THIS ISSUE...Editorialpage 3

Red scaly rashespage 4

Clinical UpdateManchester 07

reportpage 6

Getting underthe skin ofPsoriasispage 8

Listen to the patient, she is

telling you the diagnosis

Something I like about dermatology is that old

fashioned medical knowledge and skill can often get

us where we want to go without special tests. Beware

the tendency to skip the history and go straight to the

rash, hoping for a spot diagnosis. Wrong! It’s just as

important to take a proper history first for skin as for

chest or gut problems, if not more so.

History - diagnostic pointers

Atopic eczema is itchy, often starts in infancy, and

may run in the family along with hay fever and

asthma. Various forms of eczema (discoid, asteatotic,

allergic and irritant) can occur at any age, but are

always itchy. Contact

dermatitis, whether

allergic or irritant, is

likely to come with a

history, like the lady in

my surgery recently

whose facial dermatitis

began when she applied

a ‘hypoallergenic’ face cream’ (Fig 1). I was amazed

to read it contained benzoate, acrylate, parabens,

various plant extracts and plankton! I would call that

hyperallergenic!

Psoriasis is uncommon before puberty, may have

a family history and usually doesn’t itch. Fungal

infections can start at any age and often give a history

of starting in one place and spreading out with a

leading edge and central clearing.

Look carefully - with a lens!

Having taken a history you may view the rash.

Where possible, have the patient strip to underwear

for a clear view of the whole rash (and take a sneaky

peek for hidden skin cancers on the back, especially in

Misdiagnosingthe three commonred scaly rashes

czema/dermatitis, psoriasis and tinea are easily diagnosed

when present in ‘typical’ forms, but variants of these common

rashes abound, foxing even the experts at times. This is a précis

of a talk I gave recently in Southampton about diagnostic pointers

and pitfalls from my practice. There is some statement of the

obvious, no apology for this as first principles and awareness of

common pitfalls can increase our diagnostic accuracy.

MAY 07

STEPHEN HAYES

18 - 21 May 2007British Association of SkinCamouflage - Training DayContact: basc9@hotmail.com

19 - 20 May 2007PCDS Skin Surgery MeetingDurham MarriottContact: carol@pcds.org.uk

20 May 2007Walk for Skin 2007Southampton, Cardiff, Cheddar,Manchester, Windsor, London &BirminghamContact: lorna@bad.org.uk orwww.walkforskin.org.uk

9 June 2007PCDS Dermoscopy WorkshopBristolContact: carol@pcds.org.uk

9 - 10 June 2007PCDS South & West and AGMBristolContact: carol@pcds.org.uk

18 June 2007Essential Acute Dermatology forGeneral Physicians & GPsRSM, LondonContact: tori.bennett@rsm.ac.uk

4-7 July 2007BADBirminghamContact: lorna@bad.org.uk

31August – 3 September 2007British Association of SkinCamouflage - Training DayContact: basc9@hotmail.com

28 September 2007PCDS South & East MeetingKing’s Fund, LondonContact: carol@pcds.org.uk

29 September 2007PCDS Basic Dermatology DayRCP, LondonContact: carol@pcds.org.uk

2-3 November 2007PCDS Skin Surgery MeetingLitchdon Medical Centre, BarnstapleContact: carol@pcds.org.uk

10 - 11 November 2007PCDS Scottish MeetingCarnoustie, near DundeeContact: carol@pcds.org.uk

Forthcoming Meetings

PCDS Gable House, 40 High Street, Rickmansworth, Herts WD3 1ERT01923 711678 F01923 778131 pcds@pcds.org.uk www.pcds.org.uk

Company 5254647 VAT 875 1544 06

E

North &Midlands report -

Liverpool 07page 12

New DHguidancepage 15

PCDS bursarypage 15

Continued on page 4

FIG 1

COMMITTEEELECTION ANDANNUAL GENERALMEETING

Just a reminder to those of you who

haven’t already booked a place - the

AGM is being held in Bristol on 9th and

10th June.

It is also your opportunity to vote

for a new committee or even perhaps

stand for election. The Society needs

new and fresh minds to take us forward

and we therefore ask that you consider

whether you could give the Society

some of your valuable time and

expertise for the coming years.

Get your form back to Carol in the

PCDS Secretariat office to

be sure of a place.

Stephen Kownacki

Chairman PCDS

Cartoon by S J Russell

– PRIVATE EYE issue 1173, p.18

I probably shouldn’tmention it…but I don’t like thelook of that mole”

3

he second last day of March was

pleasantly warm in southern

Hampshire and I planted out nine

standard apple trees. These were rare

old varieties (Cornish Gillyflower,

Adam’s Pearmain, Court Pendu Plat

etc).* I had grafted them on to large

growing rootstocks several years

ago, hoping to use them to plant

community orchards. Of course, this

‘good idea’ never got off the ground

as I was too busy, nobody was very

interested and perhaps it wasn’t such

a good idea anyway. The trees were

overcrowded in their nursery and

nearby fast growing poplars in our

orchard shelter belt were blocking

out the light. The trees had run out of

time, and had to be planted out by the

spring or dug up and destroyed.

Ideally my wife would have helped me (as

the great English apple expert Lawrence Hills

wrote ‘it takes two to plant a tree, and they

should take their time over it, for they cannot

have anything more important to do with the

time saved by haste’) but she was too busy

redecorating the newly spare bedroom for an

imminent guest, so I planted the trees alone.

