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Ungureanu S, Arzpayma P, Edwards C, Anstey AV. Home phototherapy in the U.K.'s National Health Service: time to reach out. Br J Dermatol 2018; 176:1339-1340. [PMID: 28504385 DOI: 10.1111/bjd.14993] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- S Ungureanu
- Heart of England NHS Foundation Trust, Birmingham, U.K
| | - P Arzpayma
- Ysbyty Gwynedd, Betsi Cadwaladr University Health Board, Bangor, Gwynedd, North Wales
| | - C Edwards
- Aneurin Bevan University Health Board, Newport, South Wales
| | - A V Anstey
- Ysbyty Gwynedd, Betsi Cadwaladr University Health Board, Bangor, Gwynedd, North Wales
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Ismail N, Callander J, Williams M, Anstey AV. Erythrodermic pityriasis rubra pilaris managed at home: intensive community care followed by ustekinumab. Clin Exp Dermatol 2018; 43:749-751. [PMID: 29779249 DOI: 10.1111/ced.13626] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2018] [Indexed: 11/27/2022]
Affiliation(s)
- N Ismail
- Department of Dermatology, Ysbyty Gwynedd, Bangor, UK
| | - J Callander
- Department of Dermatology, Ysbyty Glan Clwyd, Rhyl, Clwyd, UK
| | - M Williams
- Department of Dermatology, Ysbyty Gwynedd, Bangor, UK
| | - A V Anstey
- Department of Dermatology, Ysbyty Gwynedd, Bangor, UK.,Department of Dermatology, Cardiff University, Cardiff, UK
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Callander J, Anstey AV, Ingram JR, Limpens J, Flohr C, Spuls PI. How to write a Critically Appraised Topic: evidence to underpin routine clinical practice. Br J Dermatol 2017; 177:1007-1013. [PMID: 28967117 DOI: 10.1111/bjd.15873] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2017] [Indexed: 12/26/2022]
Abstract
Critically appraised topics (CATs) are essential tools for busy clinicians who wish to ensure that their daily clinical practice is underpinned by evidence-based medicine. CATs are short summaries of the most up-to-date, high-quality available evidence that is found using thorough structured methods. They can be used to answer specific, patient-orientated questions that arise recurrently in real-life practice. This article provides readers with a detailed guide to performing their own CATs. It is split into four main sections reflecting the four main steps involved in performing a CAT: formulation of a focused question, a search for the most relevant and highest-quality evidence, critical appraisal of the evidence and application of the results back to the patient scenario. As well as helping to improve patient care on an individual basis by answering specific clinical questions that arise, CATs can help spread and share knowledge with colleagues on an international level through publication in the evidence-based dermatology section of the British Journal of Dermatology.
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Affiliation(s)
- J Callander
- Department of Dermatology, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, U.K
| | - A V Anstey
- Department of Dermatology, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, U.K
| | - J R Ingram
- Division of Infection and Immunity, Department of Dermatology and Academic Wound Healing, Cardiff University, Cardiff, U.K
| | - J Limpens
- The Medical Library, Research Support, University of Amsterdam, Amsterdam, the Netherlands
| | - C Flohr
- Unit for Population-Based Dermatology Research, St John's Institute of Dermatology, Guy's& St Thomas' NHS Foundation Trust and King's College London, London, U.K
| | - P I Spuls
- Department of Dermatology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
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Al-Ismail D, Edwards C, Anstey AV. Erythema action spectrum of topical 8-methoxypsoralen-sensitized skin re-evaluated: implications for routine clinical practice. Br J Dermatol 2015; 174:131-5. [PMID: 26383592 DOI: 10.1111/bjd.14101] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Published methodology used to determine psoralen plus ultraviolet A (PUVA) erythemal action spectrum does not reflect current clinical practice for psoralen sensitization. We re-evaluated the PUVA action spectrum using aqueous 8-methoxypsoralen (8-MOP) 2·6 mg L(-1) as used routinely in current clinical practice. OBJECTIVES To determine the UVA erythema action spectrum of topical 8-MOP-sensitized normal skin. METHODS Twenty healthy volunteers with skin phototypes I-V were recruited. Forearms were psoralen-sensitized at 37 °C for 10 min. Six UVA irradiations at 10-nm intervals between 325 and 375 nm were randomly allocated to forearm sites and were applied using a 10-nm bandwidth irradiation monochromator. The visual minimal phototoxic dose (MPD) was recorded on each site at 96 h. RESULTS Volunteer Boston phototypes were: I, n = 2; II, n = 6; III, n = 6; IV, n = 5 and V, n = 1. The mean MPD (J cm(-2) ) for all subjects at each wavelength was as follows: 325 nm, 0·64 (SD 0·37); 335 nm, 0·80 (SD 0·58); 345 nm, 0·96 (SD 0·55); 355 nm, 1·50 (SD 0·85); 365 nm, 2·19 (SD 0·90); and 375 nm, 2·89 (SD 1·06). Therefore, the relative sensitization at each wavelength (erythemal action spectrum) was: 1, 0·83, 0·67, 0·43, 0·29 and 0·22. There were significant differences between the PUVA erythemal effectiveness at different wavelengths but none between skin types. CONCLUSIONS This study has established the erythemal action spectrum for bath/soak PUVA therapy as is currently performed. In all volunteers, the peak sensitivity was at 325 nm. All volunteers showed a similar trend across the wavelengths studied irrespective of skin type. The determination of the action spectrum for PUVA-induced erythema is important as it permits reliable estimates of erythemal efficacy of any UVA source where the emission spectrum of the lamp is known or can be measured.
