Good news! Our efforts to prevent the imposition of Generic Substitution have been

successful, at least for now, since the Department of Health has decided to drop the

idea. In conjunction with the All Party Parliamentary Group on Skin and a group of

concerned patient groups as well as a few non dermatological pharma companies the

PCDS raised awareness of the risk of what would have amounted to a limited list.

Those of us old enough to remember the previous attempt at the imposition of a

black list of dermatological products in the 1990s will be less excited about the

winning of this round. I sadly predict that we will face increasing efforts to limit the

choice our patients will have in the future as the effects of the white paper and the

credit crunch begin to bite. We have a duty to maintain the best possible range of

treatments for our patients since the requirements of different types of skin are so

varied and make a huge difference to patients’ wellbeing.

More good news lies in the new development we have planned for next year. We

have planned an extra eight one day “Essential Dermatology” meetings to add to the

two already planned. These are a development of our previous Basic Dermatology

meetings and are designed to be aimed at your dermatology naive colleagues and

VTS registrars. We plan to take the roadshow around the country and have prepared

the series of presentations which will be presented by some of the committee and

local members who have volunteered to help. It is especially important for education

Primary Care Dermatology Society Winter 2010

Bulletinpcds.org.uk

2nd Floor, Titan Court, 3 Bishop Square, Hatfield AL10 9NA T: 01707 226024 F: 01707 226001 E: pcds@pcds.org.uk W: pcds.org.uk

Chairman’s Report

The PCDS Trustee Committee

Mr Peter Lapsley Dr Tom PoynerDr Stephen Hayes Dr Jane Rakowski Dr Julia Schofield

Forthcoming MeetingsMembers of the corporate membership scheme

2011

Basic Dermoscopy MeetingManchester Conference CentreThursday 24th February

PCDS Ireland Annual MeetingGalwayFriday 4th & Saturday 5th March

Spring MeetingSheffieldFriday 18th March

Essential DermatologyManchester Conference CentreFriday 1st April

Improvers Skin Surgery CourseLitchdon Medical Centre, BarnstapleFriday 8th & Saturday 9th April

European MeetingGrand Hyatt, BerlinFriday 13th to Sunday 15th May

Summer MeetingFriday 10th & Saturday 11th JuneThe Grand Hotel, Brighton

Autumn MeetingThursday 22nd SeptemberLady Margaret Hall, Oxford

Skin Surgery CourseSaturday 15th & Sunday 16th OctoberDurham

Advanced Dermoscopy CourseThursday 27th OctoberBMA House, London

Scottish MeetingSaturday 12th & Sunday 13th NovemberWesterwood HotelCumbernauld

Dermol knocks out Staph...

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• Over 10 million packs used by satisfied patients2

Dermol® 200 Shower Emollient andDermol® 500 Lotion Benzalkonium chloride0.1%, chlorhexidine dihydrochloride 0.1%,liquid paraffin 2.5%, isopropyl myristate2.5%. Dermol® Cream Benzalkoniumchloride 0.1%, chlorhexidine dihydrochloride0.1%, liquid paraffin 10%, isopropylmyristate 10%.Uses: Antimicrobial emollients for the management of dry andpruritic skin conditions, especially eczema and dermatitis, and foruse as soap substitutes. Directions: Adults, children and theelderly: Apply direct to the skin or use as soap substitutes.

Dermol® 600 Bath Emollient Benzalkoniumchloride 0.5%, liquid paraffin 25%, isopropylmyristate 25%.Uses: Antimicrobial bath emollient for the management of dry,scaly and/or pruritic skin conditions, especially eczema anddermatitis. Directions: Adults, children and the elderly: Add to a bath of warm water. Soak and pat dry.

Contra-indications, warnings, side-effects etc: Please refer toSPC for full details before prescribing. Do not use if sensitive toany of the ingredients. In the unlikely event of a reaction stoptreatment. Keep away from the eyes. Take care not to slip in thebath or shower. Package quantities, NHS prices and MAnumbers: Dermol 200 Shower Emollient: 200ml shower pack£3.55, PL00173/0156. Dermol 500 Lotion: 500ml pump dispenser£6.03, PL00173/0051. Dermol Cream: 100g tube £2.86, 500gpump dispenser £6.63, PL00173/0171. Dermol 600 Bath

Emollient: 600ml bottle £7.55, PL00173/0155. Legal category: PMA holder: Dermal Laboratories, Tatmore Place, Gosmore,Hitchin, Herts, SG4 7QR. Date of preparation: January 2010.

References:1. Gallagher J. Rosher P. Temple S. Dixon A. Routine infection

control using a proprietary range of combined antisepticemollients and soap substitutes – their effectiveness againstMRSA and FRSA. Presented as a poster at the 18th Congress ofthe EADV in October 2009, Berlin.

2. Dermol Range – Total Unit Sales since launch. DermalLaboratories Ltd. Data on file.

Adverse events should be reported. Reportingforms and information can be found atwww.yellowcard.gov.uk. Adverse events shouldalso be reported to Dermal.

www.dermal.co.uk

2

at GP level to be provided by those experienced in delivering the care being taught.

The aim is to inspire and enthuse as well as provide the essential elements of

day-to-day dermatology. Following the Health Care Needs Assessment by Dr Julia

Schofield, we know that dermatology contributes to 24% of consultations. In addition

delegates will be provided with a memory stick which will include the presentations

and extended details of all the subjects covered. Guidelines, further reading

suggestions and references will also be provided to make the stick almost a

complete, up-to-date, dermatology manual.

Please encourage your colleagues and registrars to attend when we are in your area

since I am very conscious of the risk of deskilling generic GPs as the attention has

been towards GPSI development. Details of venues and dates as well as booking

details can be found on the website or by calling the PCDS office.

The usual range of meetings have also been arranged for next year maintaining our

high standard and variety. These do not just happen and there is a great deal of

thought and research which goes into the planning. The venues have to be assessed

and our increased attendance numbers and range of sponsors cause a happy difficulty

in finding venues with sufficient facilities and size at a price we, and you, can afford.

The administration team (Siobhan and Carol) spend a lot of time and effort visiting and

planning hotel arrangements and we are so grateful to them for all their hidden work

which only comes to notice when, rarely, hotels let us down in some way.

Dr Elizabeth Ogden is our main educational advisor and her knowledge of speakers is

a huge asset to the rest of us who help with the different meetings. She is always

keen to hear of good speakers and interesting subjects for future meetings so please

drop us an email if you hear one. We are especially interested in presenters new to

the Society.

Happy new year to all our members and good luck for 2011.

Stephen Kownacki

Executive Chair

Editorial Winter 2010

Scottish Meeting The Scottish meeting was an overwhelming success again

this year. The venue was the Radisson Blu Hotel,

Edinburgh. I’m sure that those of you who were brave

enough to venture North of the Border would all agree.

The hotel was ideally situated on the Royal Mile with close

access to local attractions and shops . There was also the

Salisbury Craggs at the bottom of the mile for those who

fancied a breath of very fresh air. The speakers were of a high

standard and the talks were varied and interesting. Stephen

Hayes will be summarising the salient points from Jonathan

Bowing’s Dermoscopy workshop later, for those who did not

attend. I particularly enjoyed a lively debate between Julian

Peace and George Moncrieff on behalf of Primary Care and

Chris Bower and Peter Lapsley representing Secondary Care on

whether BCC’s could be safely managed in the community. All

parties represented themselves very well. The winners were

primary care; not surprising in view of the audience. However,

it was a close call. I’d like to thank all the speakers on behalf of

the Committee and Carol, Siobhan and Iain for organising an

excellent event. A very energetic Ceildih followed the dinner on

Saturday evening. There was some over exuberant flinging

around of partners. I hope everyone enjoyed it despite several

people having bruised limbs the next day!

