RSS 1.0Dermatology
Recent Submissions
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Dermatologic surgery : an update on secondary intention healing and adjuncts : part 2Secondary intention healing (SIH) is utilised by various surgical specialities. The formation of granulation tissue is crucial for initiating the healing process, necessitating robust support at this stage. Numerous adjunct therapies are available, with new developments aimed at treating both acute and chronic wounds undergoing SIH. This article continues from part 1, examining the efficacy of various adjunct therapies in promoting SIH. This article continues from part 1, examining the efficacy of various adjunct therapies in promoting SIH.
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A review of consent policies in Dermatological Surgery in the United Kingdom and the impact of leaner pathways and teledermatology on consentObtaining valid consent is an ethical and legal requirement in clinical practice, ensuring patients are adequately informed about their treatments. Recent updates in consent policies, including GMC guidance, the Patterson inquiry report, and key legal rulings like Montgomery, emphasise a shift towards patient-centred care and the importance of a comprehensive patient-clinician dialogue. Budget constraints and increasing NHS demand have led to the adoption of digital solutions and streamlined pathways, such as teledermatology and direct booking to surgery, potentially compromising the consent process. This review examines the current state of informed consent in UK dermatology, particularly in light of the Montgomery ruling, which requires clinicians to ensure patients are aware of all material risks and alternatives associated with their treatments. The two-stage consent process, involving consent at two distinct points, is advocated to allow patients adequate time for reflection and decision-making. However, challenges remain in pathways like one-stop clinics and direct booking for surgery, where limited face-to-face interaction and time constraints can undermine the quality of informed consent. To mitigate these issues, integrating multimedia tools and standardised procedure-specific consent forms can enhance patient comprehension and satisfaction. These tools ensure consistent and clear communication of risks, benefits, and alternatives, maintaining robust informed consent amidst evolving healthcare delivery models. Sustaining a thorough and individualised dialogue throughout the patient care journey is essential for upholding patient autonomy and shared decision-making in dermatological surgery.
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National Dermatological Surgery Sustainability Survey : an evaluation of healthcare professional beliefs and practicesBackground: Dermatological surgery contributes to the large environmental impact of healthcare, but to date there are no data on the current sustainability practices, attitudes, or behaviours of UK and Republic of Ireland health professionals involved in skin surgery. Objectives: We sought to evaluate this using a national sustainability questionnaire, organised by the British Society for Dermatological Surgery. Methods: Over 12-weeks, a 17-item online questionnaire was distributed nationally to healthcare professionals involved in skin surgery. Results: 115 UK healthcare professionals responded. 'See and Treat' provision for non-Mohs skin surgery was described by 32% of respondents. When compared to single-use equipment (Median=4), reusable equipment (Median=7) outperformed on perceived safety (p =.0056), quality (p =.00001), and patient outcomes (p =.0067), but no difference was found in usability (p =.68916). Perceived sustainability was greater in the reusable (Median=7) than single-use (Median=1)(p=.00001). Almost all (97%) respondents believe global climate change is happening, and the majority (74%) are concerned by dermatological surgery's impact. However, only 44% feel comfortable discussing health effects of climate change with patients. Whilst 75% turn off surgical lighting in between lists, often room lighting (31%), equipment (32%) or heating/air conditioning (22%) is forgotten. Conclusion: Whilst awareness of the impact of dermatological surgery on global climate change is common among healthcare professionals involved in skin surgery, there is room for improvement in translating this into local action, advocacy, and service improvement to standards dictated by national sustainability guidance.
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Environmental sustainability in dermatological surgery : part 1 : reducing carbon intensityThis two-part review addresses the pressing need for environmental sustainability in dermatological surgery, driven by the NHS's commitment to net-zero emissions. Part 1 focuses on strategies to reduce the carbon intensity of dermatological procedures by adopting low-carbon alternatives and optimising operational resource usage. Key strategies for a system-wide reduction in environmental impact include using leveraging local suppliers to reduce transport emissions, streamlining care models, promoting efficient waste management, and using mindful prescribing practices. Another aspect is integrating sustainability into dermatological education whilst minimising the carbon footprint of surgical education. Additionally, the review provides a comprehensive overview of optimising resource use in dermatological surgery, focusing on efficient management of consumables, equipment, and energy. This includes recycling, waste segregation, transitioning to reusable personal protective equipment and surgical instruments, and applying energy-saving and sustainable water use practices. By implementing these strategies, dermatological surgery can significantly reduce its environmental impact while upholding high standards of patient care.