I planted them into a neglected, scrubby

part of our smallholding. I should have cleared

the land of nettles, couch grass and other weeds

and ploughed it last winter, but never got round

to it. I gave the trees a double handful of

compost and a gallon of water each and hacked

down some weeds. I would have sprayed

weedkiller but it was too windy, I’ll try to find

time later.

And what, dear reader, does the above have

to do with the PCDS and/or UK dermatology? It

struck me as a parallel with the current rolling

out of multiple untested reforms which are well

intentioned but badly timed and causing

potential conflicts of interest. Locally, reflecting

the national scene, we have private sector

involvement, practice based commissioning, the

NICE skin cancer guidance, imminent new

guidance for GPwSIs, ‘musical desks’ at the PCT

as managers dance in circles to the tune of the

mad pipers of Westminster, and doubts about

secure funding and support of the all-important

hospital dermatology team.

Some of the ideas being implemented might

on paper deliver improvements, given good care

and good luck (which is what my trees need) but

‘ideally we wouldn’t be starting from here’. But

as with my imperfectly planted apple trees, we

ARE starting from here. We must use our hearts,

brains and relationships to make the best of it

for our patients. We’re GPs - that’s what we do!

Your Society goes from strength to strength

and is running more conferences in 2007 than

any previous year. We aim to be, perhaps

already are, the number one UK provider of

dermatology education for GPs, and also to

honestly represent our patients’ and our

colleagues’ needs during times of sometimes

chaotic and questionably managed change. Our

membership has passed 850, I would like to see

it pass 1,000 by our 2008 AGM. May I strongly

encourage every member to come to one

conference this year. These are excellent

opportunities to meet like-minded colleagues

and hear expert speakers on relevant subjects.

Hope to see you at the AGM in Bristol

in June.

Kindest regards,

Stephen Hayes

Editor

*www.fruitwise.net

The society would like to

acknowledge support

from the following

members of the corporate

membership scheme.T

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EDITORIAL - STEPHEN HAYES

5

Again, the ‘undress the whole patient’ manoeuvre pays off when the rash is

atypical at the presenting site but present in typical form elsewhere. (Fig 6)

This patient with a flexural rash under an apron fold had umbilical psoriasis

and subtle nail pitting which pointed to the diagnosis. She was better in a

week of medium strength steroid after failure to respond to imidazole.

Rashes in disguise

Animal ringworm, as in this horse acquired case (Fig 7), can be so

inflammed and pustular it is mistaken for staphylococcal infection. Ask

about animal contact and take specimens for mycology as well as ordinary

culture. Another common pitfall is putting steroid on a rash thinking it is

eczema only for the patient to come back worse a week later because the

rash was fungal. Steroid alters the immune response and the tinea goes wild

- tinea incognito. The patient may be fooled as the steroid relieves the itch,

but the rash spreads fast (Fig 8). This mistake is forgivable, but ALWAYS tell

the patient to come back if they aren’t better soon.

It can be easy to confuse scabies and eczema - classically, a child is given

hydrocortisone for his ‘eczema’ and returns in 2 weeks - it’s worse and now

his sister has it. Always think of scabies with new-onset ‘eczema’ in a child

and - you guessed, undress the whole patient! Scrotal nodules and burrows

between fingers or in the natal cleft may give the game away.

Primum non nocere!

As my old mate Hippocrates says, ‘first do no harm’. Oral antifungals are

great drugs, but have a range of potential side effects and interactions.

Fungus and psoriasis both affect nails, but so do other things. I saw a patient

whose GP was perplexed that his fungal toenails hadn’t improved despite 6

months of itraconazole. Turned out he was a semi-professional footballer,

careful examination showed ridged and tatty nails with subungual

haematomas. The problem was repeated minor trauma due to kicking. It is

wise to prove fungus mycologically before starting prolonged oral therapy -

it could be hard to defend prescribing an expensive and relatively toxic drug

which had no prospect of doing the patient any good due to the wrong

diagnosis (Fig 9).

Why you can’t always win

As my teacher Professor Eugene Healy (a very clever man) says “the genes

for eczema and psoriasis are widely distributed and there’s nothing to say

you can’t have both rashes in the same patient at the same time or different

times”. They may even intereract. This patient (Fig 10) shows typical

psoriasis (extensor surface, unscratched, clear border) and eczema (flexor

surface, poorly defined edge, excoriated) present at once.

This unilateral foot rash (Fig 11) was biopsied as I couldn’t decide between

eczema and psoriasis. The histopathologist couldn’t tell either, giving

‘eczematous psoriasis’ (or was it psoriasiform dermatitis?). Don’t worry, it

happens!

Misdiagnosis is very easy in dermatology; I hope the above

observations and tips may help colleagues avoid some of the

more common pitfalls with these three common rashes which

have so much clinical overlap.

4

Continued from page 1

sun damaged patients.) Vesicles are a useful sign of eczema, they may be tiny

and are often missed unless looked for in a good light with a lens. Sterile

pustules which fade to brown macules occur in palmo plantar psoriasis but

clear fluid filled vesicles point strongly to eczema. Vesicles were visible in this

very angry discoid type eczema, (Fig 2) which had failed to respond to 3

courses of oral antibiotics after being misdiagnosed as cellulitis. It cleared

completely with a week of potent steroid.

