The south-east Scotland dermatology workload study: 30 years’ analysis

Fractional CO2 laser - assisted methylene blue photodynamic therapy is a potential alternative therapy for onychomycosis in the era of antifungal resistance

BACKGROUND

Treatment of onychomycosis is challenging by virtue of the impact of nail disfigurement, the location of the fungi within the nail and reported antifungal resistance worldwide. Light-based technologies are promising primary or adjunctive therapeutic modalities. We aimed to compare the efficacy of photodynamic therapy and fractional CO2 laser monotherapy either alone or in combination for onychomycosis.

PATIENTS AND METHODS

This prospective randomized comparative study was conducted on 51 onychomycosis patients divided into three groups. In group A, patients were treated using 6 photodynamic therapy sessions using methylene blue and IPL (560 to 700 nm, fluence 12 J/cm2). Group B patients were treated using 6 bimonthly fractional CO2 laser sessions (10,600 nm, 1.600 mj energy and 0.6 mm density) and group C patients were treated using 6 combined fractional CO2 laser and photodynamic therapy sessions. Patients were evaluated mycologically, dermoscopically and clinically by calculation of proximal nail diameter percentage at baseline, monthly, at the end of treatment and after a 6-month follow-up period post-treatment.

RESULTS

Candida was the most commonly isolated organismin in 64.7%, 70.6% and 70.6% of the pateints in groups A, B and C, respectively. The dermoscopic findings in the total dystrophic onychomycosis was subungual hyperkeratosis in 6 patients (100%), longitudinal streaks and striae in 1 patient (16.7%). In dorsolateral subungual onychomycosis, jagged proximal edge in 31 patients (70.5%), and pigmentation in 30 patients (68.2%) were noted. In proximal subungual onychomycosis irregular matt patches were seen in 1 patient (100%). Proximal nail diameter percentage showed statistically significant improvement after treatment and 6 months follow up in the 3 studied groups. Mean increase of proximal nail diameter after treatment was highest in group C (52.94 ± 20.24), followed by group B (43.82 ± 21.03) and least in group A (35.29 ± 17.0). This difference was statistically significant (p = 0.044). Reported side effects were mild-moderate pain, discoloration and paronychia.

CONCLUSION

We conclude that fractional CO2 laser and photodynamic monotherapy, and their combination achieve high success rates, good patient satisfaction and safety profile. Fractional CO2-assisted photodynamic therapy is associated with the highest improvement over either fractional CO2 or photodynamic therapy alone.

Inflammatory skin diseases and the risk of chronic kidney disease: population-based case-control and cohort analyses

BACKGROUND

Emerging evidence suggests an association between common inflammatory skin diseases and chronic kidney disease (CKD).

OBJECTIVES

To explore the association between CKD stages 3-5 (CKD3-5) and atopic eczema, psoriasis, rosacea and hidradenitis suppurativa.

METHODS

We undertook two complementary analyses; a prevalent case-control study and a cohort study using routinely collected primary care data [UK Clinical Practice Research Datalink (CPRD)]. We matched individuals with CKD3-5 in CPRD in March 2018 with up to five individuals without CKD for general practitioner practice, age and sex. We compared the prevalence of CKD3-5 among individuals with and without each inflammatory skin disease. We included individuals in CPRD with diabetes mellitus (2004-2018) in a cohort analysis to compare the incidence of CKD3-5 among people with and without atopic eczema and psoriasis.

RESULTS

Our study included 56 602 cases with CKD3-5 and 268 305 controls. Cases were more likely than controls to have a history of atopic eczema [odds ratio (OR) 1·14, 99% confidence interval (CI) 1·11-1·17], psoriasis (OR 1·13, 99% CI 1·08-1·19) or hidradenitis suppurativa (OR 1·49, 99% CI 1·19-1·85), but were slightly less likely to have been diagnosed with rosacea (OR 0·92, 99% CI 0·87-0·97), after adjusting for age, sex, practice (matching factors), index of multiple deprivation, diabetes, smoking, harmful alcohol use and obesity. Results remained similar after adjusting for hypertension and cardiovascular disease. In the cohort with diabetes (N = 335 827), there was no evidence that CKD3-5 incidence was associated with atopic eczema or psoriasis.