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Environmental sustainability in dermatological surgery : part 2 : reducing activity and future ecological strategiesThis two-part review addresses the pressing need for environmental sustainability in dermatological surgery, driven by the NHS's commitment to net-zero emissions. Part 2 of this review extends the discussion of sustainability in dermatological surgery by focusing on system-wide changes in service delivery and identifying future opportunities for reducing environmental impact. Building on the strategies outlined in Part 1, which explored low-carbon alternatives and operational resource optimisation, Part 2 advocates for a comprehensive shift in the skin surgery service. Key strategies include reducing overall surgical activity, advancing research and innovation, and enhancing management practices to align with sustainability goals. Reducing surgical activity mainly involves the prevention of skin cancers, in addition to optimising current patient pathways and empowering patients to take ownership of their follow-up. Outside of immediate clinical decision-making at the individual level, the review highlights the importance of managerial policy, procurement practices and supply chain factors in driving broader national and international sustainability efforts. Advancing the sustainability agenda will also require targeted research and innovation, particularly in digital health solutions using evidence-based practices. By integrating these strategies, this review aims to provide a framework for reducing the environmental footprint of dermatological surgery and advancing towards a more sustainable healthcare system.
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The natural progression of basal cell carcinomas (BCCs) awaiting surgical interventionBasal cell carcinomas (BCCs) are slow growing keratinocyte tumours with limited literature reporting the natural history of untreated BCCs. This study evaluated the natural progression and patient outcomes of BCCs whilst awaiting surgical intervention. Only patients with histologically proven BCCs were included in the data collection. Retrospective data analysis was performed on 55 patients (total of 70 lesions) and showed a statistically significant correlation between average growth of BCCs and time waiting for a procedure. Twenty percent of the cases had a larger procedure than originally planned at the time of booking. The top three symptoms reported include itching (39.4%), crusting (36.4%) and bleeding (30.3%). In conclusion, we reported a positive relationship between BCC growth and length of time from initial presentation to surgical treatment where patients often ended up with more symptoms, larger and complex surgical procedure than originally planned especially on the head and neck.
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Appraisal of AI-generated dermatology literature reviewsBackground: Artificial intelligence (AI) tools have the potential to revolutionize many facets of medicine and medical sciences research. Numerous AI tools have been developed and are in continuous states of iterative improvement in their functionality. Objectives: This study aimed to assess the performance of three AI tools: The Literature, Microsoft's Copilot and Google's Gemini in performing literature reviews on a range of dermatology topics. Methods: Each tool was asked to write a literature review on five topics. The topics chosen have recently had peer-reviewed systematic reviews published. The outputs of each took were graded on their evidence and analysis, conclusions and references on a 5-point Likert scale by three dermatologists who are working in clinical practice, have completed the UK dermatology postgraduate training examination and are partaking in continued professional development. Results: Across all five topics chosen, the literature reviews written by Gemini scored the highest. The mean score for Gemini for each review was 10.53, significantly higher than the mean scores achieved by The Literature (7.73) and Copilot (7.4) (p < 0.001). Conclusions: This paper shows that AI-generated literature reviews can provide real-time summaries of medical literature across a range of dermatology topics, but limitations to their comprehensiveness and accuracy are apparent.
