PCDS Bulletin May 2007 - Primary Care Dermatology Society

Forthcoming Meetings
18 June 2007
Essential Acute Dermatology for
General Physicians & GPs
RSM, London
Contact: [email protected]
18 - 21 May 2007
British Association of Skin
Camouflage - Training Day
Contact: [email protected]
COMMITTEE
ELECTION AND
ANNUAL GENERAL
MEETING
Just a reminder to those of you who
haven’t already booked a place - the
AGM is being held in Bristol on 9th and
10th June.
It is also your opportunity to vote
for a new committee or even perhaps
stand for election. The Society needs
new and fresh minds to take us forward
and we therefore ask that you consider
whether you could give the Society
some of your valuable time and
expertise for the coming years.
Get your form back to Carol in the
PCDS Secretariat office to
be sure of a place.
Stephen Kownacki
Chairman PCDS
19 - 20 May 2007
PCDS Skin Surgery Meeting
Durham Marriott
Contact: [email protected]
4-7 July 2007
BAD
Birmingham
Contact: [email protected]
20 May 2007
Walk for Skin 2007
Southampton, Cardiff, Cheddar,
Manchester, Windsor, London &
Birmingham
Contact: [email protected] or
www.walkforskin.org.uk
31August – 3 September 2007
British Association of Skin
Camouflage - Training Day
Contact: [email protected]
28 September 2007
PCDS South & East Meeting
King’s Fund, London
Contact: [email protected]
9 June 2007
PCDS Dermoscopy Workshop
Bristol
Contact: [email protected]
9 - 10 June 2007
PCDS South & West and AGM
Bristol
Contact: [email protected]
I probably shouldn’t
mention it…
but I don’t like the
look of that mole”
Cartoon by S J Russell
– PRIVATE EYE issue 1173, p.18
29 September 2007
PCDS Basic Dermatology Day
RCP, London
Contact: [email protected]
2-3 November 2007
PCDS Skin Surgery Meeting
Litchdon Medical Centre, Barnstaple
Contact: [email protected]
10 - 11 November 2007
PCDS Scottish Meeting
Carnoustie, near Dundee
Contact: [email protected]
PCDS Gable House, 40 High Street, Rickmansworth, Herts WD3 1ER
T01923 711678 F 01923 778131 [email protected] www.pcds.org.uk
Company 5254647 VAT 875 1544 06
MAY 07
Misdiagnosing
the three common
red scaly rashes
STE P H E N HAYE S
czema/dermatitis, psoriasis and tinea are easily diagnosed
when present in ‘typical’ forms, but variants of these common
rashes abound, foxing even the experts at times. This is a précis
of a talk I gave recently in Southampton about diagnostic pointers
and pitfalls from my practice. There is some statement of the
obvious, no apology for this as first principles and awareness of
common pitfalls can increase our diagnostic accuracy.
E
Listen to the patient, she is
telling you the diagnosis
Something I like about dermatology is that old
fashioned medical knowledge and skill can often get
us where we want to go without special tests. Beware
the tendency to skip the history and go straight to the
rash, hoping for a spot diagnosis. Wrong! It’s just as
important to take a proper history first for skin as for
chest or gut problems, if not more so.
History - diagnostic pointers
Atopic eczema is itchy, often starts in infancy, and
may run in the family along with hay fever and
asthma. Various forms of eczema (discoid, asteatotic,
allergic and irritant) can occur at any age, but are
always itchy. Contact
dermatitis,
whether
allergic or irritant, is
likely to come with a
history, like the lady in
my surgery recently
whose facial dermatitis
began when she applied
a ‘hypoallergenic’ face cream’ (Fig 1). I was amazed
to read it contained benzoate, acrylate, parabens,
various plant extracts and plankton! I would call that
hyperallergenic!
Psoriasis is uncommon before puberty, may have
a family history and usually doesn’t itch. Fungal
infections can start at any age and often give a history
of starting in one place and spreading out with a
leading edge and central clearing.
Look carefully - with a lens!
Having taken a history you may view the rash.
Where possible, have the patient strip to underwear
for a clear view of the whole rash (and take a sneaky
peek for hidden skin cancers on the back, especially in
Continued on page 4
THIS ISSUE...
Editorial
page 3
Red scaly rashes
page 4
Clinical Update
Manchester 07
report
page 6
Getting under
the skin of
Psoriasis
page 8
FIG 1
North &
Midlands report Liverpool 07
page 12
New DH
guidance
page 15
PCDS bursary
page 15
E D ITO R IAL - STE P H E N HAYE S
IN ACNE TREATMENT
T
he second last day of March was
pleasantly warm in southern
Hampshire and I planted out nine
standard apple trees. These were rare
old varieties (Cornish Gillyflower,
Adam’s Pearmain, Court Pendu Plat
etc).* I had grafted them on to large
growing rootstocks several years
Tetralysal 300 is proven as effective as Minocycline2
• Cost saving of 33%1
• Recommended over minocycline based on
side effect profiles by European acne experts3
• Recommended for first line treatment of
LYM/16/0307d
acne by Prodigy4
PRESCRIBING INFORMATION
Tetralysal 300 Presentation: Capsule containing lymecycline 408mg
(equivalent to 300mg tetracycline base). Indications: Acne and treatment
of infections caused by tetracycline-sensitive organisms. Dosage and
administration: Adults – One capsule daily for at least 8 weeks for the
treatment of acne. For other infections, usual dose is 1 capsule b.d. Not
recommended for use in children. Contra-indications: Renal insufficiency.