Excoriations are typical in eczema - they are caused by scratching.

Lichenification, a thickening of the skin creases, is caused by chronic

rubbing. Both are caused by the itch of severe eczema and are notably absent

in psoriasis and fungus. If treatment has been applied, the redness, scale and

vesicles may go but the lichenification will fade last.

Annular lesions often lead to a ‘spot diagnosis’ of ringworm. Colleagues

often send me ringworm that won’t respond to antifungal - usually because

it’s granuloma annulare (GA) (Fig 3). I point out in my clinic letter that GA

is a dermal process, so is never scaly, whereas tinea is epidermal, so produces

scale. GA also doesn’t itch and tends to be indolent, while fungus often

advances rapidly and itches. The illustrated case was referred after failing to

respond to oral terbinafine. All that rings isn’t ringworm, and ringworm

doesn’t always ring!

Think about scale

Always look for presence or absence of scale, note how much, how big,

and how well organised. Hand fungus (Fig 4) often has very fine scale in the

skin creases on a background of red, with no vesicles. This case was

misdiagnosed and treated as eczema which made it worse - mycology grew

trichophyton rubrum and the patient was quickly cured with oral terbinafine.

This rash on the ankle (Fig 5) with large well organised scale on a deep

red background was confirmed as psoriasis by my consultant mentor, who

commented on how much foot psoriasis he saw misdiagnosed as fungus. It

responded to calcipotriol after failed antifungal treatment. On reflection, I

don’t know how I got this wrong - just goes to show how much we all need

CME, audit, and our senior colleagues.

Eczema scale is scanty as the fundamental eczematous process doesn’t

produce much scale and it’s mostly scratched off due to the itch, whereas

psoriasis produces superabundant scale which forms big flakes and sheets.

Emollients may remove scale (a useful treatment) but it doesn’t get

scratched off as in eczema and can be very thick.

An important exception to the above is flexural psoriasis, which gets

misdiagnosed a lot as it doesn’t look like psoriasis elsewhere. Flexural

psoriasis occurs in axillae, groin, natal cleft, umbilicus and wherever

opposing folds of skin touch, moisture collects and any scale tends to get

rubbed off. There may be fine scale at the edge if you look carefully. I’m often

asked ‘why isn’t this candidal intertrigo getting better with Nystatin?’ Answer

- because it’s flexural psoriasis. Diagnostic pointers are a well defined edge,

no pustules or satellite lesions, a history of psoriasis and psoriasis elsewhere.

Misdiagnosing the three common

red scaly rashes

FIG 2 - ANKLE ECZEMAMISDIAGNOSED AS CELLULITIS

FIG 3 - GRANULOMA ANNULAREMISDIAGNOSED AS FUNGAL

FIG 4 - HAND FUNGUS

FIG 5 - PSORIASISMISDIAGNOSED AS FUNGUS

FIG 6 - FLEXURAL PSORIASIS

FIG 7 - HORSE RINGWORM

FIG 8 TINEA INCOGNITO

FIG 9 - FOOTBALLER’S TOENAILS

FIG 10 - ECZEMA & PSORIASISSAME PATIENT

FIG 11 - PSORIASIFORM ECZEMA

76

Meeting for non-consultant career gradedoctors held at the SAS RadissonManchester Airport on 8 - 9 March 2007

attended this meeting sponsored by LEO Pharma in March. It was well attended

with 134 delegates. The venue for the meeting at Manchester airport was easy to

get to and delegates came in roughly equal numbers by plane, train and own transport.

It was interesting to eat in a restaurant overlooking the runaway and watch planes

arriving and leaving the gates. The meeting started at 11.00am on the Thursday which

gave people time to travel that day.

The entrance lobby was on the third floor, connected to the airport terminal by a futuristic corridor, while the

meeting rooms were on the lower levels. Several delegates from Ireland and Scotland commented on the “smoke

fug” in the entrance lobby emanating from the bar which was right beside the check in desks. Already in both

these countries smoking in public places is banned. Roll on July 1st! The meeting was attended by a few PCDS

members but the vast majority were Staff Grades, non GP Clinical Assistants and Associate Specialists.

The meeting opened with Dr Robin

Graham Brown giving a review of

paediatric dermatology with a lot of

anecdotes from his own clinical experience

- a big topic to try to cover. He mentioned

that Malignant Melanoma occasionally

occurs in children under the age of ten. He

also said that in his experience Lichen

Planus in children was relatively common

and was often atypical. Dr Shernaz

Walton from Hull gave a review of Drug

Reactions. She described the different

mechanisms which can cause a reaction,

their clinical presentations and which

drugs can cause what type of reaction. She

reminded us that HIV causes a 100 fold

increase in the frequency of drug reactions.

After lunch Dr Chris Lovell gave an

entertaining and very informative talk

entitled “Something Lurking in the

Compost Heap” on the hazards to the skin

from plants. Common ivy (Hedera Helix) is

felt to be an under reported cause of

dermatitis. Tea tree oil has been linked to

several different types of dermatitis

including a bullous variety and there has

been provocation of linear IgA disease. Dr

Lovell recommended a CD produced

jointly by Kew and Guys

and St Thomas’ Hospital

entitled Poisonous Plants

and Fungi.