CONCLUSIONS

Atopic eczema, psoriasis and hidradenitis suppurativa are weakly associated with CKD3-5. Future research is needed to elucidate potential mechanisms and the clinical significance of our findings.

The spectrum of skin-related conditions in primary care during 2015-2019-A Finnish nationwide database study

Background

Skin‐related conditions are the frequent cause of doctors’ consultations in primary care.

Methods

Based on nationwide data bank information of the Finnish Institute for Health and Welfare, we analysed the 20 most frequent main diagnoses for each ICD‐10 category of all general practitioners’ visits in the public health care in Finland over the years 2015–2019.

Results

The total amount of doctor’s visits was 19 204 613 of which 1 489 228 consultations (7.80%) had a skin‐related condition as the main diagnosis. The most frequent skin‐related conditions were eczematous eruptions, bacterial skin infections and benign skin neoplasms accounting for 749 351 consultations (50.32%). The spectrum of skin‐related conditions was diverse, with a large quantity of rarer diagnoses. Some diagnoses showed significant proportional changes.

Conclusions

The results demonstrate that a limited amount of conditions comprises most of the skin‐related consultations in primary care in Finland. Undergraduate education in dermatology should concentrate on the most frequent conditions seen by general practitioners, but also address the wide range of skin problems.

An Australian tertiary hospital analysis of outpatient dermatology clinical and demographic characteristics

OBJECTIVES

Literature on dermatology outpatient demographic and clinical data is limited, and the few studies on this topic are mainly conducted overseas, with medical systems and case mix different to Australia. This study presents demographic data relating to dermatology public outpatient referrals to a tertiary hospital in Brisbane, Australia, and determines what additional structured data should be collected to formulate and evaluate initiatives to address service issues such as referral quality, triage process and wait times.

METHODS

A four-year retrospective audit was undertaken, summarising all referrals (n = 7140) and clinical dermatology encounters (n = 53 844) between January 2016 and December 2019 at Princess Alexandra Hospital (PAH), the largest hospital in Metro South Health (MSH), serving a population of one million. PAH has one of the two largest public dermatology clinics in Queensland and is the only dermatology service within MSH.

RESULTS

Patient demographic data, wait time by triage category, referral rates over time and encounter durations were collected. Structured diagnostic data (e.g. ICD-10 coding) of the provisional diagnosis, comorbidities, medications and the final diagnosis are not collected in a structured format and would be a valuable addition.

CONCLUSIONS

The clinical burden of public dermatology is increasing. Both collection and analysis of structured data pertaining to the referrals and encounters are important to help formulate, implement and evaluate initiatives that aim to improve health service provision in this area.

What Proportion of the Caseload at Dermatology Outpatient Clinics in Spain Do Skin Tumors Account for? Results from the DIADERM National Random Sampling Project

INTRODUCTION AND OBJECTIVE

A significant part of a dermatologist's activity involves the diagnosis and management of tumors. The aim of this study was to analyze the caseload at public and private dermatology outpatient clinics in Spain to determine the proportion of tumor diagnoses.

MATERIAL AND METHOD

Observational cross-sectional study of diagnoses made in dermatology outpatient clinics during 2 data-collection periods in the DIADERM study, an anonymous survey of a random, representative sample of dermatologists across Spain. Diagnoses made during the 2 periods were coded according to the CIE-10. There were 165 tumor-related codes, classified into 24 groups. For the purpose of this study, these groups were then reduced to benign melanocytic lesions, malignant melanocytic lesions, benign nonmelanocytic lesions, and malignant nonmelanocytic lesions.

