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DERMATOLOGY: A Handbook for Medical Students and Junior Doctors (3rd Edition)

The Undergraduate Workstream are pleased to announce the 3rd edition (2020) of the handbook available in electronic copy, and printed copy upon request.
 

Foreword to 3rd Edition by Dr Tanya Bleiker, President and Professor Mini Singh, Chair of Undergraduate Work Stream, British Association of Dermatologists:

Past BAD President Dr Mark Goodfield wrote in the first edition:

‘There is a real need for appropriate information about dermatological diseases to meet the educational needs of doctors at all levels.’

This holds true even more today than in 2009 with the exponential use of social media as an information sourced by patients and clinicians alike. Since its first publication, this book has been the go to resource for accurate knowledge in common and urgent dermatological problems. Its essential role in supporting their workplace learning is highlighted by the 8,843 downloads and 50,000 requests for hard copies from individual students and medical schools throughout the UK. Starting with scientific and epidemiological facts, moving through clinical features and management, medical students are given a structure that enables them to organise learning effectively. The content remains focused on learning at the undergraduate stage of the medical education spectrum: a vital foundation for postgraduate training in dermatology. 
 
The UK population has become increasingly diverse over the last few decades, it is therefore necessary to update the handbook to highlight tips for assessment, variation in presentation in common and important skin conditions (e.g. common pigmentary disorders) that reflect the spectrum of cutaneous diversity junior clinicians will encounter in their practice. This, in combination, with other BAD resources under current development will ensure that medical students continue to learn from the highest quality education in dermatology to the benefit of our patients.
 

Medical Schools wishing to place an order

Handbooks can only be delivered to addresses within the UK. We are no longer able to post to the Republic of Ireland.

To place an order, please contact admin@bad.org.uk providing the following details:

  • Subject of the email: Dermatology Handbooks
  • Number of copies
  • Contact Name
  • Organisation 
  • Full postal address including postcode
  • Telephone number

Please ensure the delivery address is correct and someone is available to accept your delivery. Handbooks returned as undeliverable will not be resent.

Bulk orders (30+) will be sent out on a limited weekly basis. Please submit your order by Friday noon for Tuesday delivery (excluding bank and public holidays).

The handbook service is currently suspended for individual single orders and orders under 30. Please check here for updates when service will fully resume.

 

Dermatology Medical Student App

A free learning tool for medical students and junior doctors updated by Leicester Consultants Matt Scorer and Ingrid Helbling is available to download from the App Store and Google Play
 

 

Setting up a Dermatology Society

Please visit the DermSoc page for information on how to set up a Dermatology Society at your medical school. For further information, please contact the BAD Student Section at  dermsocnational@gmail.com 
 
To access the UK DermSoc Newsletters, please click here
 

Student membership of the BAD

Student membership will be medical students attending a UK or Irish medical school.
 
Should you wish to become a student member of the BAD, please view the ‘how to join’ page. Please read our membership guidelines before completing your application.

Undergraduate Medical Students Awards

Undergraduate Medical Students Awards are available, the deadlines are 10 January and 10 May each year. Please visit our Undergraduate Awards page.

A Guide for Medical Students

This guide is intended for British medical students, in the hope that it will encourage them take an interest in the skin and its disorders. For those who already know a bit, there are some easy questions as you go along.
 
You can also download 'A Guide to Training in Dermatology' leaflet.
 
 
 
Why does dermatology matter?
 
As well as being the most visible organ in the body, the skin is also the biggest. It fulfils many diverse functions, and to do so contains lots of cell types and organelles, and appendages like hair and nail. What do you use your skin for? No prizes, but if you can write down more than 5 functions of the skin, award yourself 5 points; more than 10, 15 points; more than 15, 25 points.
 
The skin is in the front line of environmental attack from physical and biological agents. Each of the skin's physiological roles can malfunction. Benign and malignant tumours can develop in all of its many cell types. The skin may also be damaged as a result of disease arising elsewhere in the body. All this means that there are lots of dermatological diseases: the British Association of Dermatologists diagnostic index has over 4000 preferred terms.
 
Broadly speaking, skin disorders can be divided into rashes and lesions. Rashes are things like psoriasis, eczema, acne, and drug eruptions, and lesions are things like moles, warts, and benign and malignant tumours.
 
Nobody has a perfect skin, and a lot of lesions never reach medical attention. Skin disease generally starts to matter to people because 1) it doesn't look nice, to themselves or others 2) they don't know what might be 3) it itches or hurts 4) it might be contagious 5) it can kill them or 6) all of the above. Dermatology is about responding to all these needs.

Who needs to know about skin disease? 