Dr Jane Sansom from Bristol gave a

very good summary on the causes,

investigations and treatment of the red

face as well as updating us on the patch

testing fragrance batteries.

After the tea break Dr Chris Dobson

from Preston talked about Dermato-

pathology. He covered the problems of

biopsying, the limitations of histology,

sampling errors, the way skin lesions evolve

and why an early biopsy is usually better, the

variability of certain stains and what to do

when there was a discrepancy between your

original diagnosis and the pathology report.

The day finished with DDrr IIaann CCoouullssoonn

talking about “Fat and other Fascinomas”

- a neglected area of dermatology. He went

through the different types of fat disorders

in a logical and very helpful way.

The evening meal was taken in the

same room where the meeting had been

held after being rapidly transformed by the

hotel staff. There was no formal

entertainment after the meal on this

occasion and I recollected that last year we

had been unexpectedly serenaded by the

Three Waiters who had seemed to be

ordinary waiters and who burst into opera

after the meal.

The Friday morning started with a

discussion of the current political situation

from Dr Julia Schofield entitled

“Dermatology services: threats and

opportunities”. She gave an excellent

summing up of the unsettled state of

dermatology at the present time.

She was followed by the president of

the Royal College of Physicians, Professor

Ian Gilmore, who spoke on “Liver

Dysfunction, Drugs and the Skin”. He talked

about the variety of enzyme systems which

led to patients dealing with drugs differently.

He highlighted the importance of taking a

careful drug history, including over the counter

drugs, when dealing with a suspected drug

reaction. Usually the culprit drug has been

started in the previous 6 weeks.

After the coffee break Dr Richard

Parslaw from Liverpool talked about Leo’s

Psoriassist campaign and about prescribing

in dermatology especially as regards the

problems of topical treatments and how to

overcome steroid phobia. Dr Paul Yesudian

from Chester gave a very good summary of

the treatments used in Sarcoidosis, including

a list of unusual treatments which in some

cases had been found to be beneficial. He

said there has been no randomised control

trials for this condition at all.

After lunch Dr Diane Williamson, from

North Wales gave a very comprehensive

lecture on “Difficult Leg Ulcers”. She

covered this cinderella topic very well, with

many pointers as to diagnosis and treatment.

Next was Professor John McGrath

from St Johns, London talking on

Genodermatoses. He explained the

complex genetics of the commoner

genoderamotoses. He spoke on a variety of

other recent developments including

prenatal diagnosis for severe inherited skin

disease. He showed how the filaggrin

mutations found in Ichthysosis Vulgaris

has led to the revelation that filaggrin

mutations are a major factor in the

development of Atopic Dermatitis.

The meeting closed with a Question

and Answer session on SAS and NCCG

issues with Dr Sue Jackson and Dr Libby

Stewart answering questions on contracts

and the current negotiations which are

taking place.

This was a very comprehensive update

meeting. Congratulations to

the organising committee

of Dr Sue Jackson, Dr

Glenda Hill and Dr Sue

Welsh.

Dr Elizabeth Ogden

Poisonous Plants and Fungi

ISBN 190034792X 2nd edition 2002

I

CLINICALUPDATE

98

General Hospital and spoke on the

Primary Care Management of Psoriasis.

The condition characterised by epidermal

hyperproliferation (every 10 days instead

of 6 weeks) causing thickened red scaly

patches, affects 2% of the population, the

incidence peaking in the third decade.

Early onset, (associated with HLA cw6) is

more severe than later onset (no HLA

association). In women it improves during

pregnancy and tends to get worse at the

menopause.

The most common presentation is

plaque psoriasis (90%) with sharply

demarcated salmon-pink lesions with

silvery scale affecting extensor surfaces,

sacrum and scalp. Treatment is topical,

including using emollients, calcipotriol/

betamethasone (Dovobet) and coal tar

(Exorex). Flexural psoriasis is smooth, red,

non scaling, in submammary, perineal and

axillary areas. It is more common in the

elderly and is well demarcated helping to

distinguish it from candida and eczema.

Treatment is again with emollients,

clobetasone (Eumovate) and calcitriol

(Silkis). The guttate variety (Latin: gutta a

drop) tends to affect the young, involves

trunk, upper arms and thighs and can be

associated with a streptococcal infection.

It often clears spontaneously but can be

treated with 1% coal tar (Exorex).

Recurrent attacks may warrant a

tonsillectomy. Psoriasis may also be

confined to the scalp; treatment is with

Cocois to remove the scales (wash out with

Fairy Liquid) and topical steroid +/-

calcipotriol. Psoriasis affecting the nails is

difficult to treat though calcipotriol

applied in the nail fold occasionally helps.

Because of its visibility, psoriasis often

affects patients more than other more

serious though less visible conditions, such

as heart disease. As ‘cure’ is not an option,

Dr Kownacki emphasised matching

treatment to individual patient

requirements, citing the case of a lady who

was concerned only by a small patch of

disease on her upper sternum and not by

extensive involvement of other less visible

areas of her body.