Hypersensitivity. Children under 12 years. Pregnancy and lactation. Warnings
and precautions: Prolonged use of broad spectrum antibiotics may result
in the appearance of resistant organisms and superinfection. Exercise care in
hepatic impairment. Tetracyclines may rarely cause photosensitivity. May cause
exacerbation of systemic lupus erythematosus. Can cause weak neuromuscular
blockade so use with caution in Myasthenia Gravis. Interactions: The absorption
of tetracyclines may be affected by the simultaneous administration of calcium,
aluminium, magnesium, bismuth and zinc salts, antacids, bismuth containing ulcerhealing drugs, iron preparations and quinapril. These products should not be taken
within two hours before or after taking Tetralysal 300. Absorption of Tetralysal 300
is not significantly impaired by moderate amounts of milk. Concomitant use of oral
retinoids may increase the risk of benign intracranial hypertension. Tetracyclines
may increase the effects of anticoagulants. Concomitant use of diuretics should be
avoided. Concurrent use of tetracyclines and oral contraceptives has been associated
with a few cases of pregnancy or breakthrough bleeding (not reported for Tetralysal 300).
Undesirable effects: Rarely anaphylaxis & dysphagia. Nausea, vomiting,
diarrhoea. A few cases of oesophagitis, oesophageal ulceration and pancreatitis
Reducing the cost of effective acne treatment
have been reported. Overgrowth of nonsusceptible organisms may cause
candidiasis, pseudomembranous colitis (Clostridium difficile overgrowth),
glossitis, stomatitis, vaginitis, or staphylococcal enterocolitis. Transient
increases in liver function tests, hepatitis, jaundice and hepatic failure have
been reported rarely. Bulging fontanelles in infants and benign intracranial
hypertension in juveniles and adults have been reported. Presenting
features were headache and visual disturbances including blurring of vision,
scotomata and diplopia. Permanent visual loss has been reported. Skin
rashes, photosensitivity, erythematous, and maculo-papular rashes, pruritis,
bullous dermatoses, exfoliative dermatitis. Teeth discoloration – usually only
obvious after repeated doses. MA Number: PL 10590/0019. Package
quantities and cost: Available in packs of 28 capsules £7.16
and 56 capsules £14.26. Legal category: POM. Full prescribing information
is available from: Galderma (UK) Ltd, Meridien House, 69-71 Clarendon Road,
Watford WD17 1DS. Telephone: 01923 208950. Fax: 01923 208999.
Date of revison: May 2006. References: 1.
MIMS March 2007.
56 capsule packs. 2. Bossuyt L et al. Lymecycline in the treatment
of acne: an efficacious, safe and cost-effective alternative to minocycline.
Eur J Dermatol 2003; 13:130-5. 3. Dreno B
et al. European recommendations on the use
of oral antibiotics for acne. Eur J Dermatol
2004; 14: 391-9. 4. www.prodigy.nhs.uk
Date of preparation: March 2007
ago, hoping to use them to plant
community orchards. Of course, this
‘good idea’ never got off the ground
as I was too busy, nobody was very
interested and perhaps it wasn’t such
a good idea anyway. The trees were
overcrowded in their nursery and
nearby fast growing poplars in our
orchard shelter belt were blocking
out the light. The trees had run out of
time, and had to be planted out by the
spring or dug up and destroyed.
Ideally my wife would have helped me (as
the great English apple expert Lawrence Hills
wrote ‘it takes two to plant a tree, and they
should take their time over it, for they cannot
have anything more important to do with the
time saved by haste’) but she was too busy
redecorating the newly spare bedroom for an
imminent guest, so I planted the trees alone.
I planted them into a neglected, scrubby
part of our smallholding. I should have cleared
the land of nettles, couch grass and other weeds
and ploughed it last winter, but never got round
to it. I gave the trees a double handful of
compost and a gallon of water each and hacked
down some weeds. I would have sprayed
weedkiller but it was too windy, I’ll try to find
time later.
And what, dear reader, does the above have
to do with the PCDS and/or UK dermatology? It
struck me as a parallel with the current rolling
out of multiple untested reforms which are well
intentioned but badly timed and causing
potential conflicts of interest. Locally, reflecting
the national scene, we have private sector
involvement, practice based commissioning, the
NICE skin cancer guidance, imminent new
guidance for GPwSIs, ‘musical desks’ at the PCT
as managers dance in circles to the tune of the
mad pipers of Westminster, and doubts about
secure funding and support of the all-important
hospital dermatology team.
Some of the ideas being implemented might
on paper deliver improvements, given good care
and good luck (which is what my trees need) but
‘ideally we wouldn’t be starting from here’. But
as with my imperfectly planted apple trees, we
ARE starting from here. We must use our hearts,
brains and relationships to make the best of it
for our patients. We’re GPs - that’s what we do!
Your Society goes from strength to strength
and is running more conferences in 2007 than
any previous year. We aim to be, perhaps
already are, the number one UK provider of
dermatology education for GPs, and also to
honestly represent our patients’ and our
colleagues’ needs during times of sometimes
chaotic and questionably managed change. Our
membership has passed 850, I would like to see
it pass 1,000 by our 2008 AGM. May I strongly
encourage every member to come to one
conference this year. These are excellent
opportunities to meet like-minded colleagues
and hear expert speakers on relevant subjects.
Hope to see you at the AGM in Bristol
in June.
The society would like to
acknowledge support
from the following
members of the corporate
membership scheme.
Kindest regards,
Stephen Hayes
Editor
*www.fruitwise.net
Consult the Summary of Product Characteristics before prescribing. Information about adverse event
reporting can be found at www.yellowcard.gov.uk. Adverse events should also be reported to Galderma (UK) Ltd.