6 7

Melanoma Taskforce and SkinCancer Visions 2015 Report

On November 1st, the Melanoma

Taskforce published their

recommendations for Prevention,

Diagnosis and Treatment of the disease.

The Taskforce included patient group and

charity representatives (including Cancer

Research UK, The Teenage Cancer Trust,

SKCIN, Factor 50 and the Skin Care

Campaign), MPs, GPs, Skin Cancer

Nurses, Dermatologists, Oncologists and

Surgeons, as well as representatives from

the National Cancer Action Team and the

National Cancer Intelligence Network.

Key recommendations included:n Public awareness campaigns on the

dangers of overexposure to the sun

and the importance of early detection

of skin cancer should be more

targeted on the most susceptible

groups

n Better training for GPs and information

for pharmacists, hairdressers,

physiotherapists, swimming

instructors and others who come into

contact with peoples’ skin, on how to

spot the signs of skin cancer

n Further regulations on sun bed use to

ensure all salons are supervised and

all adult users of sun beds are provided

with health information warnings about

the dangers of sun bed exposure

n Prioritise the development of a Quality

Standard for melanoma; standards that

will mandate innovation in skin cancer

service design, incentivise the best

use of clinical expertise and drive

improvements in patient outcomes

throughout the patient pathway

The Taskforce has made submissions to

the Department of Health consultations

on the Cancer Reform Strategy and the

NHS White Paper.

This is obviously a step in the right

direction but it may be some time for the

message to filter through to address the

learning needs of health care

professionals and give dermatology the

place it deserves as an important part of

the core curriculum .

New Anti-wrinkle Treatment –whatever next?

After a series of tests, French scientists

at the Centre d’Etudes et de Recherches

Cosmetologique (CERCO) have proved

that a Dutch anti-wrinkle bra, La

Decollette does really work. Their test

results show that cleavage wrinkles

disappear after 24 hours and skin is

smooth again after about two weeks. It

is worn at night and prevents the

formation of permanent vertical wrinkles

developing. Three dimensional

techniques employing lasers and

cameras were used to measure the

wrinkles. I’m not sure of the number of

patients included in the study. Perhaps

they should branch out to balaclavas

next it may save patients having to pay

for expensive injections!

Nightmare last night – I woke up with

palpitations and in a cold sweat thinking

that Christmas was around the corner.

Clearly that would be awful; I’m too

busy to prepare for such festivities…

reality dawns only 28 days and

counting-less by the time you read this.

Season Greetings.

Helen Frow

8 9

Nodular Prurigo

Nodular prurigo is a common skin disease in which

multiple, intensely pruritic, excoriated nodules are found

on any area of the body. Patients with nodular prurigo

complain bitterly about the itch as well as the eroded,

oozing lumpy appearance of their skin and, of course, the

associated loss of confidence and self esteem concomitant

with such disease. Chronic rubbing of the skin causes

lichenification (thickening) of the skin, and excoriation from

scratching results in eroded plaques or nodules. Pigmentary

changes often result from such repetitive trauma to the skin.

Nodular prurigo affects all ages, races and both genders, but is

probably more common in middle aged and elderly individuals.

Patients with nodular prurigo freely admit that they scratch at

their skin and that the intractable itch drives their symptoms.

Although there is usually not much in the way of obsessive or

compulsive symptoms, there is often a habit associated with

scratching and patients will note that the condition deteriorates

at times of stress. This can prove a useful way of treating the

patient with ‘habit reversal’ techniques (below).

The causes of nodular prurigo include those of any unremitting

itch:

• Chronic liver disease

• Chronic renal disease

• Infections

• HIV

• Hepatitis B and C

• Syphilis

• Malignancy

• Lymphomas

• Haematological Malignancy

• Others

• Anxiety or other psychiatric condition

• Medication

• ACE inhibitors

• Anti-psychotics

• Others

• Idiopathic

• Metabolic disease such as hyper- and hypothyroidism and

diabetes mellitus

• Long standing skin disease such as eczema

Most patients present initially to their general practitioners, and

most are treated effectively in primary care.

Treatment of Patients with Nodular Prurigo inPrimary Care1 Establish the diagnosis by history and examination

2 Exclude (as best as possible) differential diagnoses such as

a. Immuno-bullous disease for example pemphigoid in a

nodular prurigo pattern

b. Lichen planus

c. Cutaneous neoplasia (especially cutaneous lymphoma)

d. Other dermatoses such as eczema, psoriasis and contact

dermatitis

3. Look for an underlying cause (above). This will include

routine blood tests (FBC, renal, liver and thyroid function,

glucose). It may include HIV and hepatitis serology and,

sometimes, a skin biopsy. If a skin biopsy is taken,

immunofluorescence is important to exclude immuno-

bullous disease (though this is more likely to be performed

by GPwSIs or in secondary care)

4. Patch tests can be useful to exclude a contact dermatitis

component (via the local secondary care unit)

5. Referring the patient to advocacy groups such as

www.nodular-prurigo.org.uk

6. Enter into a dialogue about treatment options

It is very important to remember that treatment for nodular

prurigo is often applied in a step-up and step-down manner

similar to the treatment of asthma and atopic eczema. This

means that patients will start off on easily administered

treatment such as emollients and topical steroids and then, if

not responding, ‘step-up’ to ADDITIONALLY using treatments

such as antihistamines and UVB. Once control of the nodular

prurigo is effected, patients can ‘step-down’ to treatments with

less risk of side effects and toxicity.

EmollientsEmollients are the first line treatment for nodular prurigo, and

will be necessary once the condition has been successfully

treated to avoid a recurrence. Emollients are used either directly

onto the skin or as bath emollients, and are important because

they help repair the skin’s barrier function and because they act

as anti-pruritics. Some emollients (for example Balneum Plus

cream and bath emollient) contain specific agents (such as

lauromacrogols) which can help reduce itch. Patients like to

choose their own emollient and, where possible, it is best to

give patients a trial of a variety so that they can pick the

emollient which suits them best.

Topical Steroids Topical steroids act as anti-inflammatories and as such will have

an indirect anti-pruritic activity. Stronger topical steroids are

usually required to treat nodular prurigo as the skin is thickened

(so absorption reduced) and the inflammation is relatively deep

and active. Most Dermatologists tend to use ointments rather

than creams as the creams often contain preservatives to

which the patient can be allergic. Clobetasol (despite being

super potent) is best used initially for most patients with

nodular prurigo. The strength of the steroid can then be titrated

down after a few weeks. A great treatment option is also

Healan Tape (steroid, fluandrenalone, impregnated sticking

tape) which can be applied overnight to each of the individual

nodules and then removed the following day.

Topical Calcineurin InhibitorsThese agents can be very useful in nodular prurigo of the face,

but are probably too expensive and too problematic (burning

and itching side effects) to be used extensively.

BandagingWraps and impregnated bandages are great treatments for

nodular prurigo as they provide an extra layer between the

patient’s skin and his or her nails. The impregnations in some

bandages (such as ichthopaste and viscopaste) can have

additional anti-pruritic and anti-inflammatory properties.

Nursing colleagues will initially need to demonstrate the

application of these bandages, but, once patients have learned

how to apply them, they are relatively easy to use. Using

steroids beneath the bandages augments the action of the

steroids, so topical steroids need to be reduced in potency

when using bandages. Nevertheless it is essential that topical

steroids are used at the same time as the bandages.

AntihistaminesSedating anti-histamines are usually best in nodular prurigo as

the patient often has disturbed sleep patterns and because the

pruritus is often worse in bed. Hydroxyzine 25 to 50mg at

night is the most common dose to use, but lower doses

(10mg) are possible in patients who find the sedation too

much with higher doses. Non-sedating antihistamines during

the day (or night) can be useful for those who cannot tolerate

sedating medication (for example patients who are driving for

an occupation).