The second part of the meeting began

with a talk by Dr Sarah Rogers, Consultant

Dermatologist in Dublin, for many years at

Hume Street Hospital until its closure and

now at St Vincent’s Hospital. In her talk,

entitled ‘What’s New in Dermatology’, she

spoke first about her recent move to a new

department in St Vincent’s and about the

changed economic climate which

discouraged in-patient treatment (the

Celtic Tiger notwithstanding) except in

critical situations (erythroderma,

widespread pustular psoriasis and

unstable plaque psoriasis).

She went on to discuss the newer

systemic agents beginning with

methotrexate (MTX) which is administered

weekly by the patient. It can cause marrow

depression and hepatic fibrosis, this latter

aggravated by alcohol consumption so

regular monitoring is essential. Fumaric Acid

Continued over page

A PCDS Ireland Educational Meeting. Kindly sponsored by an

educational grant from FOREST LABORATORIES, the makers of Exorex

Radisson SAS Hotel, Athlone. Saturday 26 November 2006

Athlone, County Westmeath, and capital of the Midlands was the location for the twelfth meeting of the Irish branch of the Primary

Care Dermatology Society. Athlone is situated on the Shannon, the longest river in the British Isles and the new Radisson Hotel on

the riverside was the venue of choice for the meeting. It is built on the site of the old Athlone Woollen Mills, which was destroyed

in a fire in the 1940s, and employed was Andrew McCormack, father of Athlone’s most famous son; the singer John McCormack.

he topic on this occasion was Psoriasis and things got off to an unusual

start with a presentation by a patient. Brian Donnelly is originally from

Co Tyrone but lives in Dublin and is a lecturer in English at University College

Dublin. Brian’s psoriasis, which he describes as ‘the affliction of the well’

began when he was a young boy, initially presenting on his knees and

elbows. He described how he felt ‘unclean’ and was preoccupied with

self-image. However his GP, whom he likened affectionately to Dr Finlay

of television fame, reassured him by scraping off some of Brian’s scales

and placing them on his own tongue! (We commend this doctor’s

empathy but cannot endorse the practice of tasting patient’s scales! -

Editor)

Brian’s psoriasis became more severe when he reached his 30s and he began

treatment at Hume Street Hospital, Dublin under the care of Dr Sarah Rogers who

continues as his Consultant. Brian’s initial treatment was with topical applications,

later moving to PUVA. However, on stopping this he developed erythroderma and

required a week’s treatment as an in-patient. Brian then started on cyclosporin

which he found very good until, after a number of years it stopped working.

For the past four years he has been on infliximab, a ‘biological’ which is

given as an intravenous infusion in a day ward once every eight

weeks. He felt that his psoriasis had impacted only minimally on

his life.

Stephen Kownacki is a GP in the

UK who has also worked for 20

years as a Clinical Assistant in

Dermatology at Northampton

T

Getting under the skin of…

10

Continued from page 9

Esters (FAE) cause immunosuppression (monitor lymphocyte

count) but are not affected by alcohol. Azothioprine causes

hypertension and renal damage and is used mainly as a

rescue drug. An important advantage of these treatments

is that Psoriatic Arthropathy, occurring in up to 10% of

cases is also benefited; however, efficacy wanes with

time as resistance develops.

The most recent development has been the

introduction of the biologicals which are

manufactured using recombinant technology.

Infliximab has to be administered intravenously and can cause

anaphylaxis. Etanercept is given weekly subcutataneously, does

not cause anaphylaxis and can therefore be administered by the

patient as can Adalimumab (fortnightly). All of these are also

effective in the associated arthropathy. They are hugely expensive

and, as with the earlier drugs, resistance can develop; though this

can be delayed by the concomitant use of MTX. They can also

reactivate dormant TB necessitating pre-treatment screening.

Cases of SLE have been found in association with Infliximab and

there is a theoretical risk of lymphoma with these drugs.

The final speaker was Dr Johnny Loughnane, a GP from West

Limerick with a special interest in Dermatology. He presented a

series of case studies, inviting the delegates to choose from a list

of differential diagnoses including Bowen’s disease, seborrhoeac

dermatitis, Lichen (simplex and planus), pityriasis (rosea and

versicolor) and fungal infection. This lively presentation, which

included a discussion of problem cases, brought proceedings to

a close.

The meeting was chaired by Dr Hilda O’Shea, secretary of

PCDS Ireland. Representatives from the main sponsors FOREST

LABORATORIES and co-sponsors 3M Healthcare, LEO Pharma

and SCHWARZ PHARMA without whose generous help the

meeting would not have been possible, were on hand at

registration and during coffee with informative displays. They

also sponsored the excellent lunch which followed the

meeting.

Dr Ronan O’Sullivan,

South Terrace Medical Centre, Cork, Ireland.

1312

to their regime shows the scale of the

problem. The real eye-opener, however, is

that there is a negative correlation between

compliance and disease severity. We have a

lot of work to do to change these figures

for the better.

Dr Nick Craven then gave a

presentation based on his experiences of

Toxic Epidermal Necrolysis and Stevens-

Johnson Syndrome. Whilst many of us are

unlikely to have to deal with such a

devastating condition - knowing that

there is someone who has the

experience and the enthusiasm to

help in such an eventuality is actually

rather reassuring!