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Affiliation(s)
- D Al-Ismail
- Department of Dermatology, St Woolos Hospital, Aneurin Bevan University Health Board, Newport, NP20 2UB, U.K.,Cardiff University, Heath Park, Cardiff, CF14 4XN, U.K
| | - C Edwards
- Department of Dermatology, St Woolos Hospital, Aneurin Bevan University Health Board, Newport, NP20 2UB, U.K
| | - A V Anstey
- Cardiff University, Heath Park, Cardiff, CF14 4XN, U.K.,Department of Dermatology, Ysbyty Gwynedd, Betsi Cadwaladr University Health Board, Bangor, LL57 2PY, U.K
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Hung R, Ungureanu S, Edwards C, Gambles B, Anstey AV. Home phototherapy for psoriasis: a review and update. Clin Exp Dermatol 2015; 40:827-2; quiz 832-3. [DOI: 10.1111/ced.12703] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2014] [Indexed: 12/28/2022]
Affiliation(s)
- R. Hung
- Department of Medicine; University Hospital Lewisham; London UK
| | - S. Ungureanu
- Birmingham Skin Centre; City Hospital; Birmingham UK
| | - C. Edwards
- Academic Dermatology Unit; St Woolos Hospital; Newport Gwent UK
| | - B. Gambles
- Academic Dermatology Unit; St Woolos Hospital; Newport Gwent UK
| | - A. V. Anstey
- Academic Dermatology Unit; St Woolos Hospital; Newport Gwent UK
- Academic Dermatology Unit; University Hospital of Wales; Cardiff University; Cardiff UK
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Ponnambath N, Kalavala M, Anstey AV, Piguet V, Ingram JR. Practical experience of biologics for treatment of very severe psoriasis: a retrospective case cohort study of patients with a baseline Psoriasis Area and Severity Index greater than 20. Clin Exp Dermatol 2015; 41:95-6. [DOI: 10.1111/ced.12651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2014] [Indexed: 11/29/2022]
Affiliation(s)
- N. Ponnambath
- Department of Dermatology; University Hospital of Wales; Cardiff and Vale University Health Board; Cardiff UK
| | - M. Kalavala
- Department of Dermatology; University Hospital of Wales; Cardiff and Vale University Health Board; Cardiff UK
| | - A. V. Anstey
- Department of Dermatology; Royal Gwent Hospital; Aneurin Bevan Health Board; Newport UK
| | - V. Piguet
- Department of Dermatology and Wound Healing; Institute of Infection and Immunity; University Hospital of Wales; Heath Park Cardiff CF14 4XN UK
| | - J. R. Ingram
- Department of Dermatology and Wound Healing; Institute of Infection and Immunity; University Hospital of Wales; Heath Park Cardiff CF14 4XN UK
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Alshiyab D, Edwards C, Chin MF, Anstey AV. Targeted ultraviolet B phototherapy: definition, clinical indications and limitations. Clin Exp Dermatol 2014; 40:1-5. [DOI: 10.1111/ced.12441] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2014] [Indexed: 11/29/2022]
Affiliation(s)
- D. Alshiyab
- Department of Dermatology; Faculty of Medicine; Jordan University of Science and Technology; Irbid Jordan
| | - C. Edwards
- Academic Dermatology Unit; St Woolos Hospital; Newport UK
| | - M. F. Chin
- Department of Dermatology; University Hospital of Wales; Cardiff UK
| | - A. V. Anstey
- Academic Dermatology Unit; St Woolos Hospital; Newport UK
- Cardiff University; Cardiff UK
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Ingram JR, Wood M, John B, Butler R, Anstey AV. Absence of pathogenic γ-secretase mutations in a South Wales cohort of familial and sporadic hidradenitis suppurativa (acne inversa). Br J Dermatol 2013; 168:874-6. [PMID: 23013355 DOI: 10.1111/bjd.12048] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Katugampola RP, Anstey AV, Finlay AY, Whatley S, Woolf J, Mason N, Deybach JC, Puy H, Ged C, de Verneuil H, Hanneken S, Minder E, Schneider-Yin X, Badminton MN. A management algorithm for congenital erythropoietic porphyria derived from a study of 29 cases. Br J Dermatol 2012; 167:888-900. [PMID: 22804244 DOI: 10.1111/j.1365-2133.2012.11154.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Congenital erythropoietic porphyria (CEP) is an autosomal recessive photomutilating porphyria with onset usually in childhood, where haematological complications determine prognosis. Due to its extreme rarity and clinical heterogeneity, management decisions in CEP are often difficult. OBJECTIVES To develop a management algorithm for patients with CEP based on data from carefully characterized historical cases. METHODS A single investigator collated data related to treatments and their outcomes in 29 patients with CEP from the U.K., France, Germany and Switzerland. RESULTS Six children were treated with bone marrow transplantation (BMT); five have remained symptomatically cured up to 11.5 years post-transplantation. Treatments such as oral charcoal, splenectomy and chronic hypertransfusion were either of no benefit or were associated with complications and negative impact on health-related quality of life. Lack of consistent genotype-phenotype correlation meant that this could not be used to predict disease prognosis. The main poor prognostic factors were early age of disease onset and severity of haematological manifestations. CONCLUSIONS A management algorithm is proposed where every patient, irrespective of disease severity at presentation, should receive a comprehensive, multidisciplinary clinical assessment and should then be reviewed at intervals based on their predicted prognosis, and the rate of onset of complications. A BMT should be considered in those with progressive, symptomatic haemolytic anaemia and/or thrombocytopenia. Uroporphyrinogen III synthase genotypes associated with poor prognosis would additionally justify consideration for a BMT. Rigorous photoprotection of the skin and eyes from visible light is essential in all patients.