Because skin disorders are so common and so obvious, all doctors ought to have some idea about what is and what isn't normal in the skin. Amongst purely cutaneous lesions, for some reason non-dermatologists reliably recognise only Campbell de Morgan angiomas ("associated with ageing, of no significance"). Somehow folk seem not to wonder about all the other spots on the patients whose chests they auscultate or whose tummies they prod. Would you notice the melanoma lurking amongst the moles, keratoses and other pigmented lesions? 25 points for getting it right, otherwise none. Click on an image for the answer.
 
Pigmented lesion Pigmented lesion Pigmented lesion Pigmented lesion
 
Future General Practitioners: In the United Kingdom, general practitioners deal with most skin problems, which are relevant to 10-15% of consultations. GP trainees often do not discover how little they know about dermatology until they undertake their practice year. Typical presentations include various lumps and bumps, and psoriasis, eczema, and acne. Skin infections are also common. Can you identify these typical skin infections? 5 points each if you can name the causative organism. Click on an image for the answer.
 
Infect Infect Infect Infect
 
Future Physicians: Physicians have kidnapped a number of cutaneous disorders for their own use, especially in final and membership examinations. Things like clubbing, spider naevi, pretibial myxoedema, necrobiosis lipoidica, acanthosis nigricans, and so on. 10 points each for identifying the medical significance of these skin lesions. Click on an image for the answer.
 
Cutaneous lesion Cutaneous lesion Cutaneous lesion Cutaneous lesion
 
Future Surgeons: Surgeons, of course, need to have some idea what they are cutting out before they cut it out, in case they should cut it out differently or don't need to cut it out at all. Dermatological knowledge may often save an unnecessary biopsy.

What do dermatologists do? 

British dermatologists are hospital based specialists who provide a secondary care service for the diagnosis and management of skin disease. Dermatology training in the UK involves 3 years of general professional training, and MRCP prior to specialist training.
 
The majority of clinical activity in dermatology takes place in out-patient units. General dermatology clinics deal with an exceptional variety of conditions. Typical and appropriate referrals in a single clinic might include presentations such as severe or refractory plaque psoriasis, various forms of eczema, nodulocystic acne, acute erythemas or blistering, chronic urticaria, hair loss, pruritus, actinic keratoses and other solar damage, basal cell carcinomas, and worrying pigmented lesions. In amongst this "bread and butter" stuff will frequently be something more unusual: granuloma annulare, morphea, lichen planus, vasculitis, lupus erythematosus, dermatomyositis, an ichthyosis…
 
Dermatological management is both medical and surgical. Dermatology units undertake a great deal of diagnostic and therapeutic minor surgery. Dermatological surgery is expanding and some dermatologists are exceedingly proficient in flaps, grafts and other specialised techniques. Many units also have lasers for dealing with vascular and other lesions.
 
Other specialist services in dermatology include contact dermatitis clinics for investigating possible occupational or other allergy, photobiology clinics, second-line clinics for management of cytotoxic and immunosuppressive therapy, and paediatric dermatology clinics. In larger units dermatologists may super-specialise in these or other areas such as cutaneous cancer & lymphoma. In addition, British dermatologists are all trained in skin pathology, and may maintain a special interest in this field.
 
Dermatologists work best with dedicated teams of nurses, who may also be specialists. The major workload of dermatology in- and out-patient units is in providing care for chronic inflammatory skin diseases, mainly psoriasis and eczema. The great advantage of treating the skin is the ability to target not only the organ but also the lesion, for example in plaque psoriasis. For this purpose, we use topical dressings of various time-honoured noxious and smelly potions. Of course the patients would much rather take tablets, because they can't see the adverse effects on their kidneys or liver. Fortunately, we also use phototherapy, which is clean and gives a tan, which makes people think they look healthy.

Dermatology can be fun 

The sheer variety of dermatological disease provides enormous opportunities for the development of special interests and expertises. Equally, the often very basic standard of dermatological knowledge among other doctors means that one's opinion tends to be highly valued. Think of the impression created when you declare that yet another referral with "maculo-papular rash, query drug-related" is in reality a classic case of teleangiectasia macularis eruptiva perstans or, perhaps more frequently, scabies.
 
Mind you, many of the abstruse terms used by dermatologists are simply rather banal descriptions cobbled together from Latin and/or Greek. For example "Bullous ichthyosiform erythroderma" means "red skin with fish-like scale and blisters". 5 points each if you you can name the following skin disorders (click on an image for the answer):
 
Names Names Names Names
 
Dermatologists are very social beings. In the UK there are regular clinical meetings in all regions, where one can share problems or boast of diagnostic and therapeutic triumphs. Numerous national and international meetings cater for both clinically based and academic dermatologists.

