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The need for psychological support amongst dermatology patients is not being met

Experts from an award winning multidisciplinary team, the Severe Eczema and Psoriasis Team at St. John's Institute of Dermatology, St Guys’ and St Thomas’ NHS Foundation Trust, today warned that the true need for psychological support amongst dermatology patients is not being met.

The team recently won the first ever “BMJ Dermatology Team of the Year”, up against excellent competition, for their commitment to holistic care - care which accounts for, and treats, the range of issues that come with having a skin disease, particularly the psychological impact.

Recognising that their standard approach to patients wasn’t efficient enough at recognising patients in need of psychological support, the St. John’s team rewrote the rulebook using a tripartite approach first developed by the IMPARTS* team led by Professor Matthew Hotopf. They developed a system whereby iPads are used to survey patients with pre-selected and validated questionnaires relevant to their condition, whilst waiting for their appointment. This information is then automatically uploaded to their electronic patient record.

The questionnaire results are then used to alert doctors to any potential emotional wellbeing issues and automatically suggest treatments or referral pathways that may be appropriate for them. In some cases there may be no need for psychological support. Those who do require help may be provided with self-help materials – such as the IMPARTS materials or the British Association of Dermatologists’ Skin Support** website – or be offered a referral to a team psychologist or liaison psychiatry.

The team found that 71 per cent of their patients, who were subsequently diagnosed with major depressive illness using the new system, and 88.6 per cent with anxiety, were previously unrecognised as having mental health problems.

Professor Catherine Smith, consultant dermatologist within the Severe Eczema and Psoriasis Team, said:

“This rigorous and systematic approach to providing holistic care within our team has reaped huge benefits for our patients, who previously might have had unrecognized morbidity. Prior to evaluating our service and introducing this new approach, we considered that we were already providing holistic care.

“Identifying the high needs of our patient population motivated us to fully integrate psychological support with treatment of the physical symptoms of skin disease throughout the visit to our service. We improved training for all staff, from our receptionists to our consultant dermatologists, and implemented internal care pathways that ensure the mental wellbeing of the patient is monitored and treated according to their needs. By taking this methodical approach we were also able to quantify and justify the need for a full time clinical health psychologist on staff.”

Dr Nick Levell, President of the British Association of Dermatologists, said:

“We are enormously proud of all the teams that were in the running for dermatology team of the year, and I am particularly pleased to see the incredible work that this winning team has put into achieving a parity of esteem between physical and mental health, something the BAD recognises as being hugely important for patient wellbeing. I hope that this will encourage other departments to reflect on their own work, and investigate ways in which they can improve.”

The multidisciplinary team of specialists included consultant dermatologists, receptionists, clinical research and specialist nurses, a consultant rheumatologist, a specialist pharmacist, and a clinical health psychologist in collaboration with the King’s Health Partners IMPARTS team.

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Notes to editors:

For more information please contact the media team: comms@bad.org.uk, 0207 391 6084. Website: www.bad.org.uk.

The BAD Annual Conference will be held at the Birmingham ICC from July 5th to 7th and is attended by approximately 1,300 UK and worldwide dermatologists.

*IMPARTS stands for Integrating Mental & Physical healthcare: Research, Training & Services (IMPARTS) and is an initiative funded by King's Health Partners to integrate mental and physical healthcare in research, training and clinical services at Guy’s, St Thomas’s and King’s College Hospitals, as well as South London and Maudsley NHS Foundation Trust (http://www.kcl.ac.uk/ioppn/depts/pm/research/imparts/index.aspx).

**Skin Support is a psychological support website for people in distress due to skin conditions (www.skinsupport.org.uk). It is owned and managed by the British Association of Dermatologists.

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.

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
 

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Male genital piercing – a sensitive subject

Men who undergo genital piercing, the most common being the ‘Prince Albert’, are at risk of painful allergic reactions, scarring and infection, according to a study being presented at the British Association of Dermatologists’ Annual Conference in Birmingham this week.

The warning is being issued by doctors from Burnley General Hospital, who reviewed a number of studies looking at dermatological complications arising from male genital piercing.