Treatment for Nodular Prurigo in SecondaryCareIf a referral to secondary care is necessary because,

• The diagnosis is in doubt

• The patient has not responded to initial treatment

• The nodular prurigo is severe

• The patient is thought to have an underlying cause such as

bullous pemphigoid and a skin biopsy is necessary

• The patient needs patch testing

• The patient is demanding a referral to secondary care, after

any relevant biopsies or patch tests are performed, the patient

can be treated in ADDITION to topical treatments with;

UVB and PUVAUltra-violet light treatment using narrow band UVB (which only

uses the relatively less harmful UVB light) and PUVA

(ultra-violet A light plus psoralen medication) may be beneficial

for severe pruritus. UVB and PUVA work by reducing pruritus,

and by reducing the cutaneous inflammation. But the adverse

effects of prolonged UV exposure need to be explained before

such treatment is commenced and a formal consent is

important. Most recalcitrant nodular prurigo patients will

respond to UVB or PUVA and can then be switched back to

topical treatments once their skin is clear.

Post inflammatory hyperpigmentation Excoriated nodules Excoriations and hypopigmented scarring

10 11

place and frequency of most scratching, and then over the

following weeks attempts to reduce that scratching habit.

Usually the patient has a counter and can count the number of

times he or she scratches at the skin. Initially, the patient will

record a high frequency of scratching ‘episodes’, which will

gradually tail off as habit reversal starts to work. But person-

centred cognitive behavioural therapy (CBT) can also be

invaluable in the management of nodular prurigo, both to address

any self-esteem issues and to manage anxiety and depression.

CBT can also act as a mirror to reflect life-events and issues back

to the patient, so that the patient can address these. In

addressing life-issues the patient may well be addressing the

cause of the nodular prurigo itself.

ConclusionsNodular prurigo is a common condition which can be difficult to

treat. Using a step-up and step-down model of care and engaging

the patient in the management of their condition is key to

successful treatment.

Dr Anthony Bewley FRCP

Consultant Dermatologist, Whipps Cross University Hospital

& Barts and the London NHS Trust

Dr Bowling told us that despite the

doubters, dermoscopy is becoming

steadily more accepted as a tool

which provides additional diagnostic

evidence, reducing needless benign

excisions while reducing missed

melanomas. In Oxford, the ratio of

benign to malignant moles excised has

now been reduced by dermoscopy to an

astonishingly low 2:1, even better than

the 5:1 which has been reported by

Argenziano. Without dermoscopy this

ratio can be as high as 18:1 or higher, an

argument which apart from the issue of

needless scars should interest

Commissioners. Cutting out benign

lesions pointlessly is neither good

medicine nor good economics.

This was the 4th time I have heard Dr

Bowling present, but the slides were

new and the presentation adapted to the

changing dermoscopic scene. He

mentioned his personal series of 1,000

melanomas including many unusual

presentations, but, recognising we GPs

will not see many melanomas, he

concentrated mainly on using

dermoscopy to make the referral

decision. The goal is positive

identification of benign lesions, referring

whenever dermoscopy could not enable

safe reassurance. Secondary care does

not necessarily want fewer referrals, just

better grading. He mentioned the terrors

of the web which sometimes had

patients planning their funerals in the 10

days waiting for the skin cancer clinic

appointment – at which he would take 3

seconds to diagnose a seborrhoiec wart

or haemangioma.

Beware nonspecific lesionsA very slow growing 5cm irregularly

shaped and pigmented lesion on a man's

back yielded no useful dermoscopic

criteria – but it was impossible to

confidently assign the lesion to a benign

diagnostic category, which equals a

referal. It was dermatofibrosarcoma

protuberans (DFSP), a rare sarcoma

which grows so slowly it may be ignored,

but can still kill. Again, if it looks wrong

and can't be proved benign, refer. Rare

things are rare, but do occur, and as with

Merkel cell cancer, (a dangerous cancer

mainly of older men’s’ head and neck

which is on the increase and like DFSP

lacks dermoscopic features) are often

missed. We were reminded that the

ABCD rule doesn’t work for nodular

lesions, and is anyway a crude tool

compared to systematic examination of

lesion architecture by dermoscopy, our

window into the histopathologist’s world.

BCC pigment and pseudolacunaeLacunae are a stereotypical dermoscopic

feature of haemangiomas, often allowing

extremely confident diagnosis and

avoiding referral. They can be red, blue,

purple or black (when thrombosed), and

may be mixed within a lesion, BUT the

colour within each individual lacuna

should be homogenous. ‘Lacunae’ which

are grey, brown or of mixed/granular

colours occur in basal cell cancers as we

were shown, catching some of us out.

We spent half an hour looking at

pigmentation in BCCs. Dr Bowling said

once you got used to seeing BCC

pigment through the dermoscope; you

get your eye in and see it more often on

naked eye appearance – something I

have noticed. Fully pigmented BCCs are

uncommon, but probably 40% of BCCs

have some pigment, a dermoscopic

feature often allowing a firm diagnosis.

The pigment in BCCs is not melanocytes,

but melanin in abnormal basal cells. Leaf

like structures, ovoid globules and

cartwheel structures are among the

irregular blue, brown and grey pigmented

structures seen in BCCs, all part of the

chaos that occurs in a growing tumour.

Dr Bowling stressed that the morphology

of a malignant tumour changes

dynamically over time. Even the most

experienced dermoscopist cannot always

tell a pigmented BCC from a melanoma.

Reduced referrals

We saw 30 plain views and then

dermoscopic views of the same tumours

and marked to refer or reassure. On a

show of hands, there was a significant

Improvers’ Dermoscopy Workshop

I know we have written often about dermoscopy: this report concentrates on someadvanced teaching points presented by the UK’s top Dermoscopist with whom thePCDS has been working for several years

2.5 hours with Jonathan Bowling, Edinburgh

1. Nodular Prurigo UK. http:// www.nodular-prurigo.org.uk /

2. Hyde JN, Montgomery FH. A practical treatise on disease of the skin for the use of students and practitioners. 1909; 174-175

3. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI): A simple practical measure for routine clinical use. Clinical and ExperimentalDermatology 1994; 19: 210-216.

As a retired nurse I have a continuing

interest in health matters. Being

someone who has had a lifetime of

deriving satisfaction from caring for

others both professionally and in a

voluntary capacity, when I was

diagnosed with nodular prurigo (NP) and

found no support organisation for this

condition, I decided to start a website dedicated to this –

Nodular Prurigo UK1.

NP (Pruritus Nodularis, Hyde’s Disease) is a chronic skin

condition first described by Hyde & Montgomery2. It has no

known cause or specific treatment. I was diagnosed 3½ years

ago, but had suffered for about 1½ years before this. Having

had other skin conditions most of my life (urticaria, eczema) it

had been assumed both by my GP and me that this was just

an extension of these. It was not until another partner in the

practice specialising in skin disorders ordered a skin biopsy

that a precise diagnosis was reached. Treatment then has

been various and ultimately unsuccessful, now reaching into

immunosuppressant drugs.

With all my own experience I recognised that a website giving

clear information and acting as a contact point for people

affected by NP through a support forum, would be a useful

addition to the online support dermatological networks. Having

started in March 2010 it is still early days, but if the demand is

sufficient there is always the possibility of Nodular Prurigo UK

becoming a charity or not-for-profit organisation. This project is

currently self-funded, donations, however, will always be

welcome!

Please visit the website and get in touch with any comments,

items for publication or suggestions to improve the site. You

might also encourage anyone affected by NP to visit the site

and help me build statistics on their experiences by completing

the two online questionnaires – the Dermatology Life Quality

Index (DLQI)3 and a Treatment Survey.