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Affiliation(s)
- R P Katugampola
- Department of Dermatology and Wound Healing, Cardiff University, UK.
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Ingram JR, Anstey AV, Piguet V. Combination treatment with a tumour necrosis factor antagonist and an oral retinoid: efficacy in severe acral psoriasis? Br J Dermatol 2012; 167:949-51. [PMID: 22486276 DOI: 10.1111/j.1365-2133.2012.10983.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ingram JR, Anstey AV, Piguet V. Combination treatment with a tumour necrosis factor antagonist and an oral retinoid: efficacy in severe acral psoriasis? Br J Dermatol 2012. [PMID: 22486276 DOI: 10.1111/j.1365-2133.2012.10983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Meggitt SJ, Anstey AV, Mohd Mustapa MF, Reynolds NJ, Wakelin S. British Association of Dermatologists' guidelines for the safe and effective prescribing of azathioprine 2011. Br J Dermatol 2012; 165:711-34. [PMID: 21950502 DOI: 10.1111/j.1365-2133.2011.10575.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- S J Meggitt
- Department of Dermatology, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK.
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Anstey AV. Commentary: pharmacogenetic screening to prevent carbamazepine-induced toxic epidermal necrolysis and Stevens-Johnson syndrome. Br J Dermatol 2012; 166:14-5. [PMID: 22212060 DOI: 10.1111/j.1365-2133.2011.10761.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- A V Anstey
- Aneurin Bevan Health Board and Cardiff University, Cardiff, UK.
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Abstract
A number of skin conditions are characterised by photosensitivity to UVA. Some of these are exclusively UVA-mediated conditions, while others include UVA in the action spectrum which also include UVB and/or visible light. This review aims to describe this diverse range of conditions for non-dermatologist scientists with an interest in this topic. As such, clinical details, including treatments, are brief and succinct. Recent advances in understanding the pathogenesis of these conditions is highlighted.
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Affiliation(s)
- E Smith
- Cardiff and Vale University Health Board, Heath Park, Cardiff, United Kingdom CF14 4XN
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Affiliation(s)
- A V Anstey
- Department of Dermatology, Royal Gwent Hospital, Newport, Gwent NP9 2UB, UK.
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Gawkrodger DJ, Ormerod AD, Shaw L, Mauri-Sole I, Whitton ME, Watts MJ, Anstey AV, Ingham J, Young K. Vitiligo: concise evidence based guidelines on diagnosis and management. Postgrad Med J 2010; 86:466-71. [DOI: 10.1136/pgmj.2009.093278] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Jarrett R, Gonsalves R, Anstey AV. Differing obstetric outcomes of rosacea fulminans in pregnancy: report of three cases with review of pathogenesis and management. Clin Exp Dermatol 2010; 35:888-91. [DOI: 10.1111/j.1365-2230.2010.03846.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Smith CH, Anstey AV, Barker JNWN, Burden AD, Chalmers RJG, Chandler DA, Finlay AY, Griffiths CEM, Jackson K, McHugh NJ, McKenna KE, Reynolds NJ, Ormerod AD. British Association of Dermatologists' guidelines for biologic interventions for psoriasis 2009. Br J Dermatol 2010; 161:987-1019. [PMID: 19857207 DOI: 10.1111/j.1365-2133.2009.09505.x] [Citation(s) in RCA: 347] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- C H Smith
- St John's Institute of Dermatology, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK.
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Abstract
BACKGROUND Erythropoietic protoporphyria (EPP) is a cutaneous porphyria caused by mutations in the ferrochelatase (FECH) or, less frequently, the delta-aminolaevulinate synthase 2 (ALAS2) gene. Predictive genetic counselling requires accurate molecular diagnosis and knowledge of patterns of inheritance. OBJECTIVES To investigate the molecular epidemiology of EPP in the U.K. METHODS DNA samples from 191 unrelated patients resident in the U.K. were analysed for mutations in the FECH and ALAS2 genes and for the FECH IVS3-48 dimorphism. RESULTS Mutations were identified in 179 (94%) patients. Most (169; 94%) had a FECH mutation on one allele and were classified as having pseudodominant EPP (psdEPP); seven (4%) patients had FECH mutations on both alleles (autosomal recessive EPP) and three (2%) patients had ALAS2 mutations (X-linked dominant protoporphyria). The FECH IVS3-48C allele was strongly associated with psdEPP and with the absence of mutations at the FECH or ALAS2 loci. Fifty-six FECH mutations were identified, 19 being previously unreported. Missense mutations were predominant in autosomal recessive EPP (82%) but not in psdEPP (32%). One mutation (c.314 + 2T>G) was present in 41 (24%) of EPP families, most of whom appeared to be descended from a common ancestor resident in the north of England. CONCLUSIONS These data define the prevalence and molecular epidemiology of each type of EPP in the U.K.