They found that between 10 and 23 per cent of men with genital piercings develop hypersensitivity dermatitis, which is irritation of the skin caused by an allergic reaction to a particular substance. This can be painful, itchy and unsightly.

However, this is not the only complication arising from the piercings. Between seven and 18 per cent of men in the studies developed a similar reaction called irritant dermatitis, which is a type of rash that develops when the skin is in contact with irritant substances.

Between four and eight per cent suffered from keloid formation, a type of scar that grows too much and can become larger than the original wound, and between three and eight per cent experienced an infection.

In addition to these, there have been two reports of squamous cell carcinoma, a type of skin cancer, developing at the site of glans piercings in patients infected with HIV.

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The ‘Prince Albert’

The ‘Prince Albert’ style of piercing involves an insertion through the external urethra and exits at the base of the frenulum, where the head of the penis meets the shaft. This ring style piercing was popularised during the 1970s, and is considered the most common form of male genital piercing.

The reason for the name ‘Prince Albert’ is unclear, claims have been made that this style of piercing was used to secure the penis when wearing the particularly tight trousers that were in fashion during the Victorian era – hence the link with the Queen’s Prince Consort. However, there is no evidence to suggest that this is anything other than an urban legend.

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A 2008 study* on the prevalence of various piercing sites, other than the earlobe, found that 0.3 per cent of English men had undergone genital piercing, compared to 0.2 per cent of English women. The same study also demonstrated that genital piercings are becoming increasingly popular, with 0.8 per cent of 16 to 24 year olds having ever had a genital piercing compared to 0.2 per cent of over 25s (both genders).

Dr Adam Daunton, one of the authors of the study, said: “Whilst there is a good level of awareness within the dermatology community and indeed amongst the general public of the sorts of complications that can ensue from piercings at commonly pierced sites such as the earlobe, there is much less awareness of potential complications arising from penile piercings. Thus far, there have not been any studies focusing specifically upon the types and rates of dermatological complications experienced by men who undergo these piercings. Our review attempts to extract and synthesise information from a range of other studies in a systematic fashion to give estimates of the rates of potential complications. We hope this information will be of value in helping men to make informed decisions, as well as for healthcare professionals”.

Matthew Gass of the British Association of Dermatologists said: “Statistics seem to show that penis piercings are on the rise in Western cultures. As with any form of body modification, people need to be made aware of the potential risks. This is particularly important as we are talking about a particularly sensitive part of the male anatomy, which could have an impact on your health, wellbeing, and future relationships.

“Although this is the sort of subject that people may make light of, it is important that men considering this procedure know what they might be getting themselves into. It is our hope that this warning will get people talking, and raise awareness around the potential risks.”

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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 the Birmingham ICC from July 5th to 7th and is attended by approximately 1,200 UK and worldwide dermatologists.

For more information please contact the media team: comms@bad.org.uk, 0207 391 6084. Website: www.bad.org.uk.

Study Information:

A systematic review of dermatological complications following male genital piercing
A. Daunton and M. Shah
Department of Dermatology, Burnley General Hospital, Burnley, Lancashire, U.K.
Male genital piercing is becoming increasingly popular in Western culture. Estimates of prevalence vary from 0.4% of all British men aged > 16 years, to 2% of American men aged 18–50 years. The commonest type of male genital piercing (the ‘Price Albert’) involves insertion through the external urethra and exits at the base of the frenulum. Medical complications arising from genital piercing are managed by a range of specialities, including urology, dermatology and genitourinary medicine. While complications have received attention within urology and primary care, they remain largely unknown within the dermatology literature. We performed a systematic literature review searching the Medline and Embase databases using the medical subject heading keywords, ‘genital piercing’, ‘urethral piercing’, ‘body piercing’ and ‘genital modification’. This yielded a total of 3867 articles. Exclusion of duplicates and articles not available in English left 2425 articles. Interrogation of the titles and abstracts of these articles was performed by two dermatology professionals, to review them for relevance. Articles focusing exclusively upon female genital piercing were excluded. This yielded a total of 156 full-text articles, distributed across general medicine, urology, genitourinary medicine and primary-care journals. Full-text articles were interrogated using a standardized pro forma, and information was extracted on dermatological complications of piercings including postinsertion infection, hypersensitivity dermatitis, irritant dermatitis, keloid scar formation, lichen sclerosus and association with malignancy. No studies had been designed specifically to categorize and record dermatological complications. Most articles comprised studies of piercings across all body sites. However, two cross-sectional studies examining self-reported complication rates in patients with male genital piercings were identified, encompassing a total of 494 men, alongside 16 individual case reports describing complications. Estimates of postinsertion infection rates ranged from 3% to 8%. Symptoms consistent with hypersensitivity dermatitis were exhibited in 10–23%. Irritant dermatitis occurred in 7–18%, while keloid formation occurred in 4–8%. There are no reports of lichen sclerosus following genital piercing. There have been two reports of squamous cell carcinoma developing at the site of glans piercings in patients infected with HIV. This review highlights the need for dermatology-focused recording of complications following male genital piercing, as no studies thus far have been undertaken by dermatologists. It also highlights the need for studies utilizing objective, physician-measured outcome data, rather than self-reported measures.

