Updates from the British Association of Dermatologists Meeting 292/10/Thursday 07h37

www.medscape.com

To Print: Click your browser's PRINT button. NOTE: To view the article with Web enhancements, go to: http://www.medscape.com/viewarticle/533355

Updates from the British Association of Dermatologists 85th Annual Meeting, 5-8 July 2005, Glasgow, U.K.

D.J. Eedy; J.S.C. English; I.H. Coulson

Br J Dermatol. 2006;154(6):1028-1045. ©2006 Blackwell Publishing Posted 06/05/2006

Summary

The conference highlighted the progress made in understanding recent biological, epidemiological and therapeutic advances in dermatology. Here we provide a synopsis of the main research and clinical findings presented at the meeting of the British Association of Dermatologists (BAD) held during 5-8 July 2005, in Glasgow, U.K., drawing attention to the most important advances and summaries. The BAD meeting was held at the Scottish Exhibition and Conference Centre, Glasgow (Fig. 1). The annual dinner was held in the wonderful setting of Stirling Castle, with Dr Robin Graham-Brown as host.

Figure 1.

Glasgow Conference Center

Skin Cancer

Achieving prompt referral and appropriate treatment of melanoma remains an important topic in British

http://www.medscape.com/viewarticle/533355_print Page 1 sur 23 Updates from the British Association of Dermatologists Meeting 292/10/Thursday 07h37

dermatology. A number of studies set out to audit how we are doing or how we might do better. In one study, funded by the NHS Modernisation Agency 'Action on Plastic Surgery' programme, digital photographs were sent by GPs to a plastic surgery department and were reviewed by four different plastic surgeons and later audited by a dermatologist.[1] Overall agreement between the plastic surgeons and the dermatologist was generally good, especially for suspected malignancies and their management plan. Nearly 50% of all patients referred were returned to primary care, and of those accepted by the secondary care service many were booked directly on to minor surgery lists, thereby releasing new plastic surgery outpatient appointments. In this cohort of patients melanoma was suspected in 2% and 3% of the cases by plastic surgeons and dermatologists, respectively. Further work on the clinical and histological correlation is being carried out.

In Edinburgh a designated pigmented lesion clinic has been in operation for almost 20 years. The recognition of potential melanomas from the data in the referral letters remained as difficult as ever despite ongoing primary care education; therefore to try to reduce waiting time and to select more successfully the urgent referrals, an electronic clinical communication implementation (ECCI) was initiated.[2] All seven melanomas referred were picked up on electronic referral, and this pilot study showed that ECCI referral for potential melanomas was acceptable to GPs, facilitated assessment of the likelihood of melanoma with more confidence than does a conventional referral and reduced the waiting time to appointment.[2]

Where they have been implemented, the 2-week skin cancer clinics do seem to be working well and it was felt that such clinics did justify the burden on departmental resources and provide a valuable service with a relatively high pick-up rate.[3]

In a separate audit of the 2-week skin cancer clinics the majority of patients were seen in the 2-week period; when delay occurred it was usually with the onward referral of patients to plastic surgery, suggesting that, if skin cancer clinics are established, a fast track onward referral to plastic surgery should be incorporated into the plan.[4]

In an audit carried out in a large university-based hospital, the incidence of skin cancer was approximately 157 for basal cell carcinoma, 28 for squamous cell carcinoma and 12 for malignant melanoma per 100 000 of population. Most of the skin tumours (81%) were managed by the dermatology department while 15% were managed by plastic surgery, GPs, ophthalmology and ear, nose and throat surgeons. These data provide good information regarding the incidence and management of skin cancers in that region.[5] The same department uses a SIAscope™ as a skin imaging device as a diagnostic aid in their melanoma clinic. Where a biopsy was not performed the decision of the melanoma clinic physician with 10 years' experience was taken as the reference standard. Of 500 skin lesions assessed and scanned, 64 biopsies were performed and 11 melanomas diagnosed. The performance of the SIAscope™ seemed to be highly accurate.[6]

Following up multiple atypical melanocytic naevi can represent a challenge for doctor and patient alike. In one study the use of the digital Molemax II™scanner was used to follow selected high-risk patients from this group of patients. Planned yearly follow-up of digital dermoscopy is anticipated but it was also felt that the use of this technology encouraged patients in more frequent self-examination.[7]

Despite all of our education of the public, typical nodular melanomas continue to present in the U.K. In one study carried out over a 24-year period, of 3353 melanomas registered, 447 nodular melanomas were identified. Not unexpectedly the Breslow thickness was generally high and the typical patient with a nodular melanoma tended to be older, more frequently female and have a relatively small lesion with high Breslow thickness, located on the head and neck or distal limbs, that is, on regularly sun-exposed sites.[8] It is clear that we have not yet done enough to capture these patients at an earlier stage.

