatologist’s Annual Meeting this week, looked at whether this stigma is a hangover from Elizabethan England, preserved by the enduring popularity of Shakespeare.

Researchers from Nottingham, Leicester and Derby, analysed Shakespeare’s language and found that it reflected the Elizabethan obsession with perfect, unmarked, pale skin. They speculate that the playwright’s status as the most well-known English language writer of all time, may be helping to fuel ongoing stigma around skin disease. Many of his most memorable insults are derived from skin imperfections:

“Thou art a boil, a plague sore, an embossed carbuncle” (King Lear).

“Thou art a perpetual triumph, an everlasting bonfire night. Thou has saved me a thousand marks in links and torches” (Henry IV part 1).

“A pox upon him” (All’s Well That Ends Well)

“I scorn you, scurvy companion” (Henry IV part 2).

Dr Catriona Wootton, Dermatologist at Queen’s Medical Centre in Nottingham and one of the study’s authors, said: “Rat-infested and with open sewers, overcrowding and sexual promiscuity, Elizabethan London was a melting pot for diseases such as plague, syphilis and smallpox. Many of the diseases of the time involved lesions or sores on the skin, so skin imperfections were seen as a warning sign for contagious disease.  This was not limited to signs of infection, but to any blemishes or moles, which were considered ugly and signs of witchcraft or devilry. Shakespeare uses these negative undertones to his advantage, employing physical idiosyncrasies in his characters to signify foibles in their behaviour.”

Shakespeare was not at the root of this stigmatisation, and indeed in Hamlet, he highlights the innocence of affected individuals: “that for some vicious mole of nature in them, as in their birth – wherein they are not guilty, since nature cannot choose his origin – their virtues else, be they as pure as grace, as infinite as man may undergo, shall in general censure take corruption from that particular fault”.  However, many far less tolerant examplesabound and it is argued that his success has led to the perpetuation of this stereotype.

Nina Goad of the British Association of Dermatologists said:

“It is interesting to note that much of the Elizabethan stigma over disfiguring skin disease still persists today.  Over the last few decades dermatologists have tried to address the effect this can have on patients.  However, even now, many examples exist in films and literature where visible disfigurements are used to represent villainy or malice. This is particularly concerning when such films are aimed at children, who learn that beautiful, flawless people are kind and trustworthy, and scarred or blemished people are to be feared. Nobody is suggesting that we edit Shakespeare but maybe we should ensure that new films and books don’t reinforce this stereotype. Many skin patients require psychological support to deal with the visual aspect of their disease. Whilst this support remains patchy, the British Association of Dermatologists is working on a Department of Health funded project to provide online support, which is a good first step.”

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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

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