The morning workshops were an

interesting mix - more than one

delegate was torn between the topics

on offer. Dr Christy Chou’s basic

skin surgery course was well received

and Dr Goodfield popped up again

to discuss difficult psoriasis. I attended Dr

Leslie Millard’s workshop on Body

Dysmorphic Disorder. I think we all see

cases of this and this presentation helped

me, at least, to feel slightly less at sea when

thinking about the issues concerned. It

would make an interesting full

presentation at a future meeting.

Immediately before lunch is not the

ideal slot to present, but Dr Colm

O’Mahony provided both a tour de force

and many delegates highlight of the

conference. His talk, on HIV and the skin,

was, in turn, erudite, amusing,

educational, entertaining and inspiring.

Both HIV and syphilis are easily detected

and, if caught early, are eminently

treatable (curable in the case of syphilis).

We have to get over the old reticence

about testing for these diseases - after all,

we routinely test for far worse conditions

without the recourse of extensive pre-test

counselling.

Lunch provided an opportunity for

gossip, perusing the pharmaceutical

stands and a bracing stroll on the banks of

the Mersey. I must say, I took the last

option and acquainted myself with the

‘Three Graces’ - the buildings that line the

Liverpool Pier Head. Suitably fed, watered

and refreshed the afternoon session kicked

off with Dr Niamh Leonard’s presentation

on ‘Making sense of histology reports’. In

recent years, reports have become longer

and longer. I’m sure I am not alone in

finding them increasingly impenetrable. Dr

Leonard helped to make sense of the

changes and also showed the importance

of the information provided. We, for our

part, need to provide as much information

as possible to help our pathology

colleagues out. Like so many things in life,

what you get out of a report depends on

what you put into the request form.

Next was the turn of Dr Anne Field

who managed to demystify the oral cavity -

her ‘Suspicious Oral Lesions’ was concise

and clear. The sections on pre-malignant

lesions and oral manifestations of systemic

disease were particularly illuminating.

Into the final straight - the second

round of workshops brought a Dr Chou

masterclass for the nimble fingered

surgeons wanting to extend their skills. Dr

Tom Poyner ran through current

thinking on acne treatments and Dr

Liz Ogden made everyone itch with a

workshop on infestations and

infections - I’ll treat my fish tank with

more respect in future now I know all

about fish tank granuloma…

The imminent Friday evening

rush hour caused the audience to

noticeably thin for the last

presentation of the day - this was a

shame because Dr Sue MacDonald

Hull gave an excellent talk on hair and

scalp problems - never an easy thing to

condense into 45 minutes and it is to her

credit that not only did she keep to time,

but also covered an awful lot of ground. I,

for one, will look into the treatment of

alopecia a little more deeply in future.

Many thanks to Dr Ogden for

arranging the course, to Carol and

Siobhan at PCDS headquarters for their

organisational skills and to Dr Jane

Rakowski for being an excellent

chairperson. All in all, an excellent day’s

education - the traffic wasn’t too bad on

the way home either!

Julian Peace

he meteorologists tell us that Spring begins on the 1st of March. So, on

a beautiful Spring day, the PCDS gathered on the banks of the Mersey

for an excellent day’s meeting. However, all was not immediately well.

Liverpool, currently a building site in preparation for becoming European City

of Culture in 2008, has a prolonged rush hour that meant several delegates

arrived rather later and more flustered than they had hoped to.

It is hoped that not too many missed

the opening act - Dr Mark Goodfield -

presenting a thought-provoking study on

the issue of compliance in dermatology

prescribing. We all know that compliance

can be patchy, but an overall figure of

around 69% of patients actually adhering

PCDS North & Midlands MeetingFriday 2 March 2007

Crowne Plaza Hotel, Liverpool

LiverpoolT

ABBREVIATED PRESCRIBING INFORMATION. Before prescribing Enbrel® please refer to full Summary of

Product Characteristics. Presentation: Enbrel Pre-fi lled Syringe: Enbrel 25 mg or 50 mg solution for injection

in a pre-fi lled syringe. Each pre-fi lled syringe contains either 25 mg or 50 mg etanercept. Enbrel Powder:Enbrel 25 mg and 50 mg powder and solvent for solution for injection. Each vial contains either 25 mg or 50 mg

etanercept and each pre-fi lled syringe contains 1 ml water for injections. Enbrel Paediatric: Enbrel 25 mg/ml powder

and solvent for solution for injection for paediatric use. Each vial contains 25 mg etanercept and each pre-fi lled syringe

contains 1 ml bacteriostatic water for injections. Uses: Adults: Moderate to severe active rheumatoid arthritis (RA), in

combination with methotrexate, when response to DMARDS, including methotrexate (unless contraindicated), has

been inadequate. Enbrel can be given as monotherapy in the case of intolerance to methotrexate or when continued

treatment with methotrexate is inappropriate. Severe, active and progressive RA without prior methotrexate treatment.

Enbrel alone or with methotrexate has been shown to reduce the rate of progression of joint damage measured by X-ray

and to improve physical function. Patients with moderate to severe plaque psoriasis (PP) who failed to respond to,

or who have a contraindication to, or are intolerant to other systemic therapy including cyclosporine, methotrexate

or PUVA. Active and progressive psoriatic arthritis (PsA) when response to DMARDS has been inadequate. Enbrel

has been shown to improve physical function in PsA patients, and to reduce the progression rate of peripheral

joint damage as measured by X-ray in patients with polyarticular symmetrical subtypes of PsA. Severe active

ankylosing spondylitis (AS) when response to conventional therapy has been inadequate. Children aged 4-17 years(25 mg only): Active polyarticular juvenile idiopathic arthritis (JIA) when inadequate response to, or intolerant

of methotrexate. Dosage: By subcutaneous injection. Adults: RA – 25 mg twice weekly or 50 mg once weekly.

