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Patients with nodular prurigo commonly have pre-existing psychological disease that requires treatment concomitant with cutaneous therapies.Patients with nodular prurigo commonly have pre-existing psychological disease that requires treatment concomitant with cutaneous therapies
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The Skin of Colour Training Day UK: training the medical workforce in ethnic dermatologyThe Skin of Colour Training Day UK: training the medical workforce in ethnic dermatology
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A case of nodular lichen myxedematosusNo abstract available.
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Sensitisation to the acrylate co-polymers glyceryl acrylate/acrylic acid co-polymer, sodium polyacrylate and acrylates/C10-30 alkyl acrylate cross-polymer (Carbopol®) is rareBackground: Acrylate polymers and cross-polymers (ACPs) are frequently used cosmetic ingredients. The British Society for Cutaneous Allergy (BSCA) and the UK Cosmetic, Toiletry and Perfumery Association (CTPA) collaborated to investigate the allergenic potential of three commonly-used ACPs. Objectives: The objective of this study is to determine the prevalence of allergic contact dermatitis (ACD) to three ACPs: glyceryl acrylate/acrylic acid co-polymer, sodium polyacrylate, and acrylates/C10-30 alkyl acrylate cross-polymer (Carbopol®). Materials and methods: The BSCA prospectively audited data collected from 20 centres in the UK and Ireland between 1st September 2021 and 1st September 2022. Patients with suspected ACD to (meth)acrylates, with facial dermatitis, or consecutive patients, were patch tested to glyceryl acrylate/acrylic acid co-polymer 10% aqueous (aq.) sodium polyacrylate 2% aq., and to acrylates/C10-30 alkyl acrylate cross-polymer 2% aq. (Carbopol®). The frequencies of positive, irritant, and doubtful reactions were recorded. Results: In total, 1302 patients were patch tested. To glyceryl acrylate/acrylic acid co-polymer, there was one doubtful reaction in a patient allergic to multiple (meth)acrylates, and one irritant. To sodium polyacrylate, there were four irritant reactions, one doubtful, and one positive reaction; in all cases, relevance was unknown and there was no demonstrable (meth)acrylate allergy. There were no reactions to Carbopol®. Conclusions: Sensitisation to these concentrations of the three tested ACPs is rare. Elicitation of dermatitis in (meth)acrylate-sensitised patients by exposure to these three ACPs appears unlikely.
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DermatopathologyNo abstract available.
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National epidemiology of digital papillary adenocarcinoma in England 2013-2020 : a population-based registry studyBackground: Digital papillary adenocarcinoma (DPA), formerly known as aggressive DPA, is a rare adnexal cancer of sweat gland differentiation with metastatic potential. DPA epidemiology and patient outcome data are a prerequisite to develop diagnostic and therapeutic guidance, which is lacking for this rare cancer. Objectives: To report the incidence, patient demographics and treatment of patients with DPA in England from 1 January 2013 to 31 December 2020 using national cancer registry data. Methods: DPA diagnoses in England during 2013-2020 were identified from the National Cancer Registration Dataset using morphology and behaviour codes. These were registered from routinely collected pathology reports and cancer outcomes and services datasets. The 2013 European age-standardised incidence rates (EASRs) were calculated. Results: In total, 36 DPA (7 in females and 29 in males) were diagnosed. The median age at diagnosis for the cohort was 54 years (interquartile range 46-64). The most frequently affected sites were upper limbs (81%). All patients in the cohort received surgical excisions. The European age-standardised incidence rate (EASRs) was 0.10 [95% confidence interval (CI) 0.07-0.14] per 1,000,000 person-years (PY)]. Conclusion: This study reports the incidence and variation of DPA in England between 2013 and 2020. DPA was more common in older men and predominantly affected the upper limbs. This supports the need to develop a national policy for the reporting and management of DPA as well as clinical guideline development.