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Affiliation(s)
- S D Whatley
- Department of Medical Biochemistry and Immunology, University Hospital of Wales and School of Medicine, Cardiff University, Cardiff CF14 4XN, U.K
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Thomas CL, Badminton MN, Rendall JRS, Anstey AV. Sclerodermatous changes of face, neck and scalp associated with familial porphyria cutanea tarda. Clin Exp Dermatol 2008; 33:422-4. [DOI: 10.1111/j.1365-2230.2007.02579.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Affiliation(s)
- A V Anstey
- Royal Gwent Hospital, Cardiff Road, Newport, Gwent NP20 2UB, UK.
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Affiliation(s)
- M Kalavala
- Department of Occupational Dermatology, Royal Gwent Hospital, Newport, UK.
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Martin JA, Laube S, Edwards C, Gambles B, Anstey AV. Rate of acute adverse events for narrow-band UVB and Psoralen-UVA phototherapy. Photoderm Photoimm Photomed 2007; 23:68-72. [PMID: 17523927 DOI: 10.1111/j.1600-0781.2007.00278.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Ultraviolet (UV) radiation therapies are commonly used to treat a wide range of dermatological conditions. However, no published data exist regarding the rate of acute adverse events occurring within the different UV therapy modalities. AIM The aim of this study was to determine the rate of acute adverse events experienced by patients receiving narrow-band UVB or photochemotherapy in 3 neighboring dermatology units. METHOD Standardized adverse event forms from all 3 units were retrospectively analysed over a 12-month period between October 2003 and September 2004. The treatments included were narrow-band UVB and systemic, bath and hand/foot PUVA. RESULTS A total of 8784 treatments were given over the study period. The total number of acute adverse events recorded for all phototherapy treatments was 70 (0.8%). The rates of acute adverse events for each treatment modality were 0.6% for narrow-band UVB, 1.3% for systemic PUVA, 1.3% for bath PUVA and 0.8% for hand/foot PUVA. Adverse events were due to patient non-compliance with standard operating procedures in 15 cases (21%) and operator error in 2 (3%). Only 4 of the acute adverse events were considered to be severe, accounting for 0.05% of all treatments. CONCLUSIONS The rates of acute adverse events with phototherapy in this analysis were low, in particular the rate of severe adverse events. The highest rate was seen with both systemic and bath PUVA. The number of adverse events resulting from operator error was low. These published rates for adverse events associated with narrow-band UVB and PUVA may help other units when analyzing their own rate of adverse events.
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Affiliation(s)
- J A Martin
- Department of Dermatology, University Hospital of Wales, Heath Park, Cardiff, UK.
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Otman SGH, Edwards C, Gambles B, Anstey AV. Validation of a semiautomated method of minimal erythema dose testing for narrowband ultraviolet B phototherapy. Br J Dermatol 2006; 155:416-21. [PMID: 16882183 DOI: 10.1111/j.1365-2133.2006.07273.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The most widely used method for establishing the minimal erythema dose (MED) before narrowband ultraviolet (UV) B phototherapy is time-consuming, inconvenient and may yield inconsistent results. OBJECTIVES To assess the equivalence of MED assessment using a filtered xenon arc lamp UV source, a semiautomated MED tester, and a UV-opaque template method of MED determination with a panel of TL-01 311-nm UVB fluorescent tubes. Secondly, to gauge the current usage of MED testing, and the method used, in a large sample of U.K. phototherapy units. Thirdly, to assess variation in UV output of the semiautomated skin tester immediately after switching on to identify optimum warm-up time. Finally, to assess reproducibility of MED testing by assessing within-patient variability and interobserver variability of MED test results. METHODS Sixty-five patients about to undergo UVB phototherapy had their MED determined using three different methods. Within each patient we compared the values of MED determined by a semiautomated Durham MED tester, a panel of narrowband UVB lamps with a UV-opaque template constructed by a phototherapist, and a 310-nm filtered xenon arc lamp with a liquid light guide. MED test results were assessed by clinical evaluation using a 6500 K colour temperature examination lamp. The output of the semiautomated MED tester was measured by spectroradiometer over a period of 20 min in order to identify the time to steady output. Reproducibility of MED testing with the semiautomated MED tester was carried out in 25 normal volunteers. All MEDs were assessed by at least two independent observers. A postal questionnaire was sent to 78 U.K. phototherapy units to assess routine practice concerning MED testing prior to narrowband UVB phototherapy. RESULTS The semiautomated MED tester showed consistency with the panel method (r = 0.92, panel MED = -0.57 + 1.14 x Durham MED). The semiautomated MED tester produced a slightly lower MED result than the panel MED. Reproducibility tests showed high interobserver agreement (kappa value = 0.79), and high consistency for successive day testing (kappa value = 0.79). Questionnaires were returned from 67 of 78 phototherapy units (85%) and revealed that 19 units (28%) were routinely using MED testing prior to UVB therapy. CONCLUSIONS This study has shown the Durham MED tester to be a convenient, valid and reproducible method for determining patient MED values prior to narrowband UVB phototherapy when used under carefully controlled lighting, by experienced observers.