PP - 25 mg twice weekly for up to 24 weeks, or 50 mg twice weekly for up to 12 weeks followed by 25 mg twice

weekly for a further 12 weeks if needed. Discontinue if no response after 12 weeks. For re-treatment: 25 mg

twice weekly for up to 24 weeks. AS and PsA – 25 mg twice weekly or 50 mg once weekly. Children aged 4-17 years: JIA in children aged 4-17 years – 0.4 mg/kg (maximum dose 25 mg) twice weekly with an interval of

3 – 4 days. Contra-indications: Hypersensitivity to any of the ingredients, sepsis or risk of sepsis, active infections.

Enbrel Paediatric: Must not be given to premature babies or neonates as the bacteriostatic water for injections

contains benzyl alcohol. Warnings and Precautions: Enbrel should be initiated and supervised by specialist

physicians experienced in the diagnosis and treatment of RA, PsA, AS or PP. Use carefully in patients predisposed

to, or with history of, infection due to underlying diseases other than RA (e.g. advanced or poorly controlled diabetes)

or with history of blood dyscrasias, pre-existing or predisposition to CNS demyelinating disease or congestive

heart failure. Concurrent administration of Enbrel and anakinra has been associated with increased risk of serious

infections and neutropenia, and is therefore not recommended. Whether treatment with Enbrel might infl uence

the development and course of malignancies and active and/or chronic infections is unknown, however with current

knowledge, a possible risk for the development of lymphomas or other malignancies in patients treated with a

TNF-antagonist cannot be excluded. Enbrel has not been studied in combination with other systemic therapies

or phototherapy for the treatment of psoriasis. Monitor closely if patient develops new infection during treatment.

Discontinue treatment if serious infection or allergic reaction develops or if blood dyscrasias are confi rmed.

Discontinue temporarily if signifi cantly exposed to varicella virus. Live vaccines should not be given concurrently

with Enbrel. Treatment with Enbrel may result in the formation of autoantibodies. Enbrel is not recommended for the

treatment of Wegener’s granulomatosis. JIA patients (indication approved for Enbrel 25 mg strength only) should have

received all vaccines recommended in current immunization guidelines prior to starting Enbrel. Enbrel Paediatric:

Contains benzyl alcohol as an excipient, which may cause toxic reactions and anaphylactic reactions in infants and

children up to 3 years old. Pregnancy & Lactation: Enbrel is not recommended in pregnant or breast-feeding women.

Undesirable Effects: Adults: Very common side effects reported with clinical trial and post marketing experience

include infections and injection site reactions. Common adverse events were allergic reactions, pruritus, autoantibody

formation and fever. Uncommon side effects have included serious infections, thrombocytopenia, angioedema,

urticaria and rash. Rare reports of lupus-like syndrome, CNS demyelinating events, seizures, serious allergic reactions,

elevated liver enzymes, cutaneous vasculitis, anaemia, leukopenia, neutropenia, pancytopenia and tuberculosis.

Aplastic anaemia has been reported very rarely. In clinical trials serious adverse events occurred with a frequency

similar to placebo and methotrexate. These included: serious infections, malignancies, asthma, heart failure, MI

and ischaemia, chest pain, syncope, cerebral ischaemia, hyper- and hypotension, cholecystitis, pancreatitis, GI

haemorrhage, bursitis, confusion, depression, dyspnoea, abnormal healing, renal insuffi ciency, kidney calculus, deep

vein thrombosis, pulmonary embolism (PE), membranous glomerulonephropathy, polymyositis, thrombophlebitis,

liver damage, leucopenia, paresis, paresthesia, vertigo, allergic alveolitis, angioedema, scleritis, bone fracture,

lymphadenopathy, ulcerative colitis, intestinal obstruction, eosinophilia, haematuria and sarcoidosis. Rate of new

malignancies was similar to that expected for the population studied. Fatalities associated with serious infections,

pancytopenia, and aplastic anaemia have also been reported. Paediatrics (25 mg only): Generally as for adults,

except the following were more common: headaches, nausea, vomiting and abdominal pain. In addition the

following were reported as severe events: varicella, appendicitis, gastroenteritis, depression/personality disorder,

cutaneous ulcer, oesophagitis/gastritis, group A streptococcal septic shock, type I diabetes mellitus and soft

tissue and post operative wound infection. Legal Category: POM. Package Quantities: Enbrel Pre-fi lled Syringe: Each carton contains 4 pre-fi lled syringes containing either 25 mg or 50 mg of Enbrel and 8 alcohol swabs.