3
Misdiagnosing the thre e common
red scaly rashes
Continued from page 1
FIG 2 - ANKLE ECZEMA
MISDIAGNOSED AS CELLULITIS
FIG 3 - GRANULOMA ANNULARE
MISDIAGNOSED AS FUNGAL
FIG 4 - HAND FUNGUS
FIG 5 - PSORIASIS
MISDIAGNOSED AS FUNGUS
FIG 6 - FLEXURAL PSORIASIS
4
sun damaged patients.) Vesicles are a useful sign of eczema, they may be tiny
and are often missed unless looked for in a good light with a lens. Sterile
pustules which fade to brown macules occur in palmo plantar psoriasis but
clear fluid filled vesicles point strongly to eczema. Vesicles were visible in this
very angry discoid type eczema, (Fig 2) which had failed to respond to 3
courses of oral antibiotics after being misdiagnosed as cellulitis. It cleared
completely with a week of potent steroid.
Excoriations are typical in eczema - they are caused by scratching.
Lichenification, a thickening of the skin creases, is caused by chronic
rubbing. Both are caused by the itch of severe eczema and are notably absent
in psoriasis and fungus. If treatment has been applied, the redness, scale and
vesicles may go but the lichenification will fade last.
Annular lesions often lead to a ‘spot diagnosis’ of ringworm. Colleagues
often send me ringworm that won’t respond to antifungal - usually because
it’s granuloma annulare (GA) (Fig 3). I point out in my clinic letter that GA
is a dermal process, so is never scaly, whereas tinea is epidermal, so produces
scale. GA also doesn’t itch and tends to be indolent, while fungus often
advances rapidly and itches. The illustrated case was referred after failing to
respond to oral terbinafine. All that rings isn’t ringworm, and ringworm
doesn’t always ring!
Think about scale
Always look for presence or absence of scale, note how much, how big,
and how well organised. Hand fungus (Fig 4) often has very fine scale in the
skin creases on a background of red, with no vesicles. This case was
misdiagnosed and treated as eczema which made it worse - mycology grew
trichophyton rubrum and the patient was quickly cured with oral terbinafine.
This rash on the ankle (Fig 5) with large well organised scale on a deep
red background was confirmed as psoriasis by my consultant mentor, who
commented on how much foot psoriasis he saw misdiagnosed as fungus. It
responded to calcipotriol after failed antifungal treatment. On reflection, I
don’t know how I got this wrong - just goes to show how much we all need
CME, audit, and our senior colleagues.
Eczema scale is scanty as the fundamental eczematous process doesn’t
produce much scale and it’s mostly scratched off due to the itch, whereas
psoriasis produces superabundant scale which forms big flakes and sheets.
Emollients may remove scale (a useful treatment) but it doesn’t get
scratched off as in eczema and can be very thick.
An important exception to the above is flexural psoriasis, which gets
misdiagnosed a lot as it doesn’t look like psoriasis elsewhere. Flexural
psoriasis occurs in axillae, groin, natal cleft, umbilicus and wherever
opposing folds of skin touch, moisture collects and any scale tends to get
rubbed off. There may be fine scale at the edge if you look carefully. I’m often
asked ‘why isn’t this candidal intertrigo getting better with Nystatin?’ Answer
- because it’s flexural psoriasis. Diagnostic pointers are a well defined edge,
no pustules or satellite lesions, a history of psoriasis and psoriasis elsewhere.
Again, the ‘undress the whole patient’ manoeuvre pays off when the rash is
atypical at the presenting site but present in typical form elsewhere. (Fig 6)
This patient with a flexural rash under an apron fold had umbilical psoriasis
and subtle nail pitting which pointed to the diagnosis. She was better in a
week of medium strength steroid after failure to respond to imidazole.
Rashes in disguise
Animal ringworm, as in this horse acquired case (Fig 7), can be so
inflammed and pustular it is mistaken for staphylococcal infection. Ask
about animal contact and take specimens for mycology as well as ordinary
culture. Another common pitfall is putting steroid on a rash thinking it is
eczema only for the patient to come back worse a week later because the
rash was fungal. Steroid alters the immune response and the tinea goes wild
- tinea incognito. The patient may be fooled as the steroid relieves the itch,
but the rash spreads fast (Fig 8). This mistake is forgivable, but ALWAYS tell
the patient to come back if they aren’t better soon.
It can be easy to confuse scabies and eczema - classically, a child is given
hydrocortisone for his ‘eczema’ and returns in 2 weeks - it’s worse and now
his sister has it. Always think of scabies with new-onset ‘eczema’ in a child
and - you guessed, undress the whole patient! Scrotal nodules and burrows
between fingers or in the natal cleft may give the game away.
Primum non nocere!
As my old mate Hippocrates says, ‘first do no harm’. Oral antifungals are
great drugs, but have a range of potential side effects and interactions.
Fungus and psoriasis both affect nails, but so do other things. I saw a patient
whose GP was perplexed that his fungal toenails hadn’t improved despite 6
months of itraconazole. Turned out he was a semi-professional footballer,
careful examination showed ridged and tatty nails with subungual
haematomas. The problem was repeated minor trauma due to kicking. It is
wise to prove fungus mycologically before starting prolonged oral therapy it could be hard to defend prescribing an expensive and relatively toxic drug
which had no prospect of doing the patient any good due to the wrong
diagnosis (Fig 9).
Why you can’t always win
As my teacher Professor Eugene Healy (a very clever man) says “the genes
for eczema and psoriasis are widely distributed and there’s nothing to say
you can’t have both rashes in the same patient at the same time or different
times”. They may even intereract. This patient (Fig 10) shows typical
psoriasis (extensor surface, unscratched, clear border) and eczema (flexor
surface, poorly defined edge, excoriated) present at once.
This unilateral foot rash (Fig 11) was biopsied as I couldn’t decide between
eczema and psoriasis. The histopathologist couldn’t tell either, giving
‘eczematous psoriasis’ (or was it psoriasiform dermatitis?). Don’t worry, it
happens!
Misdiagnosis is very easy in dermatology; I hope the above
observations and tips may help colleagues avoid some of the
more common pitfalls with these three common rashes which
have so much clinical overlap.