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Estimating the burden of vitiligo : a systematic review and modelling studyBackground: Vitiligo is a chronic autoimmune disease characterised by depigmented skin patches, which can pose substantial psychosocial challenges particularly in individuals with dark skin tones. Despite its impact on quality of life, there is an absence of standardised global epidemiological data. We sought to address this gap with the present study. Methods: In this study we did a systematic review and modelling analysis to estimate the global, regional, and national prevalence and incidence of vitiligo. We did a comprehensive search of nine digital libraries (PubMed, Embase, Web of Science, Scientific Electronic Library Online, KCI Korean Journal Database, Russian Science Citation Index, Western Pacific Region Index Medicus, Informit, and Health Research and Development Information Network) from inception up to May 25, 2023. We included cross-sectional or cohort studies reporting the incidence rate or prevalence of vitiligo, or data from which incidence rate or prevalence could be calculated, in the general population of a country or area of a country. Summary estimate data were extracted. A main outcome was to estimate the worldwide, regional, and country-specific lifetime prevalence of vitiligo diagnosed by physicians or dermatologists among the general population and in adults and children (as per age groups defined in included studies). We used a Bayesian hierarchical linear mixed model to estimate prevalence, and calculated number of affected individuals using the UN population structure in 2022. In estimating lifetime prevalence, studies reporting point or period prevalence were excluded. Our other main outcome was to estimate incidence rates of vitiligo, but due to a small number of studies, the data on incidence were presented in a descriptive summary. This study was registered on PROSPERO, CRD42023390433. Findings: Our search identified 22 192 records, of which 90 studies met our inclusion criteria. Of these studies, six focused on the incidence of vitiligo, 79 reported on the prevalence of vitiligo, and five provided data on both incidence and prevalence. 71 studies reported on lifetime prevalence. In the most recent years studied, incidence rates in the general population ranged from 24·7 cases (95% CI 24·3-25·2) per 100 000 person-years in South Korea in 2019, to 61·0 cases (60·6-61·4) in the USA in 2017. In individual studies, incidence rates showed an increasing trend over the periods studied. The global lifetime prevalence of vitiligo diagnosed by a physician or dermatologist was estimated at 0·36% (95% credible interval [CrI] 0·24-0·54) in the general population (28·5 million people [95% CrI 18·9-42·6]), 0·67% (0·43-1·07) in the adult population (37·1 million adults [23·9-58·9]), and 0·24% (0·16-0·37) in the child population (5·8 million children [3·8-8·9]). Vitiligo prevalence was higher in adults than in children across all regions. Central Europe and south Asia reported the highest prevalence (0·52% [0·28-1·07] and 0·52% [0·33-0·82], respectively, in the general population). Interpretation: This study highlights the need for standardised epidemiological data collection globally to inform public health policies and improve vitiligo diagnosis and management. Emphasis on the impact on individuals with darker skin tones is crucial to reducing stigma and improving quality of life. Furthermore, our study highlights the need to conduct more research in regions and populations that have been historically under-represented, to effectively address the worldwide burden of vitiligo.
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Technology-enhanced learning interventions on skin of colour dermatology for dermatology trainees and fellows : are they effective or sustainable?Recent shifts towards synchronous online learning and raised awareness of ethnic inequalities in health have resulted in the establishment of frequent 'one-off' technology-enhanced learning (TEL) initiatives on diversity issues. There is little established evidence regarding the efficacy or sustainability of such interventions. We designed a prospective cohort pilot study including 14 dermatology registrars and fellows and delivered a TEL programme focusing on central centrifugal cicatricial alopecia and keloid scarring. Information was collected on the existing competence and confidence of our cohort about managing these conditions, as well as the short-term and long-term impact of our intervention. Following our programme, participant knowledge improved transiently, but was not sustainable 6 weeks later. Over half of participants were not confident in adopting newly acquired knowledge on skin of colour into practice. Results demonstrate a disparity between how effective one-off education initiatives are perceived vs. actual benefit. More systemic solutions may be warranted.