Dermatology can be serious 

Malignant melanoma kills about 1500 people a year in the UK, many of them relatively young; squamous carcinoma of the skin another 500. Pigmented lesion services, together with skin cancer awareness programmes, contribute to early diagnosis and treatment, and avoidance of preventable mortality. Serious malignancies of the skin also include cutaneous lymphomas, and the skin may be the site of metastatic tumours and of cutaneous signs of malignancy. 
 
Unlike hearts, livers or kidneys, skin rarely fails catastrophically. However severe psoriasis, eczema and other conditions can cause a state called erythroderma, when thermoregulation, fluid balance, and defence against infection are all severely impaired. Similar life-threatening consequences occur when large areas of necrotic epidermis are shed in toxic epidermal necrolysis, in adults usually due to drugs. Other conditions such as the blistering disorders, various forms of vasculitis, or granulomatous disorders can cause severe morbidity and may merit hazardous treatments.
 
At the other end of the scale, it is easy to underestimate the social impact of even mild skin disease. Skin disorders produce instinctive revulsion, perhaps as an evolutionary defence against infestation. When did you last see someone with psoriasis at a swimming pool, and how did you feel about it? Itch is unpleasant, and scratching unpleasant to watch. Atopic eczema keeps children awake, not to mention their parents. Hand dermatitis produces occupational handicap. Hair loss may be psychologically devastating. Psoriasis causes sexual difficulties. Even acne impairs confidence, and may affect job prospects. A dermatologist needs to understand all this, and to communicate this understanding to patients and other carers.

Science and the skin 

The accessibility of the skin to observation and experimentation has long been and is still exploited. Immunologists have led the way, and diagnostic skin tests figure prominently in the history of medicine: think of Jenner, Mantoux, and others. Can you identify the types of hypersensitivity and the relevant disorders (10 points each; click on an image for the answer):
 
Tests Tests Tests Tests

 

Inflammatory and immune mechanisms of general applicability are also accessible to study in skin. Skin can be artificially sensitised to study immune induction and expression. Inflammatory mediators can be injected into the skin, or blisters induced and used to follow the accumulation of cells, mediators or metabolites.

The skin has also been used to study physiology, for example the triple response of Thomas Lewis. In pharmacology, the mechanism of action of drugs can be studied by measuring their effect on cutaneous physiology or inflammatory or immune responses. New topical or oral preparations for skin disease continue to emerge, and require clinical trial to establish efficacy and safety.
 
In many parts of the world, leprosy and fungal and protozoal skin diseases remain major public health problems. Although tropical dermatology is of limited relevance in to UK practice, British investigators contribute importantly to the study of international problems in dermatology.
 
The epidemiology of skin disease in Britain is also a subject of intensive study. Important areas under investigation include the increasing prevalences of atopic eczema, and of malignant melanoma, and the relationship of environmental factors to skin disease.
 
In the study of neoplasia, lesions identified clinically, such as actinic keratoses, can be targetted for biopsy to look at, for example, oncogene expression. However, the mutagenic effects of UV radiation are only a part of a much larger scientific field, photobiology and photodermatology.
 
Skin manifestations facilitate the diagnosis of genetic disease - well known examples include neurofibromatosis and tuberose sclerosis but there are many others. In the investigation of inherited metabolic diseases or chromosomal defects, cultured skin fibroblasts may be of diagnostic value.
 
Skin can be biopsied to provide cells - fibroblasts, keratinocytes, melanocytes - or organs such as hair follicles for culture and use in in vitro studies. As a result of advances in molecular biology, many inherited skin disorders are now understood, but the information gained has had implications for cell biology as a whole.

Finding out more about dermatology 

Dermatologists are friendly and approachable, or at worst, "mostly harmless". Their major problem tends to be coping with a large and increasing workload. Nonetheless, many would welcome the opportunity to encourage the interest of an individual medical student. If you feel exposure to dermatology in the curriculum is inadequate for you, the best way to pick up more basic knowledge is to arrange to sit in during outpatient clinics or minor surgery lists, or to try to attend clinical meetings. Academic or general dermatologists may also be able to suggest small projects, or an interesting patient to investigate and perhaps write up as a case report. It will be much harder to find time for this when you are qualified.
 
Qualified doctors wishing to find out more about dermatology, either as a career or for general practice, are advised to think about an SHO post, ideally for 6 months or more. However, those already intent on a career in dermatology should know they will need 3 years post registration experience and MRCP before they will be eligible for specialist training.
 
If you would like any further information, approach your local dermatologist.
 
If this web page has stimulated your interest, we look forward to hearing from you.
 
Professor C S Munro
Southern General Hospital
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