RESULTS

Tumors accounted for 46.2% of all diagnoses; 18.5% of the tumors were malignant (a category that included in situ forms of keratinocyte cancers). Four of the 10 most common diagnoses were of malignant tumors: in situ keratinocyte cancers, basal cell carcinoma, melanoma, and squamous cell carcinoma. Significant differences were observed between malignant and benign tumors according to type of practice (public vs. private) and geographic region.

CONCLUSION

Skin cancer accounts for a significant part of the dermatologist's caseload in Spain. Differences can be observed depending on the public/private healthcare setting and other factors.

Minor surgery in general practice in Ireland- a report of workload and safety

BACKGROUND

The provision of minor surgical services is an established part of the task profile of general practitioners (GPs) in many countries in Europe and elsewhere. This study aimed to collect data on the clinical process and outcomes for specified minor surgical procedures undertaken in Irish general practice by GPs experienced in minor surgery in order to document the scope and safety of minor surgery being undertaken.

METHODS

Over a six-month period, 24 GPs in 20 practices recorded data on a pre-determined list of procedures undertaken in adults (aged 18 and older); procedures for ingrown toenails were also recorded for those aged 12-18 years. Clinical data were rendered fully anonymous by the participating GPs, entered onto the Excel database template and returned to the project team monthly.

RESULTS

On average, each practice undertook 212 procedures in a six-month period. The four most frequent procedures include two relatively non-invasive procedures (cryosurgical ablation of skin lesions and aspiration and/or injection of joints) and two more invasive procedures (full thickness excision of skin lesion and shave, punch or incisional biopsy). Overall, 83.8% of relevant specimens were submitted for histology. Combining benign and malignant cases, there was an overall 87% clinical and histological concordance; 85% of malignancies were suspected clinically. A complication was recorded in 0.9% after 1 month.

CONCLUSIONS

Irish GPs with experience in minor surgery can provide a range of surgical services in the community safely.

The Role of Teledermatology and Teledermoscopy in the Diagnosis of Actinic Keratosis and Field Cancerization

Actinic keratosis (AK) and field cancerization are increasing health problems insufficiently diagnosed by primary care physicians. The objective of this study was to assess the validity and reliability of teledermatology (TD) and teledermoscopy in the diagnosis of AK and field cancerization in a gatekeeper healthcare model. A prospective diagnostic test evaluation was done to assess the diagnostic concordance, accuracy, and performance parameters and the interobserver and intraobserver concordances of TD and teledermoscopy compared with dermatologists' face-to-face evaluation or histopathology. A total of 636 patients with 1,000 keratotic skin lesions were included. TD diagnostic concordance for AK and field cancerization evaluation was very high and superior to primary care physicians' diagnosis (92.4% vs. 62.4% and 96.7% vs. 51.8%, P < 0.001). TD sensitivity, specificity, and positive and negative predictive values for AK diagnosis and field cancerization were high (range = 82.2-95.0) and better than primary care physicians' diagnosis. Teledermoscopy yielded better results in diagnostic concordance, performance parameters, and AK subtypes. Intraobserver and interobserver agreement was >0.83. TD and, to a greater extent, teledermoscopy may be valid and reliable tools for the diagnosis of AK and field cancerization and may improve diagnosis and correct allocation and management in gatekeeper healthcare systems. It can be an alternative tool to training primary care physicians in direct diagnosis of these lesions.

Skin cancer screening after solid organ transplantation: Survey of practices in Canada

Guidelines recommend annual dermatology screening after solid organ transplantation to facilitate early detection of keratinocyte carcinoma (nonmelanoma skin cancer), the most common posttransplant malignancy. There are limited data on adherence levels and barriers to screening. We conducted a cross-sectional survey of 477 physicians and nurses providing posttransplant care in Canada. The questionnaire asked about skin cancer screening and education practices, including the perceived importance and barriers. Whereas care providers viewed skin cancer screening as important for adult patients (median rating of 10/10, interquartile range 8-10), only 53% ensured annual screening for white adult transplant recipients. Having a screening policy in place (adjusted odds ratio 6.78, 95% confidence interval 3.12-14.74) and a dermatologist present at the transplant center (adjusted odds ratio 2.19, 95% confidence interval 1.03-4.67) were independently associated with higher adherence. Long wait times, lack of specialized transplant dermatologists, long travel distances, and insufficient priority were cited as the most common barriers for access to dermatologic care. Skin cancer education was provided to patients by over three quarters of care providers. Given the self-reported lack of adherence to annual skin cancer screening, there is need to develop, evaluate, and implement interventions that improve screening rates and skin cancer outcomes.