FIG 7 - HORSE RINGWORM
FIG 8 TINEA INCOGNITO
FIG 9 - FOOTBALLER’S TOENAILS
FIG 10 - ECZEMA & PSORIASIS
SAME PATIENT
FIG 11 - PSORIASIFORM ECZEMA
5
CLINICAL
UPDATE
Meeting for non-consultant career grade
doctors held at the SAS Radisson
Manchester Airport on 8 - 9 March 2007
I
attended this meeting sponsored by LEO Pharma in March. It was well attended
with 134 delegates. The venue for the meeting at Manchester airport was easy to
get to and delegates came in roughly equal numbers by plane, train and own transport.
It was interesting to eat in a restaurant overlooking the runaway and watch planes
arriving and leaving the gates. The meeting started at 11.00am on the Thursday which
gave people time to travel that day.
The entrance lobby was on the third floor, connected to the airport terminal by a futuristic corridor, while the
meeting rooms were on the lower levels. Several delegates from Ireland and Scotland commented on the “smoke
fug” in the entrance lobby emanating from the bar which was right beside the check in desks. Already in both
these countries smoking in public places is banned. Roll on July 1st! The meeting was attended by a few PCDS
members but the vast majority were Staff Grades, non GP Clinical Assistants and Associate Specialists.
6
The meeting opened with Dr Robin
Graham Brown giving a review of
paediatric dermatology with a lot of
anecdotes from his own clinical experience
- a big topic to try to cover. He mentioned
that Malignant Melanoma occasionally
occurs in children under the age of ten. He
also said that in his experience Lichen
Planus in children was relatively common
and was often atypical. Dr Shernaz
Walton from Hull gave a review of Drug
Reactions. She described the different
mechanisms which can cause a reaction,
their clinical presentations and which
drugs can cause what type of reaction. She
reminded us that HIV causes a 100 fold
increase in the frequency of drug reactions.
After lunch Dr Chris Lovell gave an
entertaining and very informative talk
entitled “Something Lurking in the
Compost Heap” on the hazards to the skin
from plants. Common ivy (Hedera Helix) is
felt to be an under reported cause of
dermatitis. Tea tree oil has been linked to
several different types of dermatitis
including a bullous variety and there has
been provocation of linear IgA disease. Dr
Lovell recommended a CD produced
jointly by Kew and Guys
and St Thomas’ Hospital
entitled Poisonous Plants
and Fungi.
Dr Jane Sansom from Bristol gave a
very good summary on the causes,
investigations and treatment of the red
face as well as updating us on the patch
testing fragrance batteries.
After the tea break Dr Chris Dobson
from Preston talked about Dermatopathology. He covered the problems of
biopsying, the limitations of histology,
sampling errors, the way skin lesions evolve
and why an early biopsy is usually better, the
variability of certain stains and what to do
when there was a discrepancy between your
original diagnosis and the pathology report.
The day finished with Dr Ian Coulson
talking about “Fat and other Fascinomas”
- a neglected area of dermatology. He went
through the different types of fat disorders
in a logical and very helpful way.
The evening meal was taken in the
same room where the meeting had been
held after being rapidly transformed by the
hotel staff. There was no formal
entertainment after the meal on this
occasion and I recollected that last year we
had been unexpectedly serenaded by the
Three Waiters who had seemed to be
ordinary waiters and who burst into opera
after the meal.
The Friday morning started with a
discussion of the current political situation
from Dr Julia Schofield entitled
“Dermatology services: threats and
opportunities”. She gave an excellent
summing up of the unsettled state of
dermatology at the present time.
She was followed by the president of
the Royal College of Physicians, Professor
Next was Professor John McGrath
Ian Gilmore, who spoke on “Liver
Dysfunction, Drugs and the Skin”. He talked
about the variety of enzyme systems which
led to patients dealing with drugs differently.
He highlighted the importance of taking a
careful drug history, including over the counter
drugs, when dealing with a suspected drug
from St Johns, London talking on
Genodermatoses. He explained the
complex genetics of the commoner
genoderamotoses. He spoke on a variety of
other recent developments including
prenatal diagnosis for severe inherited skin
disease. He showed how the filaggrin
reaction. Usually the culprit drug has been
started in the previous 6 weeks.
After the coffee break Dr Richard
Parslaw from Liverpool talked about Leo’s
mutations found in Ichthysosis Vulgaris
has led to the revelation that filaggrin
mutations are a major factor in the
Psoriassist campaign and about prescribing
in dermatology especially as regards the
problems of topical treatments and how to
overcome steroid phobia. Dr Paul Yesudian
from Chester gave a very good summary of
the treatments used in Sarcoidosis, including
a list of unusual treatments which in some
cases had been found to be beneficial. He
said there has been no randomised control
trials for this condition at all.
After lunch Dr Diane Williamson, from
development of Atopic Dermatitis.
The meeting closed with a Question
and Answer session on SAS and NCCG
issues with Dr Sue Jackson and Dr Libby
Stewart answering questions on contracts
and the current negotiations which are
taking place.
This was a very comprehensive update
meeting. Congratulations to
the organising committee
of Dr Sue Jackson, Dr
North Wales gave a very comprehensive
lecture on “Difficult Leg Ulcers”. She
Glenda Hill and Dr Sue
Welsh.
Dr Elizabeth Ogden
covered this cinderella topic very well, with
many pointers as to diagnosis and treatment.