Rebecca Ditman SRNNodular Prurigo UK

Nodular Prurigo UK – A New Support Service

Psychotropic Medication• Tricyclics can be wonderfully useful in treating nodular

prurigo. Starting at low doses (such as amitriptylline10mg at

night) and increasing to higher doses is usually key. Remember

to warn patients of the side effects and check that they have no

cardiac history. Also remember to be up front with patients that

this medication is used as an anti-depressant in some (most

patients with nodular prurigo are not depressed and the clinician

can be clear that the medication is not being used for that

purpose and not at an anti-depressant dose). Some tricyclics

have additional anti-histamine properties (for example doxepin)

which can be useful

• SSRIs can also be helpful especially if the patient has an

affective disorder such as anxiety and/or depression

• Rarely agents such as opiate receptor antagonists, pregabalin

and gabapentin have been reported to benefit patients with

nodular prurigo, but this would be under Specialist supervision

PsychotherapyHabit reversal therapy for the itch-scratch cycle associated with

nodular prurigo may be helpful. This is a behavioural therapy

technique whereby the patient initially acknowledges the time,

12 13

This 69 year old man presented with a widespread, intensely itchy, rash,

that had been steadily worsening over the past year. Have a look at the

illustrations and ask yourself

What would you include in your differential diagnosis?

• What tests would you perform?

• Would a skin biopsy help?

• What are the treatment options?

The keys to the clinical diagnosis here are

1) The distribution of the very itchy rash

2) The presence of vesicles on close examination (Fig 1)

Dermatitis herpetiformis (DH) presents with intensely pruritic or stinging

polymorphous lesions, symmetrically located on extensor surfaces, especially

elbows (Fig 2), knees, scapulae, shoulders (Figs 3), sacrum, buttocks (Fig 4),

hairline and scalp (Fig 5). Close examination may show the characteristic vesicles

(Fig 1). Hence the name herpetiformis = looks like herpes. Usually itch is of such

intensity that vigorous itching and scratching removes the vesicles, leaving

widespread erosions, crusted papules, and areas of post-inflammatory

hyperpigmentation.

A not unusual presentation, especially early on, is with erythema, urticarial

plaques and papules. Rarely DH is asymptomatic. Often the patient describes

itching, burning, and stinging 8 to 12 hours before lesions develop.

DH can start at any age with a peak age of onset between 20 and 40 years. It

persists indefinitely.

It is one of the group of autoimmune blistering diseases and is associated with

many other autoimmune disorders, such as pernicious anemia, Sjögren

syndrome, Lupus erythematosus, and diabetes mellitus. The

finding, on a skin biopsy, of granular deposition of

immunoglobulin A (IgA) detected with direct

immunofluorescence (DIF) confirms diagnosis.

Nearly all DH patients have clinical or more usually subclinical

small bowel villous atrophy (gluten-sensitive enteropathy).

Indeed DH represents the cutaneous manifestation of

gluten-sensitive enteropathy, an immunologic reaction to

ingested gliadin, Circulating IgA antibodies against

endomysium and tissue transglutatminase (tTG) may be

detected on serology.

Patients are at increased risk of developing non-Hodgkins

lymphoma. However the risk is low. One follow up study

showed a risk of 1% of 1104 patients, with onset from 2 to 31

years after diagnosis of DH.

Treatment

Gluten free diet is the treatment of choice. Six to twenty-four

months of strict diet reduces or may eliminate the need for

medication. It treats the enteropathy (which is usually present)

and is protective against small bowel lymphoma.

Dapsone Starting at a dose of 25 mg to 50 mg daily gives rapid symptom

relief, often within hours of the first dose, with no new lesions

erupting after 2 to 3 days. The average daily dose is usually 50

to 75mg. The dose should be titrated down once satisfactory

response is achieved. Maintenance dose may be as low as 25

mg per week.

Dapsone causes haemolysis, methaemoglobinaemia, jaundice

and neuropathy. The haematological side effects tend not to be

a problem with a daily dose of 100 mg or less. Table 1 outlines

a schedule for monitoring dapsone.

Irish people have a very high incidence of Coeliac disease and

DH. Those of you who practice in areas of the UK with historic

high immigration from Ireland should consider the diagnosis of

DH when faced with a widespread, blistering, itchy rash in one

of your patients.Johnny Loughnane

What’s Your Diagnosis?

reduction in intention to refer with

dermoscopy, with initially suspicious

looking lesions resolving into

haemangiomas, seborrhoiec warts

and benign naevi. He made the point

that we tended to teach little

dermoscopy of benign intradermal

naevi which often look like small

papular non pigmented BCCs. The

blood vessels were the main clue,

the short curvilinear vessels (I have

heard them called comma vessels

elsewhere) in the shape of letters C,

J, E and S distributed evenly though

the lesion, not so long or well

focused as the typical arborising

telangiectatic vessels of BCCs. Very

helpful.

Horror slide

The horror slide of the presentation

was a warty pigmented scalp lesion

on a white man from a hot country.

Dermoscopy showed numerous

milia like cysts and comedo like

openings, so I thought it was a

seborrhoiec wart. However, Dr

Bowling, and the histopathologist,

thought it was a melanoma. The

clues, apart from the high risk history

including recent change, were the ill

defined edge and irregular dark

pigment, but the dermoscopic

resemblance of this warty melanoma

to a benign seborrhoiec wart scared

me witless and I consider myself an

experienced dermoscopist.

Admittedly he said it was easier in

the flesh than from the image (a

problem for teledermoscopy). A

good reminder that there is no

'always' or 'never' in medicine and

that we should beware

overconfidence. Community based

dermoscopy is already (albeit

patchily) achieving its potential to

reduce referrals by screening out

benign lesions, but let’s be careful

out there.

Stephen Hayes

Fig 1 Fig 2 Fig 3 Fig 4 Fig 5

Before initiation of therapy

1. Complete history/examination

2. Severe cardiac/lung disease – dose adjusted as it causessome degree of hemolysis

3. C/I – G6PD,severe hepatic abnormality, pregnancy and breastfeeding

4. FBC – plus differential, reticulocyte count, Urea, creatinine, LFT,G6PD

Follow-up visits

5. Periodic neurologic evaluation

6. FBC/differential and reticulocyte count every 2 weeks first 3 to6 months, then every 2 months

7. Liver and renal function tests and urinalysis monthly first 3 to6 months, then every 2 months

Table 1. Monitoring Patients on Dapsone

14 15

The revised BAD UK Guidelines forthe Management of Cutaneous Melanoma 2010

Tony, a 52 year old patient was seen in out-patient clinic this

week and informed of his diagnosis – a nodular melanoma of

Breslow thickness 4.3 mm. His outlook is not good. Tony had

been referred 14 weeks ago as a routine referral with a

relatively non-specific lump on his skin. Could the revised

Guidelines have helped improve Tony’s chance of survival?

Before I attempt to answer this question I would like to

highlight four areas within the revised Guidelines that are of

value to GPs and other primary care health professionals:

• Who is at risk of melanoma?

• Sun protection and vitamin D3

• When should family members be referred?

• Hormones and melanoma

Who is at risk of melanoma?

Slightly increased risk (1-3 times that of the general population)

• Risk factors – skin that burns easily, red or blond hair, a high

density of freckles, any family history of melanoma

• Management – give advice on sun-protection and

self-examination

Moderately increased risk (8-10 times that of the general

population)

• Risk factors – large numbers of moles, some of which may

be atypical in appearance, a personal history of melanoma,

organ transplant recipients

• Management - patients with large numbers of moles of

which some are atypical should be referred to a

Dermatologist for assessment and photography, otherwise:

• Counsel about the risk

• Give advice on sun protection

• Monthly self-examination

High-risk (more than 10 times that of the general population)

• Risk factors – patients with giant congenital melanocytic

naevi, those with a strong family history (see later)

• Management - long-term Dermatology follow-up needed

Sun protection and vitamin D3

Adequate sun exposure to allow vitamin D synthesis or

sufficient dietary intake of vitamin D3 is essential to human

health. It is now recognised that a balanced approach needs to

be given to our population:

• All individuals and especially children should not get sunburnt

• Sunbeds should be avoided - a recent meta-analysis has

shown that the use of sunbeds, particularly under the age of

35 increases the risk

• Those at risk should limit their recreational sunlight and at the

same time consider supplementing their intake of vitamin D3

in the absence of any contraindications. Foods containing

vitamin D3 include cod liver oil, fortified milk, salmon,

mackerel, sardines, egg yolk and beef liver

• It is inappropriate to greatly reduce sun exposure in those at

low-risk

When should family members be referred?