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Affiliation(s)
- S G H Otman
- Department of Dermatology, Royal Gwent Hospital, Newport NP20 2UB, UK.
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Abstract
BACKGROUND Erythropoietic protoporphyria (EPP) is a rare inherited photodermatosis that causes lifelong painful photosensitivity. Neither its full clinical spectrum nor its impact on quality of life (QoL) has been investigated in a large cohort of patients. OBJECTIVES To document the clinical features of EPP and its impact on QoL in a high proportion of all patients with EPP resident in the U.K. METHODS Patients with EPP were identified from U.K. clinical databases and assessed by the same clinical investigator over a 7-month period using a standardized proforma and validated adult (Dermatology Life Quality Index, DLQI) and children's (Children's Dermatology Life Quality Index, CDLQI) QoL questionnaires. RESULTS Three hundred and eighty-nine living patients with EPP were identified, of whom 223 [114 females, 109 males; median age 34 years (range: 5-87), from 193 families] were investigated. Total erythrocyte porphyrin (TEP) was higher in males (median: 25.3 micromol L1) than females (median: 19.3 micromol L1). The median ages at onset and diagnosis were 1 and 12 years, respectively. Median times for onset of symptoms after sun exposure, onset of signs (oedema, erythema) and resolution of symptoms were 20 min, 6 h and 3 days, respectively. Most patients reported absence of protection by glass (92%), priming (85%), exacerbation by wind (68%), no family history of photosensitivity (56%), no symptoms during winter (56%) and had chronic skin lesions (79%). Symptoms changed little with age but improved during pregnancy in 47% of gravid women. Most patients used protective clothing and a sunscreen; 28% were taking beta-carotene and a further 56% had taken it; 29% were not under regular medical care. Two patients (1%) had liver failure and 8% reported gallstone disease. QoL was markedly impaired, with scores similar to those in severe dermatological disease (mean DLQI score 14.0, n = 176; mean CDLQI score 12.8, n = 44), indicating a large effect on patients' lives. DLQI scores correlated weakly with TEP (rs = 0.228; P = 0.002) and time to onset of symptoms (rs = -0.233; P = 0.002) but not with age at onset. CONCLUSIONS EPP is a persistent, severely painful, socially disabling disease with a marked impact on QoL. Its diagnosis is often overlooked. None of TEP, age at onset nor time to onset of symptoms is a useful predictor of impaired QoL in individual patients.
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Affiliation(s)
- S A Holme
- Department of Dermatology, Cardiff University, Heath Park, Cardiff CF14 4XN, UK.
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Otman SGH, Edwards C, Pearse AD, Gambles BJ, Anstey AV. Modulation of ultraviolet (UV) transmission by emollients: relevance to narrowband UVB phototherapy and psoralen plus UVA photochemotherapy. Br J Dermatol 2006; 154:963-8. [PMID: 16634902 DOI: 10.1111/j.1365-2133.2006.07171.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with psoriasis undergoing or about to undergo ultraviolet (UV) phototherapy and photochemotherapy often have thick scale on their plaques which can prevent the penetration of UV radiation. Emollients are used to moisturize the skin and to prevent or reduce some of the milder side-effects ('dryness', itching) sometimes experienced during UV therapy. However, emollients can alter the UV transmission of skin and thus may alter the clinical effects of phototherapy and photochemotherapy. OBJECTIVES We tested 30 of the topical emollients in the British National Formulary (BNF) using a standard in vitro technique used to test sunscreens. We also surveyed U.K. phototherapy units to establish routine practice for emollient use in phototherapy and photochemotherapy. METHODS We used a standard in vitro technique to measure the monochromatic protection factors (MPFs) of 30 non-bath emollients from the BNF. An application rate of 2 mg cm-2 was used. For the assessment of effects during narrowband UVB (TL-01) phototherapy, the mean of the protection factors at 310 and 315 nm was calculated; for psoralen plus UVA photochemotherapy the mean UVA protection factor was used. A questionnaire survey was used to assess routine practice concerning emollient use prior to phototherapies in phototherapy units throughout the U.K. RESULTS In the UVA range, 17 of the 30 emollients gave protection factors of 1.2 or above. In the UVB range, 23 of 30 had an MPF of 1.2 or above. Yellow soft paraffin had the highest protection factor in the UVB range. Of 78 centres surveyed, 57 returned completed questionnaires (73%). Seventeen of 57 (30%) centres routinely used emollients immediately prior to administering phototherapy treatments. The remaining 40 of 57 (70%) did not. Forty-five (79%) responding centres recommended the use of emollients after phototherapy. CONCLUSIONS This study has revealed considerable variability in the practice of emollient use before phototherapy treatments. Although the majority of centres included in this study did not routinely use emollients, almost one third did. Our in vitro measurement of 30 emollients revealed marked variation in UV transmission, with many emollients blocking sufficient UV to affect the response to therapy.
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Affiliation(s)
- S G H Otman
- Department of Dermatology, Royal Gwent Hospital, Newport, Gwent, and Department of Dermatology, Cardiff University, College of Medicine, UK.