The evolution of dermatology: dermatological workload in southeast Scotland 1921-2010

BACKGROUND

Sequential audits over a recent 30-year period from 1981 to 2010 have documented dermatological activity data for the same region of southeast Scotland approximately every 5 years, allowing demonstration of trends in workload.

AIM

To undertake similar assessments of outpatient dermatological activity using historical documentation from 1921 to 1965, and to compare trends with modern data.

METHODS

Historical records held in the libraries of the Department of Dermatology, Royal Infirmary, Edinburgh and in the University of Edinburgh were audited. Details of new dermatological outpatients were recorded for the months of September, October and November from 1921, and at 5-year intervals from 1925 to 1965. Patient age, sex and primary diagnosis were documented. Data were analysed and compared with those of previous audits of the same geographical population from 1981 to 2010.

RESULTS

Details of 11 225 new patients were analysed during the period 1921-1965, in conjunction with 7755 patients from the period 1981-2010, giving a total of 18 980 patients included in the study. The monthly number of patients increased by over 3000%, from 74 patients in 1921-2882 patients in 2010. Trends were seen in the following diagnostic categories. Between 1921 and 2010, benign tumours increased from 1% to 36% of workload and malignant tumours from 2% to 11%. Over the same time period, dermatitis decreased from 32% to 13%, and infections from 24% to 2%. Infestations referrals peaked at 12% in the 1940s, but declined to 1% in the 1950s. Viral warts peaked at 49% of patients in 1960 and fell to 3% in 2010.

CONCLUSIONS

Over a 90-year period, there has been a dramatic rise in new patient dermatological workload. We have found trends in presentations of common dermatological conditions. Outpatient dermatology now appears to be increasingly involved in the detection and treatment of skin malignancy. Although many inflammatory dermatoses remain important, infectious dermatoses are less commonly encountered, compared with historical activity.

Skin cancer excision performance in Scottish primary and secondary care: a retrospective analysis

BACKGROUND

In contrast with most published evidence, studies from north-east Scotland suggest that GPs may be as good at treating skin cancers in primary care as secondary care specialists.

AIM

To compare the quality of skin cancer excisions of GPs and secondary care skin specialists in east and south-east Scotland.

DESIGN AND SETTING

A retrospective analysis of reports from GPs in Lothian, Fife, and Tayside regions.

METHOD

Skin cancer histopathology reports from GPs in Lothian, Fife, and Tayside regions in 2010 were compared with reports from skin specialists in November 2010. The histopathology reports were rated for completeness and adequacy of excision.

RESULTS

A total of 944 histopathology reports were analysed. In 1 year, GPs biopsied or excised 380 skin cancers. In 1 month, dermatologists biopsied or excised 385 skin cancers, and plastic surgeons 179 skin cancers. 'High risk' basal cell carcinomas (BCC) comprised 63.0% of BCC excised by GPs. For all skin cancer types, GPs excised smaller lesions, and had a lower rate of complete excisions compared with skin specialists. A statistical difference was demonstrated for BCC excisions only.

CONCLUSION

GPs in east and south-east Scotland excise a number of skin cancers including malignant melanoma (MM), squamous cell carcinoma (SCC) and high-risk BCC. Despite removing smaller lesions, less commonly on difficult surgical sites of the head and neck, GP excision rates are lower for all skin cancers, and statistically inferior for BCC, compared with secondary care, supporting the development of guidelines in Scotland similar to those in other UK regions. Poorer GP excision rates may have serious consequences for patients with high-risk lesions.