• 3 or more cases of melanoma or pancreatic cancer

• 2 cases of melanoma in a family PLUS any of the following:

• the presence of multiple primary melanomas in one of the

affected individuals

• the presence of multiple atypical moles

Family members should be referred routinely to a clinic

managing inherited predisposition to cancer (involving

Dermatologists and/or Clinical Geneticists)

Melanoma – pregnancy and hormonalmedications

• Pregnancy - there is no evidence that melanoma at or around

the time of pregnancy affects the outcome for mother or

baby, but the social and family effects of developing

recurrent melanoma during pregnancy or after birth are great

and so appropriate counseling is needed

• The COCP – there is no evidence that this plays any role in

the natural history of melanoma

• HRT – there is no evidence that this plays any role in the

natural history of melanoma, neither does it worsen the

prognosis in stage I or II melanoma

Follow up of patients with melanoma

• Patients with in situ melanomas do not require follow up

• Patients with invasive melanomas have differing risk of

relapse according to their stage group

• Patients with stage IA melanoma should be seen two to four

times over up to 12 months, then discharged

• Patients with stage IB–IIIA melanoma should be seen

3-monthly for 3 years, then 6-monthly to 5 years

• Patients with stage IIIB and IIIC and resected stage IV

melanoma should be seen 3-monthly for 3 years, then

6-monthly to 5 years, then annually to 10 years

• Patients with unresectable stage IV melanoma are seen

according to need

But what about Tony?

Effective management of melanoma is based around early

diagnosis and surgical excision, and with this in mind I don’t

believe that the revised Guidelines are going to help the likes

of Tony. Why is this?

• There are massive pressures on GPs to refer almost

everything that could vaguely be a melanoma

• Our secondary care 2-week clinics are now awash with

seborrhoeic keratoses and other benign lesions, which are

pushing up waiting lists for routine referrals

• As with Tony, significant numbers of melanoma may not

be obvious – up to 50% of melanomas arrive on routine

referrals and these patients may now be waiting longer to

be seen

• The new Guidelines do little to address the educational

needs of the community and simply state ‘Melanoma

remains relatively uncommon and therefore the opportunity

to develop diagnostic skills is limited in primary care‘

• The Guidelines do little to assist GPs to help sort out which

lesions should be referred – essentially unless the lesion is a

normal looking mole arising in puberty the Guidelines

recommend the patient should be referred

So how could Tony have fared better?

If we could take out of our secondary care clinics many of the

skin lesions that are obviously benign, then the patients

referred routinely such as Tony would be been seen quicker

and their prognosis improved.

We cannot keep on dismissing the potential to improve the

dermatology know how of GPs, and a move towards better

training and education for GPs is paramount to improved

survival rates for melanoma. Most working in primary care are

not going to become experts in the diagnoses of skin lesions

but there is certainly a great opportunity to help GPs recognise

what is very likely to be normal such as itchy moles that look

normal and which are not changing, or moles that become

raised and ‘wobbly’ while maintaining their symmetry.

And what about the role of Dermoscopy in primary care? GPs

across the county are showing a substantial interest in this

diagnostic aid, and while I cannot recommend GPs using a

dermatoscope to make a diagnosis of melanoma, with

appropriate training it surely has a place to help confirm benign

lesions such as seborrhoeic keratoses, angioma and

dermatofibroma?

Close working relationships between primary and secondary

care are also important and this is why I was concerned to read

that the authors of the revised Guidelines are all based in

secondary care. The only mention of primary care was the

RCGP, I am not aware of any contact with the PCDS, which

after all has over 1000 members with a keen interest in

dermatology.

So how do I qualify to pass comment on the strengths and

weaknesses of the BAD Guidelines? I work with patients in

general practice, as a GPwSI in dermatology and skin surgery

and also in an under-resourced dermatology out-patient

department. I also have a very personal experience – it was

over 10 years ago that I sat in my GP office and saw the report

of a 4mm pigmented lesion that had been removed from my

left shoulder, unfortunately it was not a short one, however I

was one of the lucky ones as it was only a melanoma-in-situ.

For more information on melanoma please refer to the relevant

chapter in the A-Z of clinical guidance on the PCDS website.

Dr Tim Cunliffe

16 17

Dr Snippit’s Clippings

News from IrelandIn 2011 the Annual Meeting of the PCDSI will take place in

Galway for the first time ever. The Radisson Hotel, in the

center of town, is our venue. Two very full days of

dermatology education have been arranged for Friday 4th and

Saturday 5th of March.

Connemara, an area of beautiful mountains and rugged coastline is

situated West of the City. The centre of Galway is within walking

distance of our conference venue. You might therefore consider a

short spring break, combining two days of intensive dermatology

education with a relaxing few days on Ireland’s West Coast.

The programme includes sessions on atopic eczema, psoriasis,

skin problems in different patient groups, dermoscopy, skin

infection, difficult cases, paediatric dermatology etc. Our speakers

are from Ireland, England, Wales and Scotland. There will be some

parallel sessions, where we aim to cater for delegates varying

knowledge and expertise in dermatology.

Please check out our website, www.pcdsi2011.com, for a detailed

programme, registration form and accommodation details.

I accepted an invitation to join the Expert Skin Cancer Group

advising the National Cancer Control Programme. The Chair is Dr

Patrick Ormond from St James Hospital, Dublin. The Group have

been meeting regularly, drawing up Guidelines on Referral of

Patients with Suspected Skin Cancer. A one page Guideline Sheet

and a Standard Referral Form are at present being piloted in the

Cork area. Initially they will be restricted to suspected cases of

Melanoma. After assessment of the pilot, there will be a final

refinement of the Guideline and Referral Form, after which they

will be introduced throughout the Country. It is planned that extra

Consultant Dermatologist appointments will be made to cater for

expected increased workload in secondary care. In the present

financial state of the country we can only assume that this will not

constitute a flood of appointments.

Johnny Loughnane

Tubercles from tattoos

The BMJ of 30th October1 carries an interesting story about an

outbreak of Mycobacterium chelonae (no, I’d never heard of it

either) in France. A large outbreak over 8 months was due to

contaminated tattoo ink. 48 patients presented with skin

lesions, mainly pustules, occurring several days to a month

after visiting 2 particular tattooists in Le Havre. The germ was

cultured from ink bottles, which had been refilled from a large

bottle and rinsed with tap water. The report is accompanied

with an image of a wolf tattoo sporting a crop of pustules and

papules. They all got better with antibiotics, but are stuck with

the tattoos. Silly habit.

Vitiligo and other Auto Immune Diseases

The same BMJ had a

patient authored item about

Vitiligo. Darryl Monte,

assisted by Vitiligo Society

lead Jennifer Viles and

Dermatologist David

Gawkrodger, told us about

his journey. Steroid cream was tried, then ‘holistic’

homeopathy, and then (after a possibly stress induced relapse)

PUVA, which achieved rapid repigmentation on the face.

However, his legs got worse. A change to narrowband UVB

partially improved the face, but not hands and feet. He had 250

UV treatments in all. He has also tried tacrolimus, again on

anecdotal evidence, and feels that the affected areas of skin

are thinner, especially the hands.