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Genotype-phenotype correlation in Junctional Epidermolysis Bullosa: signposts to severityJunctional epidermolysis bullosa (JEB) is a rare autosomal recessive genodermatosis with a broad spectrum of phenotypes. Current genotype-phenotype paradigms are insufficient to accurately predict JEB subtype and characteristics from genotype, particularly for splice site mutations, which account for over a fifth of disease-causing mutations in JEB. This study evaluated genetic and clinical findings from a JEB cohort, investigating genotype-phenotype correlations through bioinformatic analyses and comparison with previously reported mutations. Eighteen unique mutations in LAMB3, LAMA3, LAMC2 or COL17A1 were identified from seventeen individuals. Seven had severe JEB, nine intermediate JEB and one laryngo-onycho-cutaneous syndrome. Seven mutations were previously unreported. Deep phenotyping was completed for all intermediate JEB cases and demonstrated substantial variation between individuals. Splice site mutations underwent analysis with SpliceAI, a state-of-the-art artificial intelligence tool, in order to predict resultant transcripts. Predicted functional effects included exon skipping and cryptic splice site activation, which provided potential explanations for disease severity and in most cases correlated with lamimin-332 immunofluorescence. RT-PCR was performed for one case to investigate resultant transcripts produced from the splice site mutation. This study expands the JEB genomic and phenotypic landscape. AI tools show potential for predicting functional effects of splice site mutations and may identify candidates for confirmatory laboratory investigation. Investigation of RNA transcripts will help to further elucidate genotype-phenotype correlations for novel mutations.
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Over two years' experience with tralokinumab for moderate to-severe atopic dermatitis : three clinical case studiesTralokinumab is an anti-interleukin-13 monoclonal antibody approved in several geographical regions for the treatment of moderate-to-severe atopic dermatitis. This manuscript presents three case studies of patients with moderate-to-severe atopic dermatitis who had failed on prior treatments and took part in trials of tralokinumab. Data is available for approximately two years in each patient and indicates that treatment with tralokinumab every two weeks was associated with substantial improvements in patient itch, sleep and quality of life, with feedback from the patients suggesting that this had a meaningful impact on their daily lives.
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UK National Mohs Surgeon Survey 2020No abstract available
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International, prospective cohort study comparing non-absorbable versus absorbable sutures for skin surgery : CANVAS service evaluationBackground: Absorbable or non-absorbable sutures can be used for superficial skin closure following excisional skin surgery. There is no consensus among clinicians nor high-quality evidence supporting the choice of suture. The aim of the present study was to determine current suture use and complications at 30 days after excisional skin surgery. Methods: An international, prospective service evaluation of adults undergoing excision of skin lesions (benign and malignant) in primary and secondary care was conducted from 1 September 2020 to 15 April 2021. Routine patient data collected by UK and Australasian collaborator networks were uploaded to REDCap©. Choice of suture and risk of complications were modelled using multivariable logistic regression. Results: Some 3494 patients (4066 excisions) were included; 3246 (92.9 per cent) were from the UK and Ireland. Most patients were men (1945, 55.7 per cent), Caucasian (2849, 81.5 per cent) and aged 75-84 years (965, 27.6 per cent). The most common clinical diagnosis was basal cell carcinoma (1712, 42.1 per cent). Dermatologists performed most procedures, with 1803 excisions (44.3 per cent) on 1657 patients (47.4 per cent). Most defects were closed primarily (2856, 81.9 per cent), and there was equipoise in regard to use of absorbable (2127, 57.7 per cent) or non-absorbable (1558, 42.2 per cent) sutures for superficial closure. The most common complications were surgical-site infection (103, 2.9 per cent) and delayed wound healing (77, 2.2 per cent). In multivariable analysis, use of absorbable suture type was associated with increased patient age, geographical location (UK and Ireland), and surgeon specialty (oral and maxillofacial surgery and plastic surgery), but not with complications. Conclusion: There was equipoise in suture use, and no association between suture type and complications. Definitive evidence from randomized trials is needed.