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Anstey AV, Azurdia RM, Rhodes LE, Pearse AD, Bowden PE. Photosensitive Smith-Lemli-Opitz syndrome is not caused by a single gene mutation: analysis of the gene encoding 7-dehydrocholesterol reductase in five U.K. families. Br J Dermatol 2005; 153:774-9. [PMID: 16181459 DOI: 10.1111/j.1365-2133.2005.06761.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Smith-Lemli-Opitz syndrome (SLOS) is an autosomal recessive malformation syndrome characterized by a disorder in cholesterol metabolism. SLOS is caused by mutations in the DHCR7 gene which encodes 7-dehydrocholesterol reductase, an enzyme that catalyses the final step in cholesterol biosynthesis. We have previously established the clinical and photobiological features of the photosensitivity that is frequently a feature of SLOS. OBJECTIVES In this study, we have performed mutational analysis of the DHCR7 gene in individuals from five families with SLOS. In each family, one member was affected by severe photosensitivity as a manifestation of SLOS. METHODS Fifteen samples (including family controls) were screened using polymerase chain reaction amplification and direct automated sequencing. RESULTS Six different DHCR7 mutations were identified of which five were single point mutations that caused missense amino acid substitutions (P51H, T93M, L99P, E448K and R450L). The other was a splice site mutation (G-->C in splice acceptor site) affecting the intron 8-exon 9 splice junction (IVS8-1 G-->C). This splice site mutation and four of the five missense mutations have been previously published as causal in SLOS but the P51H is a novel mutation which has not previously been reported. CONCLUSIONS This is the first study in which DHCR7 gene mutational analysis has been performed on SLOS subjects with severe photosensitivity and indicates that no single mutation is responsible for the photosensitivity which characterizes this disorder.
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Affiliation(s)
- A V Anstey
- Department of Dermatology, Royal Liverpool University Hospital, Liverpool L7 8XP, U.K
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Smith CH, Anstey AV, Barker JNWN, Burden AD, Chalmers RJG, Chandler D, Finlay AY, Griffiths CEM, Grifitths CEM, Jackson K, McHugh NJ, McKenna KE, Reynolds NJ, Ormerod AD. British Association of Dermatologists guidelines for use of biological interventions in psoriasis 2005. Br J Dermatol 2005; 153:486-97. [PMID: 16120132 DOI: 10.1111/j.1365-2133.2005.06893.x] [Citation(s) in RCA: 207] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- C H Smith
- St John's Institute of Dermatology, GKT School of Medicine, St Thomas' Hospital, London SE1 7EH, UK.
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Abstract
Azathioprine has been available as an immunosuppressive agent for over 40 years, and current routine usage in dermatology is not restricted to licensed indications. Advances in understanding the metabolic fate of azathioprine have led to significant changes in prescribing practice and toxicity monitoring by U.K. dermatologists. The current state of knowledge concerning the use of azathioprine in dermatology is summarized, with identification of strength of evidence. Clinical indications and contraindications for azathioprine usage in dermatology are identified. Evidence-based recommendations are made for routine safety monitoring of patients treated with azathioprine, including pretreatment assessment of red blood cell thiopurine methyltransferase activity.
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Affiliation(s)
- A V Anstey
- Department of Dermatology, Royal Gwent Hospital, Cardiff Road, Newport, Gwent NP20 2UB, Wales, UK.
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Abstract
Rosacea fulminans is a rare condition with a female preponderance and unknown aetiology, characterized by the abrupt onset of papules, pustules and erythema affecting the face. Corticosteroids and isotretinoin are regarded as the two main therapeutic agents. We report a case associated with pregnancy, and discuss the therapeutic implications. This is the first published report of rosacea fulminans in pregnancy complicated by stillbirth.
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Affiliation(s)
- V J Lewis
- Department of Dermatology, Royal Gwent Hospital, Cardiff Road, Newport, NP20 2UB, UK.
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Abstract
The use of phototherapy and photochemotherapy in children has been limited due to concerns over their long-term carcinogenic potential. Furthermore, the method of administration is disconcerting to some children, particularly as phototherapy treatment units are seldom rendered 'child-friendly'. Despite these reservations, ultra-violet therapies can be useful treatment options for children with selected dermatological conditions provided they are used under carefully controlled conditions.
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Affiliation(s)
- S A Holme
- Department of Dermatology, Royal Gwent Hospital, Cardiff Road, Newport NP20 2UB, UK.
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Abstract
BACKGROUND Individuals with low activity of a key metabolic enzyme, thiopurine methyl transferase (TPMT), are more susceptible to azathioprine-induced myelosuppression. AIM To determine the pattern of use of TPMT activity estimation, with respect to azathioprine use, by medical practitioners in the UK. DESIGN Retrospective analysis of assay use. METHODS We analysed all test results (n=3291), and patient and practitioner details, from inception of TPMT assay in 1990 to the end of December 2000, held at the Purine Research Laboratory, Guy's Hospital, London. Patient details were anonymized. Repeat analyses and requests from outside the UK were excluded. RESULTS The male:female ratio was approximately equal and the mean age was 46.6 (range 0.5-97) years. Thirteen different medical specialities requested assays; Dermatology and Gastroenterology were the most frequent users, together accounting for 86% of requests. The numbers of centres requesting the assay varied widely both within and between different specialities. Some 80% of individuals had normal TPMT activity, 9% enzymic activity above normal, and 10% low activity. Fifteen had no detectable enzymic activity: 0.45% (1:220) of the study population. DISCUSSION This incidence of undetectable enzyme activity is significantly higher than the previously reported level of 1:300 derived from smaller studies, and makes the economics of screening more attractive.