Mr Monte felt his main problem from vitiligo was other

peoples’ attitude towards his appearance, describing the

psychological effect as ‘quite painful’. He subsequently

developed diabetes and then rheumatoid disease – which was

dramatically improved by etanercept. Dr Gawkrodger notes

that etanercept didn’t help the vitiligo, and that ‘there is still no

really effective treatment’ and calls for more research.

Dr Snippit’s sympathy for the patient’s suffering almost, but

not quite, prevents him from wondering about the risk/benefit

ratio of unproven treatments, including steroid and

phototherapy, for unreliable relief of benign disorders. And if

research does give us a monoclonal antibody or similar for

vitiligo, what will it cost compared to, say, a Specialist

Dermatology Nurse’s annual pay? If NICE goes, we GPs will

be responsible for decisions about such things.......

Missed Melanoma...again

If in some areas of medicine we lack good evidence, in other

areas we don’t always make best use of the evidence we

have. Father-of-four Jon Edmonds, 42, alleges a Bristol Plastic

Surgeon refused to remove a bleeding mole from his shoulder

because it was a 'cosmetic' procedure. Now he has

metastatic melanoma and is suing the NHS for £300,000. He

told reporters 'The failure to carry out that minor and

inexpensive procedure is now likely to cost the NHS a very

large sum of money.2’

Mr Edmonds's GP correctly referred him to a Pigmented

Lesion Clinic in October 2005 after noticing a mole on his left

shoulder but he was told it was a bite or sting. His friends

subsequently encouraged him to get it reviewed in February

2008 when it changed, but he evidently felt reassured by the

original advice. When his GP re-referred him in June 2009

after colour change, it was metastatic.

His lawyer said: ‘Jon should have had this mole cut out in

2005. The fact that he wasn't even followed up compounded

the error. He is now left with a far less favourable prognosis

than he should have been, and in the circumstances we are

pursuing the claim as quickly as we can, and expect to

recover very substantial damages for Jon.'

Two words: sad, instructive. But Dr Snippit hopes that Daily

Mail readers will not conclude that the NHS should always

remove moles, even if they are ‘only cosmetic’. That is not the

lesson this tragedy teaches.

Incidentally, it is whispered in high places that the continuing

uncertainty over vitamin D and the benefits of UV is being

gently stirred and spiced up by the tanning lobby. Surely not?

Next thing you know we’ll hear of a Secretary of State for

Health working for a tobacco company. No, there’s no way

that could ever happen.

Oral Isotretinoin and Attempted Suicide

We all know of the teratogenic effects of

Roaccutane (now available as generic

isotretinoin), although when Dr Snippit once

warned a female patient it was as bad as

Thalidomide, she asked ‘What’s Thalidomide?’.

But anxiety about mood change and suicide still

prevents some patients with severe scarring

acne from receiving therapy. The BMJ of 20th

November3, 4 carried a report and editorial based

on 21 years of health records to try to ‘untangle

whether the drug itself or severe acne’ causes

increased suicide risk. The answer apparently is,

it’s a bit of both, but the absolute risk is tiny

anyhow. Suicide attempts in the treatment group

were already rising before treatment began. The

authors concluded ‘The data support our

hypothesis that severe acne, regardless of

exposure to isotretinoin, carries an increased risk of

attempted suicide.... A physician would thus need

to start treatments in more than 2000 new patients

during one year to see one additional suicide

attempt (note, ‘attempt’, not completed suicide)

due to treatment. Nevertheless, the most important

proactive measure to be taken would be to closely

monitor all patients’ psychiatric status, not only

during treatment but also for at least a year after

treatment with isotretinoin.’

In other words, as far as we can tell, acne is

associated with increased levels of depression and

self harm, and oral isotretinoin apparently causes a

tiny increase in self harm events, with a number

needed to harm (NNH) of over 2,000. Helpful to

have a nice round-and reassuring-figure like this to

hand when counseling severe acne patients about

risk and benefits. But do read the whole study and

editorial. Nice bit of work.

Season’s Greetings from Dr Snippit

1. BMJ 30th October 2010 volume 341 page 938

2. http://www.dailymail.co.uk/health/article-1329078/Father-4-cancer-sues-NHS-doctor-dismisses-mole-insect-bite.html#ixzz15GwtDQvi

3. http://www.bmj.com/content/341/bmj.c5866.full?sid=cec75596-1d87-4f29-8fd3-c4a352a8d925

4. http://www.bmj.com/content/341/bmj.c5812.full

September – November 2010

So, the baking days of summer have

been replaced with the mists and

mellow fruitfulness of autumn –

without the inconvenience of all that

baking, of course...As the nights grow

longer, what could be better than

curling up with a few juicy journals?

An unexpected side effect of the

demonization (rightly so, IMHO) of

sunbeds is that the permatanned are

constantly looking for new ways to keep

up that all year round glow of...’health’.

Synthetic analogues of melanocyte

stimulating hormone – so called

melanogenic peptides – have recently

become available1. However, despite

these products still being under test by

the regulatory authorities, for it seems

likely they may have therapeutic

applications, they are already widely

available on the t’interweb, in tanning

salons and in some gyms. They are

self-administered by sub-cutaneous

injection. This is obviously not an ideal

situation. Not only are these products of

unregulated purity and potency, they also

have sometimes unexpected effects on

pre-existing melanocytic naevi, or even

cause new naevi to erupt. In addition, the

risks of blood borne virus transmission

from shared or dirty needles doesn’t go

away if the drugs are ‘tanning products’.

Another of the series of evidence based updates comes next, this time on atopic

eczema2. It would appear that research into eczema is alive and well – 260

randomised controlled trials have been conducted in the past 10 years. Evidence

was presented of the risks of oral corticosteroids in severe flares of eczema, the

efficacy of pro-biotics in the prevention of eczema (only if given to mothers in the

last trimester of pregnancy!), the confusion surrounding allergy testing (no

concensus has been reached) and the benefits of structured educational

programmes for both sufferers and carers. This is a ‘hot topic’ at the moment and

our German friends seem to be leading the way with this particular intervention.

The PCDS has a meeting, next May, in Berlin, and one of our speakers will be

detailing the German experience.

It has long been my belief that dermatology has taken over the mantle of the last

true general hospital speciality. If any further evidence is required, consider the

example of psoriasis3. We are increasingly being asked to look upon psoriasis as a

multi-system disease that just happens to have a primary cutaneous manifestation.

From America comes evidence that psoriasis carries with it an increased risk of

cardiovascular death – this is not unsurprising, chronic inflammation has been long

known to cause this. What is surprising is that psoriasis also carries an increased

risk of mortality from kidney disease, infection and dementia. Whether this is a

consequence of the disease or the treatments for the disease remains unclear.

Lichen sclerosus is a relatively common, autoimmune, inflammatory dermatosis. It

has a predilection for the genital skin of both sexes, but also can affect the

extra-genital skin. Rather oddly, it has a bi-modal distribution in both sexes too,

affecting pre-pubertal and post menopausal girls and women, but also young boys

and adult men. A biopsy is often necessary to make the formal diagnosis,

particularly on extra-genital skin where it can be hard to distinguish it from

morphoea. A timely set of guidelines4 (there seem to be some of these every

quarter...) have been produced to guide treatment and longer term care. Topical

steroids remain the mainstay of therapy, although other treatments are gaining

credence – particularly tacrolimus. The fear, as always, is that lichen sclerosus can

progress to squamous cell carcinoma – the risk, however, appears small – less than

Journal Watch

5%. Secondary care follow up is recommended for patients who have continuing

symptoms despite adequate treatment, previous SCCs, those who have treatment

unresponsive disease and those patients who present with atypical forms of the

disease. Follow up is deemed unnecessary for patients who use less than 60g of a

superpotent topical steroid in a 12 month period for symptom control.