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DS02 British Society for Dermatological Surgery sustainability guidanceSkin surgery and the patient pathway for those with skin cancer significantly contribute to the climate crisis. Dermatological surgeons recognize the role of global climate change as a significant contributor to increasing skin cancer rates and hence increase service demand. The British Society for Dermatological Surgery (BSDS) sustainability subgroup’s aim is to facilitate the integration of sustainability within all levels of service provision through the development of national sustainability guidance. We systematically searched MEDLINE, Embase, Google Scholar and the grey literature for English-language published articles related to sustainability in skin surgery. Relevant selected evidence-based articles were critically evaluated for inclusion by 11 authors and, if sufficiently rigorous, were included in the final recommendations. The guidance then underwent multiple iterations of appraisal by the guidance development group consisting of expert consultant dermatologists and Mohs surgeons, trainees and patient–public involvement. A system-wide change in service provision is required to reduce long-term service demand. This can be achieved through a focus on skin cancer prevention, patient education and facilitating early recognition of skin cancer in primary care. Another aspect includes encouraging patient empowerment through self-monitoring, thus reducing the frequency of follow-up. Lean dermatology service delivery reduces waste by utilizing efficiency, optimizing teledermatology and one-stop see-and-treat clinics, reducing travel distances, using electronic health records and identifying unnecessary/missed appointments. Reducing carbon intensity involves using low-carbon alternatives for patient/staff transport, sustainable staff food options and a wider review of procurement and supply chain that reflects sustainable trade standards. Skin surgery must re-evaluate its consumption and waste, involving reusable equipment and surgical clothing, opting for repair over machinery replacement, reducing single-use sets and using absorbable sutures and single-wrapped biodegradable packaging. Departments should preserve water used in surgery/handwashing, conserve electricity and use renewable energy sources, in addition to surgical waste management through segregation, recycling, proper disposal of environmentally harmful waste and surgical smoke evacuation. Dermatological surgery departments can advocate system-wide change by establishing a sustainability policy, which incorporates departmental sustainability education for their staff, prioritizing waste auditing and life cycle assessments and encouraging ethical purchasing. Further skin surgery sustainability research and innovation are necessary to encourage circular economy solutions for consumables and equipment use and develop sustainability quality-improvement projects and new methods of sustainable dermatological surgery service delivery. The BSDS sustainability guidance is publicly available (https://bsds.org.uk/wp-content/uploads/2022/09/2022-BSDS_Sustainability_Guidance.pdf) to inform and inspire dermatological surgery sustainability.
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BT12 A comparison of outcomes and cost-effectiveness in a teledermatology vs. a standard face-to-face 2-week wait UK modelTeledermatology (TD) assessment of lesions referred on the 2-week wait (2WW) pathway reduces the need for in-person review, and thus facilitates increased clinical capacity. Although studies have demonstrated that TD can be cost-effective compared with a standard face-to-face (F2F) model, there is a lack of literature on the cost-effectiveness of TD with medical photography in the UK 2WW skin cancer pathway (Snoswell C, Finnane A, Janda M et al. Cost-effectiveness of store-and-forward teledermatology. JAMA Dermatol 2016; 152:702). In this study, we undertook a retrospective analysis of a store-and-forward TD 2WW pathway supported by medical photography at a UK centre (October–November 2022). As a comparator, we looked at the outcomes of a 2WW F2F clinic that took place 1 year earlier. Primary outcomes included comparing costs associated with both TD and F2F clinics, and outcomes after initial TD vs. F2F review (discharges, surgeries and subsequent F2F reviews). Inclusion criteria for TD were age 18–60 years, < 3 lesions referred and lesions being on culturally nonsensitive body sites. Cost estimates were included for physicians, nurses, healthcare assistants, administration staff and medical photographers. The tariff per 2WW skin cancer referral to the trust is £159.27. In total, 292 patient images were reviewed virtually in this study. Thirty of 68 patients in the F2F group met the same age criteria as those in the TD group (18–60 years), and thus these patients were used as comparators. Each 4-h TD session comprised an assessment of 25 patients vs. 12 patients per F2F session. Discharge rates from the first clinic appointment were higher for F2F clinics than for TD clinics (76.7% vs. 58.6%). Referrals for surgery were similar between the two groups (16.7% for F2F and 17.8% for TD). However, we found there were substantially more follow-ups requested after TD assessment vs. patients reviewed in F2F clinics (23.2% vs. 6.7%). The nonattendance rate for TD was 36 of 328 patients (11.0%) vs. five of 73 (6.8%) for F2F. Per-patient cost of the TD pathway was estimated to be £16.16 vs. £25.68 for a F2F 2WW appointment. Total revenue to the trust per clinical session was estimated to be £3981.75 (TD) vs. £1911.24 (F2F). This represented additional revenue of approximately £1975 for TD. Twenty-nine of 33 TD patients who completed feedback questionnaires reported overall satisfaction with the TD pathway. In this study, outcome rates between TD and F2F groups were similar in terms of planned surgeries. Planned subsequent F2F review rates were higher for TD, and discharge rates were higher for F2F. The revenue to the trust was greater for TD than F2F.