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Affiliation(s)
- S A Holme
- Department of Dermatology, Royal Gwent Hospital, Newport, Purine Research Laboratory and Department of Gastroenterology, Guy's & St Thomas' Hospitals Trust, London, UK.
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Abstract
Cutaneous photodamage is partly mediated via oxidative pathways and there is evidence to suggest that antioxidants within the skin may have a photoprotective effect. Antioxidant activity is provided by a number of naturally occurring substances including alpha-tocopherol (vitamin E) and beta-carotene, whose effects are mediated by their capacity to quench singlet oxygen, scavenge free radicals and prevent the formation of free radicals. Beta-carotene has been used as treatment for various photosensitivity disorders for more than 30 years. The main indication for its use is in the treatment of the photosensitivity associated with erythropoietic protoporphyria. A role for beta-carotene in the prevention of non-melanoma skin cancer has yet to be demonstrated despite clinical research activity in this area. The role for alpha-tocopherol as a photoprotective agent is less clear-cut and it has yet to be established as treatment either for conditions characterized by photosensitivity or as an agent for preventing chronic photodamage or cutaneous malignancy.
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Affiliation(s)
- A V Anstey
- Photodermatology Unit, Department of Dermatology, University of Wales College of Medicine, Cardiff, UK.
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Taylor DK, Anstey AV, Coleman AJ, Diffey BL, Farr PM, Ferguson J, Ibbotson S, Langmack K, Lloyd JJ, McCann P, Martin CJ, Menagé HDP, Moseley H, Murphy G, Pye SD, Rhodes LE, Rogers S. Guidelines for dosimetry and calibration in ultraviolet radiation therapy: a report of a British Photodermatology Group workshop. Br J Dermatol 2002; 146:755-63. [PMID: 12000370 DOI: 10.1046/j.1365-2133.2002.04740.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This report examines the dosimetry of ultraviolet (UV) radiation applied to dermatological treatments, and considers the definition of the radiation quantities and their measurement. Guidelines are offered for preferred measurement techniques and standard methods of dosimetry. The recommendations have been graded according to the American Joint Committee on Cancer classification of strength of recommendation and quality of evidence (summarized in Appendix 5).
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Affiliation(s)
- D K Taylor
- Medical Physics Department, Gloucestershire Royal Hospital, Great Western Road, Gloucester, GL1 3NN, UK.
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Abstract
A 10-year retrospective analysis of the use of psoralen photochemotherapy (PUVA) in the treatment of vitiligo was undertaken at the St John's Institute of Dermatology, London, UK. Of 97 patients included in this study, eight had complete or almost complete repigmentation, 59 moderate to extensive repigmentation, and 30 showed little or no response. However, 24 of those who had responded to PUVA with extensive repigmentation did not consider their response satisfactory because of persistence of vitiligo at cosmetically sensitive sites, and poorly matching, speckled repigmentation. Fifty-seven patients who initially improved with PUVA therapy subsequently relapsed, in most cases within a year of stopping treatment. Relapses in 22 patients were on the same cutaneous sites as previously affected, while vitiligo at new sites developed in 20 patients and both new and old sites were affected in a further 15 patients. Patients who retained their pigmentation after 2 years appeared to have a better chance of permanent remission. The only statistically significant prognostic indicator of relapse was patient age at the start of treatment, younger patients tending to retain their pigmentation longer than older patients. This study emphasizes the need for careful patient counselling before PUVA therapy as this treatment seldom achieves extensive repigmentation that is cosmetically acceptable, and treatment response is often followed by relapse.
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Affiliation(s)
- Y K C Kwok
- Photobiology Unit, Department of Environmental Dermatology, St John's Institute of Dermatology, St Thomas' Hospital, London SE1 7EH, UK
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Roberts DLL, Anstey AV, Barlow RJ, Cox NH, Newton Bishop JA, Corrie PG, Evans J, Gore ME, Hall PN, Kirkham N. U.K. guidelines for the management of cutaneous melanoma. Br J Dermatol 2002; 146:7-17. [PMID: 11841361 DOI: 10.1046/j.1365-2133.2001.04614.x] [Citation(s) in RCA: 177] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
These guidelines for management of cutaneous melanoma present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation. To reflect the collaborative process for the U.K., they are subject to dual publication in the British Journal of Dermatology and the British Journal of Plastic Surgery.
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Bishop JAN, Corrie PG, Evans J, Gore ME, Hall PN, Kirkham N, Roberts DLL, Anstey AV, Barlow RJ, Cox NH. UK guidelines for the management of cutaneous melanoma. Br J Plast Surg 2002; 55:46-54. [PMID: 11783968 DOI: 10.1054/bjps.2001.3745] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
These guidelines for management of cutaneous melanoma present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation. To reflect the collaborative process for the UK, they are subject to dual publication in the British Journal of Dermatology and the British Journal of Plastic Surgery.