Poisonous Plants and Fungi
ISBN 190034792X 2nd edition 2002
7
Getting under the skin of…
A PCDS Ireland Educational Meeting. Kindly sponsored by an
educational grant from FOREST LABORATORIES, the makers of Exorex
Radisson SAS Hotel, Athlone. Saturday 26 November 2006
Athlone, County Westmeath, and capital of the Midlands was the location for the twelfth meeting of the Irish branch of the Primary
Care Dermatology Society. Athlone is situated on the Shannon, the longest river in the British Isles and the new Radisson Hotel on
the riverside was the venue of choice for the meeting. It is built on the site of the old Athlone Woollen Mills, which was destroyed
in a fire in the 1940s, and employed was Andrew McCormack, father of Athlone’s most famous son; the singer John McCormack.
T
he topic on this occasion was Psoriasis and things got off to an unusual
start with a presentation by a patient. Brian Donnelly is originally from
Co Tyrone but lives in Dublin and is a lecturer in English at University College
Dublin. Brian’s psoriasis, which he describes as ‘the affliction of the well’
began when he was a young boy, initially presenting on his knees and
elbows. He described how he felt ‘unclean’ and was preoccupied with
self-image. However his GP, whom he likened affectionately to Dr Finlay
of television fame, reassured him by scraping off some of Brian’s scales
and placing them on his own tongue! (We commend this doctor’s
empathy but cannot endorse the practice of tasting patient’s scales! Editor)
Brian’s psoriasis became more severe when he reached his 30s and he began
treatment at Hume Street Hospital, Dublin under the care of Dr Sarah Rogers who
continues as his Consultant. Brian’s initial treatment was with topical applications,
later moving to PUVA. However, on stopping this he developed erythroderma and
required a week’s treatment as an in-patient. Brian then started on cyclosporin
which he found very good until, after a number of years it stopped working.
For the past four years he has been on infliximab, a ‘biological’ which is
given as an intravenous infusion in a day ward once every eight
weeks. He felt that his psoriasis had impacted only minimally on
his life.
Stephen Kownacki is a GP in the
UK who has also worked for 20
years as a Clinical Assistant in
Dermatology at Northampton
8
General Hospital and spoke on the
Primary Care Management of Psoriasis.
The condition characterised by epidermal
hyperproliferation (every 10 days instead
of 6 weeks) causing thickened red scaly
patches, affects 2% of the population, the
incidence peaking in the third decade.
Early onset, (associated with HLA cw6) is
more severe than later onset (no HLA
association). In women it improves during
pregnancy and tends to get worse at the
menopause.
The most common presentation is
plaque psoriasis (90%) with sharply
demarcated salmon-pink lesions with
silvery scale affecting extensor surfaces,
sacrum and scalp. Treatment is topical,
including using emollients, calcipotriol/
betamethasone (Dovobet) and coal tar
(Exorex). Flexural psoriasis is smooth, red,
non scaling, in submammary, perineal and
axillary areas. It is more common in the
elderly and is well demarcated helping to
distinguish it from candida and eczema.
Treatment is again with emollients,
clobetasone (Eumovate) and calcitriol
(Silkis). The guttate variety (Latin: gutta a
drop) tends to affect the young, involves
trunk, upper arms and thighs and can be
associated with a streptococcal infection.
It often clears spontaneously but can be
treated with 1% coal tar (Exorex).
Recurrent attacks may warrant a
tonsillectomy. Psoriasis may also be
confined to the scalp; treatment is with
Cocois to remove the scales (wash out with
Fairy Liquid) and topical steroid +/calcipotriol. Psoriasis affecting the nails is
difficult to treat though calcipotriol
applied in the nail fold occasionally helps.
Because of its visibility, psoriasis often
affects patients more than other more
serious though less visible conditions, such
as heart disease. As ‘cure’ is not an option,
Dr Kownacki emphasised matching
treatment
to
individual
patient
Hume Street Hospital until its closure and
now at St Vincent’s Hospital. In her talk,
entitled ‘What’s New in Dermatology’, she
spoke first about her recent move to a new
department in St Vincent’s and about the
changed economic climate which
discouraged in-patient treatment (the
Celtic Tiger notwithstanding) except in
critical
situations
(erythroderma,
widespread pustular psoriasis and
unstable plaque psoriasis).
requirements, citing the case of a lady who
was concerned only by a small patch of
disease on her upper sternum and not by
extensive involvement of other less visible
areas of her body.
The second part of the meeting began
with a talk by Dr Sarah Rogers, Consultant
Dermatologist in Dublin, for many years at
She went on to discuss the newer
systemic
agents
beginning
with
methotrexate (MTX) which is administered
weekly by the patient. It can cause marrow
depression and hepatic fibrosis, this latter
aggravated by alcohol consumption so
regular monitoring is essential. Fumaric Acid
Continued over page
9
$ISCOVERTHE
PERSONBENEATH
Continued from page 9
s#LINICALLYPROVENTREATMENT
Esters (FAE) cause immunosuppression (monitor lymphocyte
count) but are not affected by alcohol. Azothioprine causes
hypertension and renal damage and is used mainly as a
rescue drug. An important advantage of these treatments
is that Psoriatic Arthropathy, occurring in up to 10% of
FORPSORIASIS
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10
meeting would not have been possible, were on hand at
registration and during coffee with informative displays. They
also sponsored the excellent lunch which followed the
meeting.
Dr Ronan O’Sullivan,
South Terrace Medical Centre, Cork, Ireland.
Á
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Infliximab has to be administered intravenously and can cause
anaphylaxis. Etanercept is given weekly subcutataneously, does
not cause anaphylaxis and can therefore be administered by the
patient as can Adalimumab (fortnightly). All of these are also
effective in the associated arthropathy. They are hugely expensive
and, as with the earlier drugs, resistance can develop; though this
can be delayed by the concomitant use of MTX. They can also
reactivate dormant TB necessitating pre-treatment screening.
!LOGICALFIRSTLINE
TREATMENT
FORPSORIASIS
Cases of SLE have been found in association with Infliximab and
there is a theoretical risk of lymphoma with these drugs.