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British Society for Paediatric and Adolescent Dermatology assessment and support of mental health in children and young people with skin conditions : a multidisciplinary expert consensus statement and recommendationsBackground: Psychological and mental health difficulties are common in children and young people (CYP) living with skin conditions and can have a profound impact on wellbeing. There is limited guidance on how best to assess and support the mental health of this population, who are at risk of poor health outcomes. Objectives: To provide consensus-based recommendations on the assessment and monitoring of and support for mental health difficulties in CYP with skin conditions (affecting the skin, hair and nails); to address practical clinical implementation questions relating to consensus guidance; and to provide audit and research recommendations. Methods: This set of recommendations was developed with reference to the AGREE II instrument. A systematic review and literature appraisal was carried out. A multidisciplinary consensus group was convened, with two virtual panel meetings held: an initial meeting to discuss the scope of the study, to review the current evidence and to identify areas for development; and a second meeting to agree on the content and wording of the recommendations. Recommendations were then circulated to stakeholders, following which amendments were made and agreed by email. Results: The expert panel achieved consensus on 11 recommendations for healthcare workers managing CYP with skin conditions. A new patient-completed history-taking aid ('You and Your Skin') was developed and is being piloted. Conclusions: The recommendations focus on improved mental health assessments for CYP presenting with a skin condition, with clinical guidance and suggested screening measures included. Information on accessing psychological support for CYP, when required, is given, and recommendations for staff training in mental health and neurodiversity provided. Embedding a psychosocial approach within services treating CYP with skin disease should ensure that CYP with psychological needs are able to be identified, listened to, supported and treated. This is likely to improve health outcomes.
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Topical steroid withdrawal : an emerging clinical problemBackground: Topical steroid withdrawal (TSW) is a newly described disease characterized by erythema and burning following discontinuation of prolonged use of mid- to high-potency topical corticosteroids. No consensus diagnostic criterion exists. TSW is frequently interpreted as flaring of the underlying disorder or contact allergy to topical treatment. Objectives: To better characterize TSW symptomatology, detail our experience with management and assess the proportion of patients who pursue nonconventional management. Methods: A retrospective review of case notes collected from our multidisciplinary service between January 2019 and June 2021 was carried out to identify patients presenting with TSW. Results: Nineteen cases of TSW were identified, 15 in females and 4 in males. The majority were < 35 years old. Eighteen had atopic dermatitis. The most frequently reported features were redness, skin pain (typically 'burning'), skin sensitivity, excessive skin flaking, insomnia and severe itching. There was a high burden of anxiety and depression, with three patients expressing suicidal thoughts. Nonconventional treatments were pursued by approximately half the cohort, some of whom sought private consultation with international dermatologists. Improvements were noted in the context of open psychodermatology consultations with an earlier introduction of conventional management options. Conclusions: Many patients report dismissal by dermatology healthcare professionals, often driving them to seek help from unregulated online sources, heightening the burden of mental, social and physical morbidity. Dermatology healthcare professionals need to be aware of TSW and offer support with shared decision-making when considering treatments.
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How to critically appraise a systematic review: an aide for the reader and reviewerThe number of published systematic reviews has soared rapidly in recent years. Sadly, the quality of most systematic reviews in dermatology is substandard. With the continued increase in exposure to systematic reviews, and their potential to influence clinical practice, we sought to describe a sequence of useful tips for the busy clinician reader to determine study quality and clinical utility. Important factors to consider when assessing systematic reviews include: determining the motivation to performing the study, establishing if the study protocol was prepublished, assessing quality of reporting using the PRISMA checklist, assessing study quality using the AMSTAR 2 critical appraisal checklist, assessing for evidence of spin, and summarizing the main strengths and limitations of the study to determine if it could change clinical practice. Having a set of heuristics to consider when reading systematic reviews serves to save time, enabling assessment of quality in a structured way, and come to a prompt conclusion of the merits of a review article in order to inform the care of dermatology patients.