Onto another troubling disease, but this time with a more public expression...

rosacea. Whilst some diseases – take another bow, psoriasis – have had their

impact analysed and quantified, others have had less time spent on them5. The

DLQI is the most widely used tool to define impact on quality of life, rosacea can

be shown to have a moderate impact on quality of life. The DLQI can also be used

to look at the impact of interventions, we can thus say that, because of their

relative efficacy compared to other therapeutic agents, topical metronidazole, oral

tetracyclines and oral isotretinoin have a positive life quality effect. Nice to know,

isn’t it?

Personally speaking, I always find it helpful to have another bit of evidence to beat

smokers over the head with so I am eternally grateful to Meding et al6.

What-do-you-know, smoking increases the severity of hand eczema and it has a

dose response relationship! So, if you have hand eczema, and you smoke – the

more you smoke, the worse the eczema is likely to be. The authors mention

possible confounding factors, I will choose to ignore these for the time being.

There has recently been an unaccustomed outbreak of common sense with the

shelving of the plans for generic substitution in pharmacies. One of the greatest

concerns revolved around the substitution of emollients. Aqueous cream is,

currently, the cheapest emollient cream but its use as a leave on emollient has

long been questioned. This study7 shows why. The application of aqueous cream

to normal skin resulted in a reduction in thickness of the stratum corneum, and

increased transepidermal water loss – implying a marked reduction in the barrier

function of healthy skin. This obviously calls in to question the propriety of using it

as a leave on emollient on already compromised skin.

Just when you thought it was safe to venture outside again – after all, we have all

taken on-board the SunSmart advice, haven’t we? – we now have to fear the

effects of sub-erythemal UV exposure8. Thankfully, this is a review article and

doesn’t suggest living in a cave, but the evidence is accumulating that even

avoiding sunburn doesn’t necessarily prevent photo-damage to skin. Helpfully, we

are advised that, taking a lunchtime meal, outside, in Paris, in June will result in a

skin exposure of 50% of the minimal erythema dose to exposed skin. I feel more

research in to this is essential and I propose to put myself forward as a suitable

test subject.

In the UK, however, we appear to have taken on-board the sun-protection issue to

such an extent that we are in danger of heading the other way – into sub-optimal

levels of exposure. Admittedly, using an experimental population from Manchester

may skew the results somewhat, but in this study9, only by the end of summer

can optimal levels of Vitamin D be detected in the blood – even then, many

subjects never reached this level. It is just this level that is necessary to maintain

us through the long winter months. Currently, the majority of the population, it

would seem, becomes vitamin D deficient during the dark half of the year. We

have already discussed in a previous issue that supplementation of the diet is the

most viable option to correct this – this paper provides more evidence for this.

So now we’re all feeling relaxed, it’s time

to talk about stress10. Stress affects many

diseases, and its effects on psoriasis are

well documented. Evidence is here

presented to suggest that this is, indeed,

more than skin deep. Stress, particularly

moments of high stress affect circulating

cortisol levels and it is this that influences

disease outcomes in patients with

psoriasis. It is also suggested that chronic

stress creates a ‘psycho-physiological

state’ of persistently lowered cortisol

levels and it is this that leads to the

deleterious effects of new stressors on

the skin.

Experimental data is often subject to

confounding factors that can muddy the

conclusions somewhat. In particular, the

effects of treatment on chronic diseases

can be particularly confusing. For example,

the incidence of cancer in patients with

atopic dermatitis exceeds that of the

general population11. Specific subtypes of

cancer, such as lymphoma, are also

over-represented within this population.

These are not just cutaneous cancers –

more evidence of the systemic nature of

many of ‘our’ diseases. So, does the

chronic stimulation of the immune system

lead to these neoplasms developing, or is

it the effects of immunosuppressive

treatments? Further research is needed…

For our final paper, we return to ultraviolet

radiation. We’ve had damage and

deficiency, so it only seems fair to show a

beneficial side to this part of the

electromagnetic spectrum. UVB, and in

particular, narrow band UV has become a

standard therapy in the treatment of

psoriasis. There is, however, significant

individual variation in both the number of

treatments necessary to achieve

remission and also in the duration of that

remission12. There are clinical predictors of

early success – milder disease, female

gender, lower body weight and a higher

prior exposure to therapeutic UVB. Only

one factor seemed to predict length of

remission – the more treatments needed

18 19

In patients with severe chronic hand eczema:With Toctino 30mg used for 12–24 weeks:

Clear/almost clear hands in nearly half of patients1

Improvement in 4 out of 5 patients2

Effective treatment of both hyperkeratotic and inflammatory symptoms1

Two thirds of patients remain in remission 6 months after achieving clear/almost clear hands3

Simple once daily oral dose and minimal monitoring4

PRESCRIBING INFORMATION: TOCTINO® (ALITRETINOIN) 10mg OR 30mg CAPSULES. Before prescribing Toctino please refer to the full Summary of Product Characteristics. Name of the medicinal product: Toctino (alitretinoin) 10mg or 30mg Capsules. Non proprietary name: Alitretinoin. Presentation: Soft capsules containing 10mg or 30mg of alitretinoin. Indication: Severe chronic hand eczema in adults that is unresponsive to treatment with potent topical corticosteroids. Predominantly hyperkeratotic features are more likely to respond to treatment than pompholyx. Dosage and administration: Toctino should only be prescribed by dermatologists or physicians with experience in the use of systemic retinoid therapy. The recommended dose range is 10-30mg once daily, to be taken orally with a meal. The recommended starting dose is 30mg once daily. A dose reduction to 10mg once daily may be considered in patients with unacceptable adverse reactions to the higher dose. “High risk” patients with diabetes, obesity, cardiovascular risk factors or lipid metabolism disorders should be initiated on 10mg once daily and titrated up to 30mg once daily if necessary. A treatment course can be given for 12 to 24 weeks depending on response. In the event of relapse, patients may benefit from further treatment courses. Prescriptions for women of childbearing potential should be limited to 30 days and dispensed within 7 days of the prescription in accordance with the Pregnancy Prevention Programme.Contraindications:

If pregnancy occurs, Toctino should be stopped immediately and the patient referred to a physician specialising or experienced in teratology for advice. Toctino

is contraindicated during breastfeeding. Toctino is contraindicated in patients with hepatic insufficiency, severe renal insufficiency, uncontrolled hypercholesterolaemia, hypertriglyceridaemia, hypothyroidism, hypervitaminosis A, hypersensitivity to alitretinoin, other retinoids or excipients, allergy to peanut or soya, hereditary fructose intolerance and concomitant tetracycline treatment. Precautions and warnings: Not recommended in patients under 18 years of age. Male fertility may be compromised. Patients should be reminded not to share medication or donate blood during therapy or for 1 month following therapy with Toctino. Psychiatric disorders have been seen with other retinoids, therefore particular care should be taken in patients with a history of depression. Patients should be observed for signs of depression and referred for appropriate treatment if necessary. Effects of UV light may be enhanced and patients should avoid excessive exposure to sunlight, unsupervised use of sun lamps and should use appropriate sun protection of at least SPF 15. Patients experiencing visual difficulties should be referred to an ophthalmologist and treatment discontinuation may be required. Decreased night vision has been reported and patients should be warned asymptoms of benign intracranial hypertension including headache, nausea and vomiting, visual disturbances and papilloedema should discontinue treatment immediately. Serum cholesterol and triglycerides should be monitored. Treatment should be discontinued if hypertriglyceridaemia cannot be controlled at an acceptable level or if symptoms of pancreatitis occur. In “high risk” patients with diabetes, obesity, cardiovascular risk factors or lipid metabolism disorders, more frequent serum lipid checks may be necessary. Dose reduction or discontinuation should be considered in the event of persistent clinically relevant elevation of liver transaminases. If severe diarrhoea is observed, diagnosis of inflammatory bowel disease should be considered and treatment discontinued immediately. Severe allergic reactions necessitate interruption of therapy and careful monitoring. Please refer to the Toctino Summary of Product Characteristics for further details. Interactions: Concomitant use of St John’s Wort may cause failure of combined hormonal contraceptives. Concomitant use of vitamin A or other retinoids may cause hypervitaminosis A. Concomitant use of tetracyclines may increase the risk of