Enbrel Powder: Each carton contains either 4 vials of Enbrel 25mg powder or 4 vials of Enbrel 50mg powder,

4 pre-fi lled syringes of water for injections, 4 needles, 4 vial adaptors and 8 alcohol swabs. Enbrel Paediatric: Each

carton contains 4 vials of Enbrel 25 mg powder. 4 pre-fi lled syringes of bacteriostatic water for injections, 8 empty

plastic syringes, 20 needles and 24 alcohol swabs. Basic NHS Cost: 25 mg (all presentations): £357.50 per

carton. 50 mg (all presentations): £715 per carton. European Marketing Authorisation Number: Enbrel Pre-fi lled Syringe 25 mg: EU/1/00/126/013. Enbrel Pre-fi lled Syringe 50 mg: EU/1/99/126/017. Enbrel Powder 25 mg:

EU/1/99/126/003. Enbrel Powder 50 mg: EU/1/99/126/010. Enbrel Paediatric 25 mg: EU/1/99/126/012. For

full prescribing information and details of other side effects see Summary of Product Characteristics. Full prescribing

information is available on request from: Wyeth Pharmaceuticals, Huntercombe Lane South, Taplow, Maidenhead,

Berkshire SL6 0PH. Telephone: 01628 415330. Date of Prescribing Information: 24 Jan 07.

Code no. ZAPI049. Doc ID 42874.

1. NICE technology appraisal No. 103, July 2006.

Information about adverse event reporting can be found atwww.yellowcard.gov.uk. Adverse events should also be

reported to Wyeth on 01628 415330.

Date of Preparation: February 2007. ZENB1330/0207

PLAQUE PSORIASISENBREL– FOR MODERATE TO SEVERE

Enbrel is now recommended byNICE for the treatment of adults with severe plaque psoriasis who meet NICE guidance criteria1

www.wyeth.co.uk

HELPING YOU TO MAKE A DIFFERENCE

Full NICE guidance, ‘Etanercept and Efalizumab for the treatment of adults with psoriasis’ is available from www.nice.org.uk

26.04.07

15

BursaryThe committee has agreed to make a further limited sum available on a discretionary

basis to help more PCDS members to access dermatology education they would not

otherwise be able to receive.

The bursary, or bursaries, will be used to attend courses, diplomas or other

legitimate dermatological training/education activity which can be

expected to benefit skin patients in the community. Applicants should in

the first instance write to Carol Singleton at the PCDS Secretariat, Gable

House, 40 High Street, Rickmansworth, Herts WD3 1ER and include in no

more than 500 words what activity they wish to pursue, how much they wish

to apply for, how this will benefit patient care and why they wish the PCDS to

assist them. All replies will be treated in the strictest confidence.

mplementing care closer to home - convenient

quality care for patients Parts 1-3 and National

Guidelines for the accreditation of GPwSIs:

Dermatology and skin surgery

The 26 April saw the launch, by the Department of Health, of

new commissioning guidance for Primary Care Trusts (Implementing

care closer to home - convenient quality care for patients Parts 1-

3 http://www.pcc.nhs.uk/173.php) which seeks to set standards

for high quality patient care wherever the service is delivered.

The general public involved in the consultation process prior to

the publication of the 2006 White Paper (Our Health, Our Care,

Our Say: a New Direction for Community Services) made clear that

whilst ‘Care Closer to Home’ was a good idea, it must not be

delivered at the expense of quality of care. The Department of

Health has responded to this by publishing this new suite of

documents which includes details of accreditation processes for

Practitioners with a Special Interests(PwSIs).

Part 1 reminds commissioners that quality care close to home

can be provided by a whole range of health care professionals

provided that they demonstrate the correct competencies and sit

within tight clinical governance frameworks. This includes Hospital

Consultants, Non Consultant Care Grade (NCCG) doctors, GPs

and Pharmacists with a Special Interest, Specialist nurses, Health

care Scientists and other health care professionals.

Part 2 summarises the commissioning cycle in the context of

assessing needs, reviewing current service provision, deciding

priorities, designing services, shaping the structure of the supply,

managing the demand and ensuring appropriate access to care,

clinical decision making and managing performance. Patient and

public involvement in service development is emphasised as is

patient and public feedback once the service is in place.

In Part 3 commissioners are reminded of the definition of the

GP or PhwSI which emphasises the core generalist role of the GP

or pharmacist, their ability to provide a service beyond the scope

of the core role and the requirement to have demonstrated

appropriate skills and competencies to deliver services without

direct supervision. The document then outlines the steps required

to accredit a GP and PhwSI service with detailed information

about the accreditation panel and the process of accreditation.

At the same time, new guidance for the accreditation of

GPwSIs in dermatology will be launched (National Guidelines for

the accreditation of GPwSIs: Dermatology and skin surgery). This

replaces the 2003 guidance and is the first of the speciality specific

frameworks to be refreshed. This guidance has been developed in

parallel with Implementing care closer to home - convenient

quality care for patients Parts 1-3 and together the frameworks

should ensure quality care for patients with skin disease and those

requiring skin surgery. The link to this is:

http://www.pcc.nhs.uk/uploads/pwsis/gpwsis_dermatology.pdf

It is not clear yet whether the accreditation process will be

mandatory but it does seem likely. In response to a recent

parliamentary question Rosie Winterton responded ‘The

Department is currently considering options to mandate primary

care trust compliance with the guidelines.’

Clinicians and commissioners should make themselves familiar

with this suite of documents so that patients can be reassured

that, whoever the clinician and whatever the location of the

service, quality care is provided by competent accredited clinicians.

Julia Schofield,

Consultant Dermatologist

(member of DH PwSI Steering Group)

Launch of new DH guidance on 26 April

I