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Dermatological surgery : an update on suture materials and techniques : part 2This is the second part of a two-part series summarizing the latest evidence related to suture materials and wound closure techniques in dermatological surgery. We critically appraised evidence focusing on the following consequences of suture choice: scar/cosmesis, pain, patient satisfaction, cost, infection and wound complications. We searched the databases MEDLINE, PubMed and Embase using the keywords 'skin surgery', 'dermatological surgery', 'sutures', 'braided sutures', 'monofilament sutures' and 'antibacterial sutures' to identify relevant English-language articles. This part of the review assesses the evidence for different types of buried sutures, including braided vs. monofilament sutures, longer-absorbing sutures and antibacterial sutures. The majority of trials were noted to be of poor quality, single-centre (thus lacking external validity) and underpowered, which presents challenges in comparing suture techniques in skin surgery. Future large-scale, multicentre, randomized trials are needed, with both surgeon and patient-assessed validated outcomes.
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Dermatological surgery : an update on suture materials and techniques : part 1Significant variation exists in the surgical suture materials and techniques used for dermatological surgery. Many wound-closure techniques are now practised, including use of sutures, staples and topical adhesives. The focus of our review article is to summarize the latest evidence relating to suture materials and wound-closure techniques, considering the following areas: scar/cosmesis, pain, patient satisfaction, cost, infection and wound complications. We searched the databases Medline, PubMed and Embase using the keywords 'skin surgery', 'dermatologic surgery', 'sutures', 'suture techniques', 'suturing techniques' and 'surgical techniques' to identify relevant English-language articles. Absorbable superficial sutures may be a preferred alternative to nonabsorbable sutures by both patients and surgeons. Subcuticular sutures may be preferable to simple interrupted sutures for superficial wound closure, and there may also be a role for skin staples in dermatological surgery, particularly on the scalp. However, there remains limited evidence specific to dermatological surgery supporting the use of particular suture materials and suturing techniques. Further high-quality research is required, including multicentre randomized trials with larger cohorts.
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Improving recognition among undergraduate and postgraduate trainees of dermatological conditions in skin of colour: a cross-sectional quality improvement project.It is well-recognized that skin of colour (SOC) is under-represented in undergraduate and postgraduate curricula in the UK. The primary objective of this Quality Improvement Project (QIP) was to improve the confidence of medical students and junior doctors in recognizing dermatological conditions in SOC. We developed two educational interventions to introduce participants to the clinical presentation of dermatological conditions in SOC. A five-point Likert scale measured participants' confidence, and an eight-question assessment quantified differences in knowledge. Results showed that 39% of students and 67% of junior doctors had not received SOC teaching during their undergraduate training. Following the lecture, mean Likert scores for confidence in recognizing conditions in SOC increased in the medical student and junior doctor cohorts by 2.5 and 1.82, respectively (P < 0.001 for both). The mean assessment scores increased by 3.68 and 3.87, respectively (P < 0.001 for both). These results confirm the under-representation of SOC in medical education and highlight the need to diversify the Dermatology undergraduate and postgraduate curricula.
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Full thickness skin graft versus split thickness skin graft in paediatric patients with hand burns : systematic review and meta-analysisOur objective was to compare the outcomes of full thickness skin grafts versus split thickness skin grafts in paediatric hand burn patients. A systematic review and meta-analysis were carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines, and an electronic search was conducted to identify all Randomised Controlled Trials and non-randomised studies comparing the outcomes of full thickness skin grafts versus split thickness skin grafts in paediatric hand burn patients. Primary outcomes included development of post-graft contracture and the necessity for surgical release. Secondary outcomes consisted of evaluation of function, cosmesis and colour, scar and feeling, hair growth, and other complaints. For the analysis, fixed effects modelling was applied. Results: ten non-randomised trials with a total of 532 grafts were found. Full thickness skin grafts exhibited a statistically significant decrease in the development of post-graft contracture (Odds Ratio [OR] = 0.35, P = 0.0001) and later surgical releases (OR = 0.06, P = 0.00001). For secondary outcomes, full thickness skin grafts outperformed split thickness skin grafts in post-operative functional ability. However, split thickness skin grafts, showed to be superior in scar, aesthetic, and colour assessments, and less hair growth was observed for split thickness skin grafts. No significant difference was seen in sensation and donor or recipient site complaints. Overall, full thickness skin grafts are a better alternative for paediatric hand burns than split thickness skin transplants because they are linked with reduced post-graft contracture and the requirement for surgical release.
