Dermatology in practice - 2013


Comment: The changing work of the dermatologist
Neill Hepburn
pp 3-3
At school I really enjoyed woodwork, such that I hoped to become a joiner – an ambition thwarted by my mother, who had other ideas! I have always enjoyed doing things with my hands and, indeed, built a kit car a few years ago. It’s not surprising, therefore, that skin surgery has always been an enjoyable part of my work. I like the visual aspects of working out how to remove the tumour and, more challengingly, how to reconstruct the defect. I like the ‘feel’ of the tissues and get satisfaction in seeing the results. Barry Monk’s article on the changing nature of the work we do as dermatologists is poignant. Many of the boys I shared a bench with at school went on to the highly regarded craft apprenticeships, working as tool makers and so on. I wonder what has happened to them. As the economy was ‘rebalanced’ in the 1980s, much of the manufacturing industry moved abroad and those trades were lost. Dermatology is starting to go through a similar transition. Although teledermatology seemed to be the threat a decade ago, it is now becoming more mainstream and, in limited situations, rather useful. What is more surprising is how the physical treatments are changing.
Common skin allergens: hazards on the high street
Laura Cuddy and Ian Coulson
pp 4-8
The high street has taken a pounding since the start of the recession, but the hair and beauty sector has flourished and is estimated to be worth billions of pounds. Many people feel that they are not blessed with natural beauty and need a little helping hand. This may be simply purchasing moisturisers or cosmetics over the counter or visiting the hairdresser or beauty salon. However, they may not fully appreciate the risks that they are exposing their skin to. The British Association of Dermatologists estimates that contact dermatitis accounts for between 4 and 7% of dermatological consultations and about 1–3% of the population are allergic to ingredients in cosmetics. Even when a contact allergy has been identified, shoppers need eagle-like vision to interrogate the ingredients’ lists of cosmetics, or be persistent and peel back one layer of label to reveal the list lurking below! The list of allergens commonly used in high-street products or services is surprisingly large, and the consequences wide-ranging.
The genetics of basal cell carcinoma
Nicholas J Collier, Faisal R Ali and John T Lear
pp 9-12
Basal cell carcinoma (BCC) is the most common human cancer, with a 30% lifetime risk in those of European descent. Incidence is increasing by 3–10% per annum worldwide and it is expected that, soon, the prevalence will equal that of all other cancers combined. While mortality is rare, BCC causes considerable morbidity and burden on health services. BCCs are slow-growing, locally invasive, malignant epidermal tumours which rarely metastasise (<0.1%). The underlying causal mechanism is a genetic aberration, which may be inherited or acquired. Primary risk factors are ultraviolet (UV) light exposure and genetic predisposition. Other significant risk factors include Fitzpatrick skin types I and II, immunosuppression, advanced age, male sex, previous BCCs and chronic arsenic exposure. Research into the molecular genetics of BCCs in the past two decades has uncovered many of the pathways fundamental to their pathogenesis, leading to potential therapeutic targets. Several targeted agents are currently being trialled; one, vismodegib, is licensed in the UK for use in advanced BCC. Studies to date demonstrate efficacy of these targeted agents, albeit with frequent and considerable side-effects, and evidence of resistance and recurrence, which currently limit their use to a select group of patients. Pathway inhibitors, though in their infancy, offer a novel and exciting avenue for the targeted treatment of BCC.
Update on the treatment of actinic keratosis
Colin Morton, Megan Mowbray, Colin Clark, Girish Gupta, Robert Herd and Colin Fleming
pp 14-17
Several new therapy options have recently become available for the management of actinic keratosis (AK). Most of these treatments are intended to treat small, or large, areas of sundamaged skin – recognising the importance of field cancerisation, where skin adjacent to AK may contain dysplastic cells, while other therapies are best suited for individual lesions. It is impossible to predict which AK might develop into invasive squamous cell carcinoma (SCC), so guidelines recommend widespread treatment of AK. As approximately 20% of the UK population over 60 years of age will have at least one AK, with prevalence increasing with age, this represents a considerable therapeutic challenge in an era of restricted healthcare budgets. In this article, we briefly review the therapies now available and propose a practical approach to treatment choice.
Monk's moments: Occupational health
Barry Monk
pp 18-18
In times gone by, it was often possible to tell what a patient’s job was by the occupational marks on their skin – the coal dust tattooed into the skin (colliers’ stripes) of the miner or the presternal bursa of the bootmaker, for example. Many traditional industries have vanished and are now remembered by surnames such as Fuller, Fletcher, Wainwright and Salter. Towns and cities also used to be identifiable by their traditional trades but are now recalled by the old nicknames of their football teams: The Cobblers (Northampton Town) and The Hatters (Luton Town); incidentally, the term ‘mad as a hatter’ derives from chronic mercury poisoning, which was a notorious hazard of preparing felt for use in hat-making.
FAQs: What is ‘Breslow thickness’ in melanoma?
Richard Jerrom and Neill Hepburn
pp 19-19
First described by pathologist Alexander Breslow in 1970, ‘Breslow thickness’ is a measurement of the depth of invasion of melanoma into the skin tissue, and remains the most reliable indicator of disease prognosis. The Breslow thickness is defined as the maximum vertical depth, in millimetres, of melanoma cancer cell infiltration below the granular cell layer, which is the most superficial layer of living skin cells in the epidermis. It is measured from excisional biopsies in the laboratory using an ocular micrometer.