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Facial involvement is reflective of patients' global perception of vitiligo extentBackground: The involvement of visible areas in vitiligo has been found to be correlated with increased psychiatric morbidity. Although multiple tools have been developed to assess vitiligo, no cutoff for improvement or worsening of vitiligo from a patient's perspective has been established. Objectives: To determine the minimal clinically important difference (MCID) of the Self-Assessment Vitiligo Extent Score (SA-VES) in patients with vitiligo and to evaluate, from the patient's perspective, the importance of the change in the involvement of visible areas (face and hands) in patients' overall perception of disease worsening or improving. Methods: This was a cross-sectional study in the context of the ComPaRe e-cohort. Adult patients with vitiligo were invited to answer online questionnaires. They completed the SA-VES twice, 1 year apart. In addition, patients answered a 5-point Likert anchor question aimed at assessing their perception of the evolution of the extent of their vitiligo. The MCID was calculated using distribution- and anchor-based approaches. Using ordinal logistic regression, the change of vitiliginous lesions on the face or hands was compared to the overall extent of vitiligo (patches on all body areas). Results: In total, 244 patients with vitiligo were included in the analyses; 20 (8%) were found to have an improvement in their vitiligo. The MCID in worsened patients was equal to a 1.3% body surface area [95% confidence interval (CI) 1.01-1.43] increase in the SA-VES. For participants with improved vitiligo, the MCID was equal to a decrease in total SA-VES of 1.3% (95% CI 0.867-1.697). Patients' perceptions of change in their vitiligo was increased sevenfold when it affected the face vs. the rest of the body. Conclusions: Changes in the facial SA-VES were highly correlated with patients' impressions of the extent of vitiligo.
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Risk of melanoma and nonmelanoma skin cancer in people with vitiligo : United Kingdom population-based cohort studyAlthough genetic studies have found an inverse relationship between vitiligo and skin cancer, epidemiological evidence is conflicting. We investigated the risk of skin cancer in adults with vitiligo using United Kingdom electronic primary care records from the Optimum Patient Care Research Database 2010-2020. Vitiligo cases were age, sex, and general practitioner practice matched to population controls without vitiligo. Incidence of melanoma, nonmelanoma skin cancers (squamous cell carcinoma and basal cell carcinoma), and actinic keratoses was compared between vitiligo cases and controls using Cox regression. A total of 15,156 vitiligo cases were matched to 60,615 controls. Vitiligo was associated with a 38% reduced risk of new-onset skin cancer (adjusted hazard ratio [aHR] = 0.62, 95% confidence interval [CI] = 0.52-0.75, P < 0.001) and skin cancer subtypes; melanoma (aHR = 0.39, 95% CI = 0.23-0.65, P < 0.001), squamous cell carcinoma (aHR = 0.67, 95% CI = 0.49-0.90, P < 0.01), basal cell carcinoma (aHR = 0.65, 95% CI = 0.51-0.83, P < 0.001). There was no significant association for actinic keratosis (aHR = 0.88, 95% CI = 0.77-1.01). People with vitiligo have a markedly reduced incidence of melanoma and nonmelanoma skin cancer. Given concerns that some treatments, such as phototherapy, may increase skin cancer risk, this finding provides reassurance to people with vitiligo and clinicians managing the condition.
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A national clinician survey on the practice and views of the British Society for Dermatological Surgery (BSDS) guidelines on antithrombotic agent use in skin surgery14-22.3% of patients undergoing skin surgery take an anti-thrombotic medication, with more patients now taking Direct Oral Anticoagulants (DOACs). Latest evidence suggests the risk of stopping DOACs peri-operatively is low in skin surgery, particularly for primary closures, but remains unclear for more complex procedures. The 2016 British Society for Dermatological Surgery (BSDS) guidance suggested consideration of stopping DOACS for 24-48 hours based on individual bleeding risk. We developed an online survey of BSDS members to better understand clinical practice and guideline adherence with a view to updating the guidance. Results demonstrated that there is consistency amongst clinicians in management of patients on more established antithrombotic agents, such as aspirin, clopidogrel and warfarin. However, there is a higher perceived risk of significant haematomas following higher risk procedures such as larger flaps or grafts with DOACs versus other antithrombotic post-operatively. Stopping DOACs peri-operatively for 24-48 hours for higher risk procedures can be cautiously considered following an individual risk assessment and informed discussion with the patient.
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A patient with a severe allergic reaction secondary to Efudix 5% creamNo abstract available