The final speaker was Dr Johnny Loughnane, a GP from West
Limerick with a special interest in Dermatology. He presented a
series of case studies, inviting the delegates to choose from a list
of differential diagnoses including Bowen’s disease, seborrhoeac
dermatitis, Lichen (simplex and planus), pityriasis (rosea and
versicolor) and fungal infection. This lively presentation, which
included a discussion of problem cases, brought proceedings to
a close.
The meeting was chaired by Dr Hilda O’Shea, secretary of
PCDS Ireland. Representatives from the main sponsors FOREST
LABORATORIES and co-sponsors 3M Healthcare, LEO Pharma
and SCHWARZ PHARMA without whose generous help the
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cases is also benefited; however, efficacy wanes with
time as resistance develops.
The most recent development has been the
introduction of the biologicals which are
manufactured using recombinant technology.
PCDS North & Midlands Meeting
Friday 2 March 2007
Crowne Plaza Hotel, Liverpool
Liverpool
T
he meteorologists tell us that Spring begins on the 1st of March. So, on
a beautiful Spring day, the PCDS gathered on the banks of the Mersey
for an excellent day’s meeting. However, all was not immediately well.
Liverpool, currently a building site in preparation for becoming European City
of Culture in 2008, has a prolonged rush hour that meant several delegates
arrived rather later and more flustered than they had hoped to.
12
It is hoped that not too many missed
the opening act - Dr Mark Goodfield presenting a thought-provoking study on
the issue of compliance in dermatology
prescribing. We all know that compliance
can be patchy, but an overall figure of
around 69% of patients actually adhering
to their regime shows the scale of the
problem. The real eye-opener, however, is
that there is a negative correlation between
compliance and disease severity. We have a
lot of work to do to change these figures
for the better.
Dr Nick Craven then gave a
presentation based on his experiences of
Toxic Epidermal Necrolysis and StevensJohnson Syndrome. Whilst many of us are
unlikely to have to deal with such a
devastating condition - knowing that
there is someone who has the
experience and the enthusiasm to
help in such an eventuality is actually
rather reassuring!
The morning workshops were an
interesting mix - more than one
delegate was torn between the topics
on offer. Dr Christy Chou’s basic
skin surgery course was well received
and Dr Goodfield popped up again
to discuss difficult psoriasis. I attended Dr
Leslie Millard’s workshop on Body
Dysmorphic Disorder. I think we all see
cases of this and this presentation helped
me, at least, to feel slightly less at sea when
thinking about the issues concerned. It
would make an interesting full
presentation at a future meeting.
Immediately before lunch is not the
ideal slot to present, but Dr Colm
O’Mahony provided both a tour de force
and many delegates highlight of the
conference. His talk, on HIV and the skin,
was, in turn, erudite, amusing,
educational, entertaining and inspiring.
Both HIV and syphilis are easily detected
and, if caught early, are eminently
treatable (curable in the case of syphilis).
We have to get over the old reticence
about testing for these diseases - after all,
we routinely test for far worse conditions
without the recourse of extensive pre-test
counselling.
Lunch provided an opportunity for
gossip, perusing the pharmaceutical
stands and a bracing stroll on the banks of
the Mersey. I must say, I took the last
option and acquainted myself with the
‘Three Graces’ - the buildings that line the
Liverpool Pier Head. Suitably fed, watered
and refreshed the afternoon session kicked
off with Dr Niamh Leonard’s presentation
on ‘Making sense of histology reports’. In
recent years, reports have become longer
and longer. I’m sure I am not alone in
finding them increasingly impenetrable. Dr
Leonard helped to make sense of the
changes and also showed the importance
of the information provided. We, for our
part, need to provide as much information
as possible to help our pathology
colleagues out. Like so many things in life,
what you get out of a report depends on
what you put into the request form.
Next was the turn of Dr Anne Field
who managed to demystify the oral cavity her ‘Suspicious Oral Lesions’ was concise
and clear. The sections on pre-malignant
lesions and oral manifestations of systemic
disease were particularly illuminating.
Into the final straight - the second
round of workshops brought a Dr Chou
masterclass for the nimble fingered
surgeons wanting to extend their skills. Dr
Tom Poyner ran through current
thinking on acne treatments and Dr
Liz Ogden made everyone itch with a
workshop on infestations and
infections - I’ll treat my fish tank with
more respect in future now I know all
about fish tank granuloma…
The imminent Friday evening
rush hour caused the audience to
noticeably thin for the last
presentation of the day - this was a
shame because Dr Sue MacDonald
Hull gave an excellent talk on hair and
scalp problems - never an easy thing to
condense into 45 minutes and it is to her
credit that not only did she keep to time,
but also covered an awful lot of ground. I,
for one, will look into the treatment of
alopecia a little more deeply in future.
Many thanks to Dr Ogden for
arranging the course, to Carol and
Siobhan at PCDS headquarters for their
organisational skills and to Dr Jane
Rakowski for being an excellent
chairperson. All in all, an excellent day’s
education - the traffic wasn’t too bad on
the way home either!
Julian Peace
13
Launch of new DH guidance on 26 April
I
mplementing care closer to home - convenient
quality care for patients Parts 1-3 and National
Guidelines for the accreditation of GPwSIs:
In Part 3 commissioners are reminded of the definition of the
GP or PhwSI which emphasises the core generalist role of the GP
or pharmacist, their ability to provide a service beyond the scope
of the core role and the requirement to have demonstrated
appropriate skills and competencies to deliver services without
direct supervision. The document then outlines the steps required
to accredit a GP and PhwSI service with detailed information
about the accreditation panel and the process of accreditation.