benign intracranial hypertension. Common adverse effects: Very common (≥10%): headache, hypertriglyceridaemia, hypercholesterolaemia, decreased HDL. Common (≥1%; <10%): anaemia, increased iron binding capacity, decreased monocytes, increased thrombocytes, decreased TSH, decreased free T4, conjunctivitis, dry eyes, eye irritation, flushing, increased liver transaminases, dry skin and lips, cheilitis, eczema, dermatitis, erythema, alopecia, arthralgia, myalgia, increased blood creatine phosphokinase. Serious adverse effects: Uncommon (≥ 0.1%; <1%): blurred vision, cataract, epistaxis, ankylosing spondylitis. Rare (≥0.01; <0.1%): benign intracranial hypertension, vasculitis. Overdose: reversible adverse effects consistent with retinoid toxicity, including severe headache, diarrhoea, facial flushing and hypertriglyceridaemia. Please refer to the Toctino Summary of Product Characteristics for full details of adverse effects with Toctino. Storage instructions: Store in original packaging and protect from light. Marketing authorisation number and NHS List Price: PL32205/0001/0001 Toctino 10mg 30 capsule pack £411.43; PL32205/0001/0002 Toctino 30mg 30 capsule pack £411.43 Legal Category: POM. Name and address of authorisation holder: Basilea Medical Ltd., 14/16 Frederick Sanger Road, The Surrey Research Park, Guildford, Surrey, GU2 7YD. Toctino® is a registered trademark of Basilea Pharmaceuticals International AG. Date of preparation of prescribing information: August 2008. ALI080051 recertified Oct 2010.

Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk. Adverse events should also be reported to Basilea Pharmaceuticals on 01483 790023.

Pregnancy is an absolute contraindication to treatment with Toctino. Use during pregnancy or in women of childbearing potential is contraindicated unless all conditions of Pregnancy Prevention Programme are met. If pregnancy does occur in spite of the pregnancy prevention precautions during treatment with Toctino or in the month following discontinuation of therapy, there is a high risk of very severe and serious malformation of the foetus. Please refer to the Toctino Summary of Product Characteristics for further details.

References: 1. Ruzicka T et al. Efficacy and safety of oral alitretinoin (9-cis retinoic acid) in patients with severe chronic hand eczema refractory to topical corticosteroids: results of a randomised, double blind, placebo-controlled, multicentre trial. Br J Dermatol 2008; 158(4): 808-817. 2. Data on file ALI100031, July 2010. 3. Ruzicka T et al. Re-treatment study of alitretinoin (9-cis-retinoic acid) in severe chronic hand eczema refractory to topical treatment. Poster 280 presented at EADV 2007. 4. Toctino SPC accessed on the EMC www.medicines.org.uk/emc/.

ALI100115 Oct 2010

20

I am writing this during the falling of the first snows of Autumn! So

much for global warming. It is also in the midst of the debacle of the

football referees withdrawing their services. I can’t remember the

last time we had such a plethora of good strikers in Scottish football.

It was good to see so many of you at the Radisson Blu in Edinburgh.

I hope you all enjoyed it and that all the bruises on arms etc have

disappeared. The report of the meeting and another on the

dermoscopy workshop are elsewhere in the bulletin so I shall not expand further except

to say that I hope as many of you if not more can come next year to the Westerwood

Hotel in 2011.

I mentioned in the last bulletin that I would like to set up a database of dermatology

educational meetings etc in Scotland so that doctors can tap into it to see if there is

anything local to them for CPD points etc. I have had no response yet – so please let me

know of anything, dermatology wise, happening in your area so that we can spread the

word. It’s good to talk! My niece is in South America at present and has been told that

the latest chat up line in Chilean clubs is “your place or mine?” – that’s a new one…

In my part of the world, we are trying to set up some interactive educational evenings in

the CHP to look at patient pathways in dermatology and orthopaedics, so if anyone in

NW Glasgow CHP area wishes to know if and when they are happening, please send me

an email at iain.henderson@ntlwotld.com.

Also in the CHP area we are possibly piloting an integrated care program for psoriasis

patients including the annual review mentioned in the new SIGN guidelines – watch this

space. I have also had talks with Martin Whitehead, the Oncology Policy Manager of

Bristol Myers Squibb about setting up a Melanoma Taskforce in Scotland along similar

arrangements as to the one already set up in England. If anyone has a burning desire to

be involved once again email me and I will pass your details on to them.

I attended the PSALV (Psoriatic Arthritis Patient Group) dinner in Holyrood on 17th

November which included presentations on the new SIGN guidelines. The GP annual

review for psoriasis patients was once again mentioned and being the only person there

admitting to be a GP I was asked to comment. I pointed out that it will only appear on

our radar if it is included in QoF payments. The MSP at our Table had not heard of these

and made a note to find out more. I also heard the 2 sides of the alcohol debate from an

SNP and Labour MSP which proved interesting. The main argument against was that at

45p a unit it was a tax on the poor and if it was 80p there would have been more of a

debate. The pub next to my surgery has changed its name to Moderation ,so when I ask

my patients about their drinking habits they now all tell me they drink in ………………

That’s all for now. Have a Merry Christmas and a Happy New year.

Iain Henderson

News From North ofthe Border

to achieve clearance meant a

shorter duration of remission. Life’s

hard sometimes. There were also

genetic indicators also, but these

will be harder to determine in a

clinical setting – most people, in my

experience, do not know if they are

homozygous for the C-allele of the

Taq1 VDR polymorphism. If only

people knew themselves better.

Julian Peace

References1. Langan, Nie and Rhodes - Melanotropicpeptides: more than just ‘Barbie drugs’ and‘sun-tan jabs’? BJD2010:163;451-455.

2. Flohr and Powell - Eczema: an EvidenceBased Update. Report from the 9thNottingham Evidence Based Update Meeting,13 May 2010, Loughborough, U.K.BJD2010:163;456-457.

3. Abuabara et al – Cause Specific Mortality inpatients with severe psoriasis – a populationbased cohort study in the UK.BJD2010:163;586-592.

4. Neill et al – BAD guidelines for themanagement of lichen sclerosus 2010-10-31BJD2010:163;672-682.

5. Aksoy et al – The impact of rosacea onquality of life: effects of demographic andclinical characteristics and various treatmentmodalities.BJD2010:163;719-725.

6. Meding at al – Tobacco smoking and handeczema: a population based study.BJD2010:163;752-756.

7. Tsang and Guy - Effect of Aqueous CreamBP on human stratum corneum in vivo.BJD2010:163;954-958.

8. Seite et al - Photodamage to human skin bysuberythemal exposure to solar ultravioletradiation can be attenuated by sunscreens: areviewBJD2010:163;903-914.

9. Webb et al - The role of sunlight exposure indetermining the vitamin D status of the U.K.white adult population.BJD2010:163;1050-1055.

10. Evers et al - How stress gets under theskin: cortisol and stress reactivity in psoriasis.BJD2010:163;986-991.

11. Arana et al - Incidence of cancer in thegeneral population and in patients with orwithout atopic dermatitis in the U.K.BJD2010:163;1036-1043.

12. Ryan et al - Clinical and genetic predictorsof response to narrowband ultraviolet B for thetreatment of chronic plaque psoriasis.BJD2010:163;1056-1063.