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Affiliation(s)
- J A N Bishop
- Genetic Epidemiology Division, ICRF Clinical Centre, St James's University Hospital, Leeds, UK
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Patel GK, Taylor D, Anstey AV. No need for sunscreen or occlusive dressings for benign naevi during routine phototherapy. Photodermatol Photoimmunol Photomed 2001; 17:245-6. [PMID: 11594309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
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Abstract
Rifampicin has been prescribed throughout the world for over 20 years, yet only four cases of rifampicin-induced lupus erythematosus (LE) have been reported. Rifampicin-induced LE is associated with combination therapy with clarithromycin or ciprofloxacin. These drugs are all metabolized through the cytochrome P450 liver enzyme system and combined usage may lead to higher rifampicin blood levels. Drug-induced LE differs from systemic LE; cutaneous manifestations, although uncommon, are an important clue to the diagnosis. We report a case of rifampicin-induced LE presenting with florid cutaneous features.
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Affiliation(s)
- G K Patel
- Department of Dermatology, University Hospital of Wales, Cardiff, Wales, UK.
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Varma S, Wilson H, Kurwa HA, Gambles B, Charman C, Pearse AD, Taylor D, Anstey AV. Bowen's disease, solar keratoses and superficial basal cell carcinomas treated by photodynamic therapy using a large-field incoherent light source. Br J Dermatol 2001; 144:567-74. [PMID: 11260016 DOI: 10.1046/j.1365-2133.2001.04085.x] [Citation(s) in RCA: 108] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Photodynamic therapy (PDT) has not yet been demonstrated to be superior to conventional treatment in the treatment of superficial skin cancers and premalignant skin conditions. A limitation for PDT is the absence to date of a light source suitable for the treatment of larger lesions or 'field changes' where several lesions are present on one anatomical site. OBJECTIVES To investigate the safety and efficacy of a large field light source, the Waldmann PDT 1200, in the treatment of Bowen's disease (BD), superficial basal cell carcinomas (BCCs) and solar keratoses (SKs). METHODS After application of 5-aminolaevulinic acid for 4-6 h, each lesion was irradiated with 105 J cm-2 of incoherent red light centred on 640 nm. Eighty-eight patients with 239 lesions were recruited. RESULTS Within two treatments, 88% of BD lesions, 95% of BCCs and 99% of SKs showed complete clinical clearance. At 12 months the complete response rates were 69% for BD, 82% for BCC and 72% for SK. CONCLUSIONS This study confirms that PDT is a useful treatment and that selected superficial BCCs and SKs respond well to PDT. The PDT 1200 light source proved capable of treating multiple lesions amounting to a 'field change' and also lesions up to 10 cm in diameter within an acceptable treatment time. Thus far, PDT has failed to become established as a routine treatment for small premalignant and malignant skin lesions as it has not proved superior to simple cheaper conventional therapies such as cryotherapy, curettage and cautery, topical chemotherapy with 5-fluorouracil, or surgery. However, PDT has become established as a treatment for selected cases in some centres. This study suggests a role for PDT in the treatment of large premalignancies, superficial BCCs and field change where existing treatments may be problematic.
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Affiliation(s)
- S Varma
- Department of Dermatology, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, U.K.
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Abstract
Smith-Lemli-Opitz (SLO) affected children have multiple congenital physical and mental abnormalities; photosensitivity to ultraviolet A (UVA) has recently become a recognized feature. We present a patient with SLO and prominent photosensitivity in whom detailed phototesting has been performed at baseline and following 6 months of cholesterol supplementation. There was significant improvement in the symptoms of photosensitivity, confirmed objectively by phototesting and accompanied by partial correction of the biochemical abnormalities seen in SLO. This case report is the first to show that cholesterol supplementation in SLO can lead to an objective improvement in the associated photosensitivity.
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Affiliation(s)
- R M Azurdia
- Photobiology Unit, Department of Dermatology, Royal Liverpool University Hospital, Prescot Street, Liverpool L7 8XP, UK
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Abstract
Aquagenic pruritus is a rare but distinct entity in which intense itching develops after contact with water, in the absence of cutaneous signs or underlying disorders that could explain the symptoms. The aetiology is currently unknown, and treatment difficult, with a poor response to antihistamines. Psoralen-ultra violet A (PUVA) photochemotherapy can be effective, but frequent maintenance therapy may be required to prevent relapse of symptoms. We present a patient with typical aquagenic pruritus who responded well to PUVA, and who has remained well controlled on infrequent maintenance.
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Affiliation(s)
- S A Holme
- Department of Dermatology, University Hospital of Wales, Cardiff, UK
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Abstract
We report an 81-year-old female with a heterozygous factor V Leiden mutation who developed purpura fulminans. Digital necrosis, a characteristic clinical feature of purpura fulminans was prominent. Purpura fulminans is more common in children and adult cases are rare. Of eight reported cases of purpura fulminans resulting from a heterozygous factor V Leiden mutation recorded in the literature, only two were in adults: 40 and 42 years of age, respectively. This is the first report of this condition arising in a patient in her eighties.
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Affiliation(s)
- G K Patel
- Department of Dermatology, University Hospital of Wales, Heath Park, Cardiff CF14 4XN, U.K.
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