At the same time, new guidance for the accreditation of
GPwSIs in dermatology will be launched (National Guidelines for
the accreditation of GPwSIs: Dermatology and skin surgery). This
replaces the 2003 guidance and is the first of the speciality specific
frameworks to be refreshed. This guidance has been developed in
parallel with Implementing care closer to home - convenient
quality care for patients Parts 1-3 and together the frameworks
should ensure quality care for patients with skin disease and those
requiring skin surgery. The link to this is:
http://www.pcc.nhs.uk/uploads/pwsis/gpwsis_dermatology.pdf
It is not clear yet whether the accreditation process will be
mandatory but it does seem likely. In response to a recent
parliamentary question Rosie Winterton responded ‘The
Department is currently considering options to mandate primary
care trust compliance with the guidelines.’
Clinicians and commissioners should make themselves familiar
with this suite of documents so that patients can be reassured
that, whoever the clinician and whatever the location of the
service, quality care is provided by competent accredited clinicians.
Julia Schofield,
Consultant Dermatologist
(member of DH PwSI Steering Group)
ENBREL– FOR MODERATE TO SEVERE
PLAQUE PSORIASIS
7
0
.
4
0
.
6
2
Dermatology and skin surgery
The 26 April saw the launch, by the Department of Health, of
new commissioning guidance for Primary Care Trusts (Implementing
care closer to home - convenient quality care for patients Parts 1-
3 http://www.pcc.nhs.uk/173.php) which seeks to set standards
for high quality patient care wherever the service is delivered.
The general public involved in the consultation process prior to
the publication of the 2006 White Paper (Our Health, Our Care,
Our Say: a New Direction for Community Services) made clear that
whilst ‘Care Closer to Home’ was a good idea, it must not be
delivered at the expense of quality of care. The Department of
Health has responded to this by publishing this new suite of
documents which includes details of accreditation processes for
Practitioners with a Special Interests(PwSIs).
Part 1 reminds commissioners that quality care close to home
can be provided by a whole range of health care professionals
provided that they demonstrate the correct competencies and sit
within tight clinical governance frameworks. This includes Hospital
Consultants, Non Consultant Care Grade (NCCG) doctors, GPs
and Pharmacists with a Special Interest, Specialist nurses, Health
care Scientists and other health care professionals.
Part 2 summarises the commissioning cycle in the context of
assessing needs, reviewing current service provision, deciding
priorities, designing services, shaping the structure of the supply,
managing the demand and ensuring appropriate access to care,
clinical decision making and managing performance. Patient and
public involvement in service development is emphasised as is
patient and public feedback once the service is in place.
Bursary
The committee has agreed to make a further limited sum available on a discretionary
basis to help more PCDS members to access dermatology education they would not
otherwise be able to receive.
The bursary, or bursaries, will be used to attend courses, diplomas or other
legitimate dermatological training/education activity which can be
expected to benefit skin patients in the community. Applicants should in
the first instance write to Carol Singleton at the PCDS Secretariat, Gable
House, 40 High Street, Rickmansworth, Herts WD3 1ER and include in no
more than 500 words what activity they wish to pursue, how much they wish
to apply for, how this will benefit patient care and why they wish the PCDS to
assist them. All replies will be treated in the strictest confidence.
15
Enbrel is now recommended by
NICE for the treatment of adults
with severe plaque psoriasis who
meet NICE guidance criteria1
HELPING YOU TO MAKE A DIFFERENCE
www.wyeth.co.uk
Full NICE guidance, ‘Etanercept and Efalizumab for the treatment of adults with psoriasis’ is available from www.nice.org.uk
ABBREVIATED PRESCRIBING INFORMATION. Before prescribing Enbrel®
please refer to full Summary of
Product Characteristics. Presentation: Enbrel Pre-filled Syringe: Enbrel 25 mg or 50 mg solution for injection
in a pre-filled syringe. Each pre-filled syringe contains either 25 mg or 50 mg etanercept. Enbrel Powder:
Enbrel 25 mg and 50 mg powder and solvent for solution for injection. Each vial contains either 25 mg or 50 mg
etanercept and each pre-filled syringe contains 1 ml water for injections. Enbrel Paediatric: Enbrel 25 mg/ml powder
and solvent for solution for injection for paediatric use. Each vial contains 25 mg etanercept and each pre-filled syringe
contains 1 ml bacteriostatic water for injections. Uses: Adults: Moderate to severe active rheumatoid arthritis (RA), in
combination with methotrexate, when response to DMARDS, including methotrexate (unless contraindicated), has
been inadequate. Enbrel can be given as monotherapy in the case of intolerance to methotrexate or when continued
treatment with methotrexate is inappropriate. Severe, active and progressive RA without prior methotrexate treatment.
Enbrel alone or with methotrexate has been shown to reduce the rate of progression of joint damage measured by X-ray
and to improve physical function. Patients with moderate to severe plaque psoriasis (PP) who failed to respond to,
or who have a contraindication to, or are intolerant to other systemic therapy including cyclosporine, methotrexate
or PUVA. Active and progressive psoriatic arthritis (PsA) when response to DMARDS has been inadequate. Enbrel
has been shown to improve physical function in PsA patients, and to reduce the progression rate of peripheral
joint damage as measured by X-ray in patients with polyarticular symmetrical subtypes of PsA. Severe active
ankylosing spondylitis (AS) when response to conventional therapy has been inadequate. Children aged 4-17 years
(25 mg only): Active polyarticular juvenile idiopathic arthritis (JIA) when inadequate response to, or intolerant
of methotrexate. Dosage: By subcutaneous injection. Adults: RA – 25 mg twice weekly or 50 mg once weekly.