The association between psychiatric diseases, psychotropic drugs and the risk of incident rosacea

BACKGROUND

Psychological conditions, such as traumatic events or stress, have been discussed controversially as aetiological factors for rosacea.

OBJECTIVES

To assess the association between diagnosed depression, other affective disorders or schizophrenia and subsequent incident rosacea. We further aimed at evaluating the possible role of various psychotropic drugs within this association.

METHODS

We conducted a matched case-control study of psychiatric diseases and incident rosacea, stratified by exposure to various psychotropic drugs, using the UK-based General Practice Research Database. Cases had a first diagnosis of rosacea recorded between 1995 and 2009. Each case was matched to one control on age, sex, general practice and years of history on the database.

RESULTS

A history of depression or other affective disorders was not associated with an increased risk of developing rosacea; lithium was the only antidepressant drug that significantly altered this association. Current long-term use of lithium was associated with a decreased odds ratio (OR) of 0·58 [95% confidence interval (CI) 0·38-0·88] among people without a schizophrenia diagnosis (with or without affective disorders), compared with people not exposed to lithium. Patients with diagnosed schizophrenia revealed a decreased rosacea risk (OR 0·71, 95% CI 0·60-0·91), independent of antipsychotic drug use.

CONCLUSIONS

Depression or other affective disorders were not associated with incident rosacea, whereas patients with schizophrenia were at a decreased risk of this skin disease in our study population. The materially decreased risk of rosacea among people with chronic lithium exposure may lead to new insights into the pathomechanism of rosacea.

Baboon syndrome: an unusual complication arising from antibiotic treatment of tonsillitis and review of the literature

A 40-year-old man presented with sore throat and fevers associated with bilaterally enlarged and inflamed tonsils. A clinical diagnosis of tonsillitis was made and the patient received intravenous benzylpenicillin. Over subsequent days, the patient developed a macular rash over both groins, buttocks and axillae, with necrotic patches in the groins. An assumptive diagnosis of necrotising fasciitis was made. The patient underwent urgent groin biopsy and was started on broad spectrum antibiotics. No organisms were seen on Gram stain. Following a multidisciplinary discussion, the patient was diagnosed with baboon syndrome (symmetrical drug-related intertriginous and flexural exanthema). He was treated with oral steroid along with topical agents. Baboon syndrome can develop following penicillin administration. Given the widespread use of penicillin antibiotics to treat tonsillitis and many other conditions, it is important that medical staff recognise the side effects of these medications.

The prevalence of onychomycosis in the global population: a literature study

BACKGROUND

Onychomycosis is a common disorder, and high prevalence figures are commonly cited in the literature.

OBJECTIVES

Evaluate the prevalence of onychomycosis based on published studies.

METHODS

Relevant studies were identified in Medline by using specific search criteria.

RESULTS

Eleven population-based and 21 hospital-based studies were identified. The mean prevalence in Europe and North America was 4.3% [95% Confidence Interval (CI): 1.9-6.8] in the population-based studies, but it was 8.9% (95% CI: 4.3-13.6) for the hospital-based studies. Both population-based and hospital-based studies showed that onychomycosis is more common in toenails and is seen more frequently in males. The main causative agent was a dermatophyte in 65.0% (95% CI: 51.9-78.1) of the cases. Trichophyton rubrum was the single most common fungus and was cultured on average in 44.9% of the cases (95% CI: 33.8-56.0). Moulds were found on average in 13.3% (95% CI: 4.6-22.1) and yeasts in 21.1% (95% CI: 11.0-31.3).

LIMITATIONS

We may not have been able to locate all studies.

CONCLUSIONS

Onychomycosis is a common disorder, but it may not be as common as cited in the literature, because hospital-based studies might overestimate the prevalence of onychomycosis. It is more frequent in males, and toenails are more commonly affected. Dermatophytes, particularly T. rubrum, are the main causative agents.