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Recommendation to update the British Society for cutaneous allergy corticosteroid seriesBackground: Patch testing is an important investigation when dermatitis is unresponsive to, or worsened by, topical corticosteroid treatment. There is a balance to be struck between testing too many allergens, which is expensive, time consuming and risks causing sensitization, and testing too few, which risks missing the diagnosis. The current British Society for Cutaneous Allergy (BSCA) corticosteroid series comprises eight allergens and was last updated in February 2007. Aim: To review and update the BSCA corticosteroid series. Methods: We retrospectively analysed data from 16 patch test centres in the UK and Ireland for all patients who were patch tested to a corticosteroid series between August 2017 and July 2019. We recorded the allergens tested, the number and percentage tested to a corticosteroid series and the number of positive results for each allergen. We identified the allergens that test positive in ≥ 0.1% of selectively tested patients. Results: Overall, 3531 patients were tested to a corticosteroid series in the 16 centres. The number of allergens tested ranged from 7 to 18 (mean 10). The proportion of patch test patients who were tested to a corticosteroid series ranged from 1% to 99%. Six allergens in the 2017 BSCA series tested positive in ≥ 0.1% of patients. Nine allergens not in the BSCA corticosteroid series tested positive in ≥ 0.1% of patients. Conclusion: This audit demonstrates the importance of regular review of recommended series and the significant variations in practice. The new BSCA corticosteroid series that we recommend contains 13 haptens, with the addition of the patient's own steroid creams as appropriate.
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A review of Mohs micrographic surgery for skin cancer. Part 1 : melanoma and rare skin cancersMohs micrographic surgery (MMS) is a precise and effective method commonly used to treat high-risk basal cell carcinoma and squamous cell carcinoma on the head and neck. Although the majority of evidence for MMS relates to keratinocyte cancers, there is published evidence for other types of skin cancer. This review aims to discuss the evidence for using MMS to treat six different types of skin cancer [malignant melanoma, lentigo maligna, dermatofibrosarcoma protuberans, atypical fibroxanthoma (AFX), microcystic adnexal carcinoma and pleomorphic dermal sarcoma (PDS)] particularly in the context of survival rates and cancer recurrence. These cancers were chosen because there was sufficient literature for inclusion and because MMS is most useful when cancers are contiguous, rather than for cancers with marked metastatic potential such as angiosarcoma or Merkel cell carcinoma. We searched MEDLINE, PubMed and Embase using the keywords: 'melanoma', 'mohs micrographic surgery', 'lentigo maligna', 'dermatofibrosarcoma protuberans', 'atypical fibroxanthoma', 'microcystic adnexal carcinoma' and 'pleomorphic dermal sarcoma' along with their appropriate synonyms, to identify the relevant English-language articles from 2000 onwards, given that literature for MMS on nonkeratinocyte cancers is sparse prior to this year. AMSTAR (A MeaSurement Tool to Assess systematic Review) was used to assess the validity of systematic reviews. Further high-quality, multicentre randomized trials are necessary to establish the indications and efficacy of MMS for rarer cancers, particularly for AFX and PDS, for which only limited studies were identified.
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Local anaesthetics in dermatological surgery : a review of adjuncts and pain reduction techniquesA variety of adjuncts for local anaesthesia (LA) exists for dermatological surgery, along with many options to reduce the pain of LA. This review aims to summarize the evidence relating to such adjuncts and methods to reduce the pain of LA. Adjuncts to LA can be an important consideration to optimize anaesthetic effect. Current evidence suggests that buffering and warming of LA fluid, along with cooling, pinching and administering vibrations to the skin are effective at reducing pain during administration. In this review, no significant difference in pain reduction was found between cooling and administering vibrations to the skin. Studies demonstrate that, overall, LA injection into distal sites is safe. However, the evidence specific to dermatological surgery is limited with regard to ways to reduce pain during LA injection and in determining the safety of LA for distal sites with confidence. Further high-quality research in the form of multicentre randomized controlled trials is required.
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Phenotypic spectrum of serious cutaneous-only adverse event following immunization with COVID-19 vaccines: a multicentre case series and literature reviewA letter to the Editor describing a multicentre case series and literature review of the phenotypic spectrum of serious cutaneous‐only adverse event following immunization with COVID‐19 vaccines.