*Bone A, Ncube F, Nichols T, Noah D. Body piercing in England: a survey of piercing sites other than earlobe. BMJ 2008; 336:1426-1428: http://www.bmj.com/content/336/7658/1426

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
 

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Acne patients in the UK are being over-exposed to oral antibiotics, despite antibiotic resistance concerns

Doctors at the British Association of Dermatologists’ Annual Conference have warned that oral antibiotics, which are routinely prescribed for acne, are being used for durations that exceed recommendations, despite concerns about antibiotic resistance.

Dr Alison Layton and the dermatology team at Harrogate and District NHS Foundation Trust, say that reliance on oral antibiotics beyond the recommended duration is harmful for two key reasons. The practice could cause the emergence of antibiotic-resistant Propionibacterium acnes, the bacterium implicated in acne, making acne harder to treat in some cases. Worryingly, the use of oral antibiotics is also likely to drive resistance in other bacteria, unrelated to acne*

Their recent study shows that patients are facing delays in starting treatment options which could be used effectively in place, or alongside, antibiotics resulting in more rapid and better outcomes. This is important, as delay in implementing effective treatments is known to increase the risk of acne scarring**.

A retrospective review of oral antibiotic duration for 928 patients with acne found the mean duration of oral antibiotic use prior to referral to dermatology services was six and a half months (195 days). The longest exposure to a single antibiotic was 84 months (2520 days) – a little short of seven years. Guidance from the National Institute for Health and Care Excellence (NICE) recommends that, unless an improvement in the patient’s acne is seen, GPs should only continue to prescribe antibiotics for up to three months (90 days) before considering referral to a dermatologist. In cases where patients are responding to the antibiotics, then treatment should continue for four to six months, 120 to 180 days, alongside appropriate topical (applied to the skin) treatment.

A second study being presented at the conference by the same authors, in which 4518 patients and 1227 healthcare professionals were surveyed, offers an insight into why efforts by advisory bodies are falling short. The survey found that only small numbers of healthcare providers say that they ‘often’ consult evidence-based guidance (dermatologists 15%, GPs with a Special Interest 13%, and GPs 3%), questioning the impact of guidelines on prescribing habits.

Despite this, over 50 per cent of HCPs agreed that ‘antibiotic resistance is a big problem in managing acne’, but only 25 per cent said it was a concern for their patients. This contrasts with 74 per cent of patients worrying about antibiotic-resistant infections later in life.

Dr Heather Whitehouse, one of the authors, said: “Antibiotics remain an important part of acne management, but given concerns about antibiotic resistance we should be using antibiotics judiciously as part of a treatment regime, limited to the shortest possible time period

“Oral antibiotics are frequently being prescribed on their own for patients with acne, this is not something that guidelines advocate as individually they are not effective at treating all aspects of the condition. Not to mention the fact that this sort of monotherapy is implicated in driving antimicrobial resistance

“From the patient perspective the study has shown that the duration of oral antibiotic use is longer than we would wish to ensure patients are receiving optimum therapy.”

Matthew Gass of the British Association of Dermatologists said: “As the NHS and advisory bodies get increasingly serious about the responsible use of antibiotics, it is important for doctors to reflect on how they prescribe for such a common condition which relies so heavily on antibiotic usage. This study provides an important warning, and will hopefully help healthcare professionals and patients alike.”