PP - 25 mg twice weekly for up to 24 weeks, or 50 mg twice weekly for up to 12 weeks followed by 25 mg twice
weekly for a further 12 weeks if needed. Discontinue if no response after 12 weeks. For re-treatment: 25 mg
twice weekly for up to 24 weeks. AS and PsA – 25 mg twice weekly or 50 mg once weekly. Children aged 417 years: JIA in children aged 4-17 years – 0.4 mg/kg (maximum dose 25 mg) twice weekly with an interval of
3 – 4 days. Contra-indications: Hypersensitivity to any of the ingredients, sepsis or risk of sepsis, active infections.
Enbrel Paediatric: Must not be given to premature babies or neonates as the bacteriostatic water for injections
contains benzyl alcohol. Warnings and Precautions: Enbrel should be initiated and supervised by specialist
physicians experienced in the diagnosis and treatment of RA, PsA, AS or PP. Use carefully in patients predisposed
to, or with history of, infection due to underlying diseases other than RA (e.g. advanced or poorly controlled diabetes)
or with history of blood dyscrasias, pre-existing or predisposition to CNS demyelinating disease or congestive
heart failure. Concurrent administration of Enbrel and anakinra has been associated with increased risk of serious
infections and neutropenia, and is therefore not recommended. Whether treatment with Enbrel might influence
the development and course of malignancies and active and/or chronic infections is unknown, however with current
knowledge, a possible risk for the development of lymphomas or other malignancies in patients treated with a
TNF-antagonist cannot be excluded. Enbrel has not been studied in combination with other systemic therapies
or phototherapy for the treatment of psoriasis. Monitor closely if patient develops new infection during treatment.
Discontinue treatment if serious infection or allergic reaction develops or if blood dyscrasias are confirmed.
Discontinue temporarily if significantly exposed to varicella virus. Live vaccines should not be given concurrently
with Enbrel. Treatment with Enbrel may result in the formation of autoantibodies. Enbrel is not recommended for the
treatment of Wegener’s granulomatosis. JIA patients (indication approved for Enbrel 25 mg strength only) should have
received all vaccines recommended in current immunization guidelines prior to starting Enbrel. Enbrel Paediatric:
Contains benzyl alcohol as an excipient, which may cause toxic reactions and anaphylactic reactions in infants and
children up to 3 years old. Pregnancy & Lactation: Enbrel is not recommended in pregnant or breast-feeding women.
Undesirable Effects: Adults: Very common side effects reported with clinical trial and post marketing experience
include infections and injection site reactions. Common adverse events were allergic reactions, pruritus, autoantibody
formation and fever. Uncommon side effects have included serious infections, thrombocytopenia, angioedema,
urticaria and rash. Rare reports of lupus-like syndrome, CNS demyelinating events, seizures, serious allergic reactions,
elevated liver enzymes, cutaneous vasculitis, anaemia, leukopenia, neutropenia, pancytopenia and tuberculosis.
Aplastic anaemia has been reported very rarely. In clinical trials serious adverse events occurred with a frequency
similar to placebo and methotrexate. These included: serious infections, malignancies, asthma, heart failure, MI
and ischaemia, chest pain, syncope, cerebral ischaemia, hyper- and hypotension, cholecystitis, pancreatitis, GI
haemorrhage, bursitis, confusion, depression, dyspnoea, abnormal healing, renal insufficiency, kidney calculus, deep
vein thrombosis, pulmonary embolism (PE), membranous glomerulonephropathy, polymyositis, thrombophlebitis,
liver damage, leucopenia, paresis, paresthesia, vertigo, allergic alveolitis, angioedema, scleritis, bone fracture,
lymphadenopathy, ulcerative colitis, intestinal obstruction, eosinophilia, haematuria and sarcoidosis. Rate of new
malignancies was similar to that expected for the population studied. Fatalities associated with serious infections,
pancytopenia, and aplastic anaemia have also been reported. Paediatrics (25 mg only): Generally as for adults,
except the following were more common: headaches, nausea, vomiting and abdominal pain. In addition the
following were reported as severe events: varicella, appendicitis, gastroenteritis, depression/personality disorder,
cutaneous ulcer, oesophagitis/gastritis, group A streptococcal septic shock, type I diabetes mellitus and soft
tissue and post operative wound infection. Legal Category: POM. Package Quantities: Enbrel Pre-filled Syringe:
Each carton contains 4 pre-filled syringes containing either 25 mg or 50 mg of Enbrel and 8 alcohol swabs.
Enbrel Powder: Each carton contains either 4 vials of Enbrel 25mg powder or 4 vials of Enbrel 50mg powder,
4 pre-filled syringes of water for injections, 4 needles, 4 vial adaptors and 8 alcohol swabs. Enbrel Paediatric: Each
carton contains 4 vials of Enbrel 25 mg powder. 4 pre-filled syringes of bacteriostatic water for injections, 8 empty
plastic syringes, 20 needles and 24 alcohol swabs. Basic NHS Cost: 25 mg (all presentations): £357.50 per
carton. 50 mg (all presentations): £715 per carton. European Marketing Authorisation Number: Enbrel Pre-filled
Syringe 25 mg: EU/1/00/126/013. Enbrel Pre-filled Syringe 50 mg: EU/1/99/126/017. Enbrel Powder 25 mg:
EU/1/99/126/003. Enbrel Powder 50 mg: EU/1/99/126/010. Enbrel Paediatric 25 mg: EU/1/99/126/012. For
full prescribing information and details of other side effects see Summary of Product Characteristics. Full prescribing
information is available on request from: Wyeth Pharmaceuticals, Huntercombe Lane South, Taplow, Maidenhead,
Berkshire SL6 0PH. Telephone: 01628 415330. Date of Prescribing Information: 24 Jan 07.
Code no. ZAPI049. Doc ID 42874.
Information about adverse event reporting can be found at
www.yellowcard.gov.uk. Adverse events should also be
reported to Wyeth on 01628 415330.
1. NICE technology appraisal No. 103, July 2006.
Date of Preparation: February 2007. ZENB1330/0207