Dermatology in practice - 2014


Comment: Learning from patients
Neill Hepburn
pp 3-3
Complaints from patients have been dominating my life for the past few weeks. Following the Keogh Review we have, as a trust, been reviewing and changing our complaints processes. As part of that exercise, I have ‘signed off’ many of the complaints about medical care. I have also spoken to, and met, many of the complainants. What a thoroughly humbling and educational time it has been! Reading Nicholas Collier, Faisal Ali and John Lear’s article on HIV, I recalled the last complaint made about me personally. I had failed to test a man with severe idiopathic pruritus for HIV. While I could be ‘defensive’ and point out that he had been very selective in the history he had given, it is also true that I should have at least thought of testing him. My index of suspicion had been too low. Patients who itch without an obvious cause are always something of a challenge to me – so that patient’s complaint and the book reviewed on page eight of this issue have both helped me.
Therapy update on HIV and skin disease
Nicholas J Collier, Faisal R Ali and John T Lear
pp 4-8
Skin disease is highly prevalent in patients with HIV and causes significant morbidity through severe symptoms, as well as stigmatising, disfiguring lesions. It is associated with mortality, either as a manifestation of generalised conditions or, less commonly, due to a primary cutaneous disorder. Early treatment of HIV infection provides near normal life expectancy; however, currently an estimated 24% of HIV-infected people are undiagnosed in the UK, with 47% presenting as a late diagnosis (CD4+ cell count <350 mm3). The integumentary system provides a window to immune function, enabling detection of derangement, therefore facilitating earlier diagnosis. Although some HIV-associated skin diseases may present pathognomonically, many do not. Thus, clinicians must adopt a low threshold of suspicion of HIV, particularly in conditions that are atypical, severe, occur in combination or are recalcitrant to treatment. Antiretroviral treatment has improved life expectancy and reduced opportunistic infections while newer medications have improved side effect profiles; however, adverse drug reactions are common and awareness of drug interactions is vital. This review aims to provide a brief overview of HIV-associated skin disease with a focus on cutaneous infections, inflammatory diseases and adverse drug reactions.
A non-surgical approach to non-melanoma skin cancer – part 1
Sweta Rai and Stephen Keohane
pp 10-13
Non-melanoma skin cancer (NMSC) is the most common form of skin cancer in the UK, with 99,549 cases registered in 2010 alone. Of these cases, 56% were male and 44% were female, giving a 13:10 male-to-female ratio. The true incidence of NMSC in the UK remains unknown because robust registry data are not available and many NMSCs treated in both the public and private sectors are not recorded. It is estimated that 30–50% of basal cell carcinomas (BCCs) and around 30% of squamous cell carcinomas (SCCs) are unrecorded. Although NMSC causes little mortality, it can cause significant morbidity if either detection or treatment are delayed. Therefore, both timely recognition and appropriate management of NMSC are important to prevent disfigurement and preserve function. This should also decrease the associated financial burden on the NHS. In this first part of a two-part article, we give an introduction to NMSC, outlining primary and secondary prevention and describing some emerging therapies for the most common forms of NMSC. In the second part, we will examine in more detail the emerging non-surgical therapies for actinic keratosis (AK), BCC and SCC.
How to use marking sutures on soft tissue lesions
Johann Jeevaratnam, Kamil Asaad and Nicholas Bennett
pp 14-14
Sutures are commonly used to mark excised soft tissue lesions in order to orientate the specimens for histological examination. Inappropriate application, leading to tissue trauma, has been reported by our pathology department to compromise histological examination of the specimen. Here we describe a marker suture technique that will avoid crushing the underlying tissue and therefore minimise the adverse effect on histological analysis. This technique may be applied to the excision of both superficial and deep soft tissue lesions.
Monk's moments: Who will guard the guards themselves?
Barry Monk
pp 15-15
I am a generous chap by nature and happy to spend my hard-earned money. I am, within limits, even happy for my wife and children to spend it for me. But when complete strangers want to spend my money, well that is quite another matter. I read in our local newspaper recently that the Bedfordshire Clinical Commissioning Group (CCG) has proposed spending £3.2 million on yet another review of local health provision. It reassured readers that Monitor, the health services regulator designed to ensure that NHS money is spent prudently, will provide the money. I was forced to write back to explain that, in fact, it was not Monitor that was paying, but the taxpayer, you and me, and that £3.2 million would by my calculations be enough to pay for an extra 20 hospital cleaners for the next ten years. Furthermore, I wrote that, since it was my money that the Bedfordshire CCG was planning to spend, I knew which of the two options I would prefer.
Psychological adjustment to disfiguring skin diseases
Zoe Chouliara and Andrew Affleck
pp 16-19
After diagnosis of a skin disorder, there follows a period of psychological adjustment during which most people are able to cope. Coping is a process that can be described as ‘expending conscious effort to solve personal and interpersonal problems, and seeking to master, minimise or tolerate a stressor’. Many types of coping strategies are possible, including planning; positive re-interpretation; using practical and emotional social support; venting of emotions; suppression of competing activities; emotional, behavioural and cognitive disengagement; and use of humour or religion. Several methods may be used and the methods used may change; skills are used or developed to regain a sense of equilibrium and well-being. Exploring ways of coping can be useful and an assessment tool such as The Brief COPE Questionnaire can help in this regard. Some people appear to cope well and adjust quickly despite an objectively severe skin disease, while others may become very stressed and struggle to cope in the face of an objectively minor skin disorder. Psychological adjustment is a multifactorial and fluctuant biopsychosocial process which centres around three themes: a search for meaning in the experience; an attempt to regain control over the situation and in life generally; and an effort to restore self-esteem.