Facts about acne and acne treatments

What is acne?

Acne is a very common skin condition characterised by blackheads and whiteheads and pus-filled spots. It usually starts at puberty and varies in severity from a few spots on the face, neck, back and chest, which most adolescents will have at some time, to a more significant problem that may cause scarring and impact on self-confidence. For the majority it tends to resolve by the late teens or early twenties, but it can persist for longer in some people.

According to a 2013 study** a degree of acne affects nearly all people between the ages of 15 and 17, and in 15 to 20 per cent of young people, acne is moderate to severe.

What causes acne?

The sebaceous (oil-producing) glands of people who get acne are particularly sensitive to normal blood levels of certain hormones, which are present in both men and women. These cause the glands to produce an excess of oil. At the same time, the dead skin cells lining the pores are not shed properly and clog up the follicles. These two effects result in a build-up of oil, producing blackheads and whiteheads.

Propionibacterium acnes lives on everyone’s skin, usually causing no problems, but in those prone to acne, the build-up of oil creates an ideal environment in which these bacteria can multiply. This triggers inflammation and the formation of spots.


NICE Clinical Knowledge Summary recommendations:

• To minimize the risk of P. acnes developing resistance, antibiotics should be limited to the shortest possible period, and discontinued when further improvement of acne is unlikely
• Oral antibiotics should always be combined with a topical treatment (retinoid and/or benzoyl peroxide). Topical antibiotics and oral antibiotics should not be combined together, as this combination is unlikely to confer additional benefit and may encourage the development of bacterial resistance
• Response to oral antibiotics should be reviewed at six to eight weeks. If the person has responded to treatment:
o Continue for an additional 4–6 months
o Continue topical treatment after stopping
o If the person has not responded adequately, continue for 3 months before assuming treatment is ineffective. At this stage, consider seeking specialist advice or referring to a dermatologist.

-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 the Birmingham ICC from July 5th to 7th and is attended by approximately 1,300 UK and worldwide dermatologists.

For more information please contact the media team: comms@bad.org.uk, 0207 391 6084. Website: www.bad.org.uk.

Oral antibiotics for acne: are we adopting premium use?
H.J. Whitehouse, E. Fryatt, I. El-Mansori and A.M. Layton
Department of Dermatology, Harrogate and District NHS Foundation Trust, Harrogate, North Yorkshire, U.K.
Oral antibiotics are used globally for the treatment of moderate-to-severe acne vulgaris due to their antimicrobial affects against Propionibacterium acnes. While they are still a mainstay of management, the use of antibiotics has come under increasing scrutiny from advisory bodies including the Global Alliance to Improve Acne Outcomes and the European Evidence-Based (S3) Guidelines for the Treatment of Acne. The prolonged use of antibiotics in acne is a concern due to the potential to drive antibiotic resistance in commensal bacteria, as well as antibiotic-resistant P. acnes, which may translate to reduced or lack of efficacy. The incorporation of antibiotic stewardship into commissioning programmes has therefore become a key focus for the National Health Service in England, manifest as the National Antibiotic Premium 2015–2016. Given the emphasis on antibiotic stewardship, surprisingly few studies have focused on antibiotic duration in this chronic disease. A recent study in the U.S.A. found that the average duration of antibiotic use in acne prior to commencing isotretinoin far exceeded current recommendations. To our knowledge, there are no comparable studies for antibiotic duration in the U.K. An initial pilot study has been retrospectively conducted on 100 patients with moderate-to-severe acne treated with oral antibiotics prior to referral into the secondary-care acne clinic. We now aim to determine the duration of oral antibiotic use in patients with inflammatory acne prior to referral to a secondary-care clinic for consideration of isotretinoin, by conducting a further retrospective review of data held on an ethically approved secure acne database of 1178 patients. The pilot data demonstrate that the mean age of onset of acne was 13.7 years. Lymecycline (75%) was most frequently prescribed, followed by oxytetracycline (52%), erythromycin (44%), trimethoprim (19%), doxycycline (12%), minocycline (10%) and other (4%). A mean number of 2.2 different antibiotics were prescribed per patient (range 1–5). The mean duration of antibiotic use was 305.3 days (range 7–3240). The longest duration for a single antibiotic was 1230 days. This demonstrates that patients with acne in the U.K. have exposure to antibiotics beyond current recommendations, and delays in securing adequate treatment. Delay in initiating effective therapy is known to increase the risk of acne scarring (Layton AM, Henderson CA, Cunliffe WJ. A clinical evaluation of acne scarring and its incidence. Clin Exp Dermatol 1994; 19: 303–8). Results from this study could help to drive a change in prescribing habits in line with the national antibiotic quality premium.


Prescribing for acne in the U.K.: patterns and influencers
H.J. Whitehouse, E.A. Eady, C.J. Ward and A.M. Layton
Department of Dermatology, Harrogate and District NHS Foundation Trust, Harrogate, North Yorkshire, U.K.
We sought to examine beliefs among U.K. healthcare practitioners (HCPs) and patients about acne management to identify influences on practice, including consideration of antibiotic resistance. In the U.K., acquired resistance in Propionibacterium acnes, the target of antibiotic therapy in acne, is among the highest globally. Although U.K. prescribing data are not publicly available, data on file show heavy reliance on antibiotics. Structured questionnaires developed by multidisciplinary teams were launched on 1 March 2015. To date, 4518 patient and 1227 professional responses have been secured. The professionals included 372 general practitioners (GPs), 101 GPs with a special interest (GPwSIs), 277 dermatologists, 47 nurse prescribers and 430 others/not disclosed. The results suggest that professionals consult a wide range of information concerning acne treatments. The British National Formulary (BNF) is used most widely (86%), followed by National Institute for Health and Care Excellence Clinical Knowledge Summaries (70%). Overall 89% of GPs may seek advice from consultant colleagues, GPwSIs are more likely to obtain information from training courses (33%), and dermatologists are most likely to consult specialist journals (55.6%). Multiple clinical features are considered when prescribing; acne severity and presence of scarring are the most frequent (‘always’ or ‘often’ by 98% and 91%, respectively), followed by psychological impact (88%), type of lesion (87%) and treatment history (85%). In total 33% most commonly prescribe regimens that include an oral tetracycline, whereas 24% include a topical antibiotic. Lymecycline was the most frequently prescribed oral antibiotic (90%) for moderate-to-severe acne. However, 28% of respondents used tetracyclines ‘always’ or ‘most of the time’ for comedonal acne, and 19% for mild acne. Around half (45%) of all professionals have not changed prescribing habits in the last 3 years. Over 50% agreed that ‘antibiotic resistance is a big problem in managing acne’, but only 25% said it was a concern for their patients, contrasting with 74% of patients worrying about antibiotic-resistant infections later in life. Changes in local and (inter)national guidance plus regulatory warnings were stated as factors that would alter practice. However, only small numbers suggest that they ‘often’ consult evidence-based guidance (dermatologists 15%, GPwSIs 13% and GPs 3%), questioning the impact of guidelines on prescribing habits. These initial results suggest that a significant number of HCPs are aware that antibiotic resistance should influence prescribing behaviour. However, there are some potential differences between prescribers, and possible educational requirements, including the need to appreciate patients’ concerns about antimicrobial resistance. Advice contained within the BNF and a Medicines and Healthcare Products Regulatory Agency warning might be the best ways of drawing attention to the need to reduce reliance on antibiotics for managing acne.

* This occurs because the use of anti-biotics results in selective pressure in bacteria beyond the skin, meaning that only those that are resistant to anti-biotics survive, in a form of natural selection.

** Layton AM, Henderson CA, Cunliffe WJ (1994). A clinical evaluation of acne scarring and its incidence. Clin Exp Dermatol, 19: 303–8 DOI: 10.1111/j.1365-2230.1994.tb01200.x

***Bhate, K. and Williams, H.C. (2013), Epidemiology of acne vulgaris. British Journal of Dermatology, 168: 474–485. DOI: 10.1111/bjd.12149
For more information on acne please visit our website: http://www.bad.org.uk/for-the-public/patient-information-leaflets/acne

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
 

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