Worrying histories remind us of the difficulty of diagnosing malignant melanoma. Three cases were presented where the presentation mimicked Bowen's disease, suggesting that we need to maintain a low threshold of suspicion and readily undertake diagnostic biopsy in the management of solitary lesions that might be Bowen's disease or a superficial basal cell carcinoma.[9]

Vulval melanoma is rare and illustrates that not all melanomas are linked to ultraviolet exposure.[10] In one case where vulval melanoma had been treated by radical vulvectomy with several recurrences, in situ melanoma remained at the resection margins. A short trial of imiquimod cream was undertaken and histological clearance of the melanoma was shown. However, 6 months later the patient developed right groin lymphadenopathy with metastatic disease. Clearly, it is not known whether the lymph nodes may have been coincidental or whether imiquimod triggered lymphatic spread through its effect on matrix metalloproteinases.[11]

http://www.medscape.com/viewarticle/533355_print Page 2 sur 23 Updates from the British Association of Dermatologists Meeting 292/10/Thursday 07h37

The controversy surrounding sentinel node biopsy in melanoma continues and was discussed previously in several Controversies in Dermatology articles,[12-14] and some recent publications question the survival benefit of sentinel node biopsy in melanoma.[15,16] In a study from Glasgow of 318 patients with primary melanoma > 1 mm in thickness who had sentinel node biopsies, 76% of the sentinel nodes were free from tumour. Although a negative sentinel node biopsy indicates a good chance of long-term survival, 6% of these patients had a recurrence, several of which occurred 4 years or more after the negative sentinel lymph node biopsy. Side-effects of sentinel lymph node biopsy were rare but, surprisingly, three patients had an anaphylactic reaction to the patent blue V dye. Patients with head and neck tumours find the persistence of blue dye staining troublesome. It was concluded that until clear evidence of survival benefit has been demonstrated, sentinel node biopsy should be used only as a staging procedure for stratification into appropriate clinical trials.[17]

A group from London felt that sentinel node biopsy evaluation was crucial in melanoma management as it provides accurate staging. They suggested that subcapsular micrometastatic deposits tend to have a better prognosis and that complete lymphadenectomy may not be required in these patients,[18] a management method which is supported by other trials. Moyes et al. felt that interpretation of sentinel node biopsy histopathology was generally straightforward as positive nodes are usually picked up on haematoxylin and eosin sections alone, although immunocytochemistry is useful in identifying micrometastases, sometimes not obvious on conventional staining. The significance of cells, suspicious on immunocytochemistry, that cannot be demonstrated on haematoxylin and eosin sections remains unclear.[19]

A large multicentre case-control study was set up in Europe to investigate the potential association between sun bed use and melanoma. There was a greater prevalence of sun bed use in Northern Europe compared with that in Southern Europe. This study did not confirm an association between melanoma and sun bed use although it acknowledged that the full effect of this exposure on skin cancer may not become apparent for many years.[20]

In an audit into the treatment of squamous cell carcinoma the main causes of delay in referral were incorrect diagnosis and failure to state the urgency of the suspected skin lesion.[21] The treatment of widespread actinic keratoses (AK) on the face and scalp remains a challenge. In a trial from Australia, photodynamic therapy (PDT) using methylaminolaevulinate (MAL) was compared with cryotherapy and placebo. MAL-PDT, using two sessions 1 week apart, appeared to be an excellent treatment for thin and moderate AK and was significantly better than cryotherapy or PDT with placebo cream. The cosmetic results were also better with MAL-PDT and the majority of patients preferred this treatment modality.[22] This study was strongly supported by a European multicentre study,[23] which gave very similar results and conclusions. In a similar vein, a placebo-controlled European multicentre trial[24] of MAL-PDT appeared to have recurrence rates slightly less than those for cryotherapy or 5- fluorouracil (5-FU) and it appeared that MAL-PDT gave a better cosmetic result than either cryotherapy or 5-FU.

McCormack and Kemmett[25] examined the treatment of basal cell carcinoma in patients under the age of 50 years. At presentation the lesions had been present for an average of 27 months and had reached an average diameter of 1 cm. In 8·2% of 231 patients multiple lesions were found, usually on the trunk. Primary excision was performed in 59% of patients and 41% underwent a diagnostic biopsy; of these 46 were referred for plastic surgery. It was deemed that there was a history of excess sun exposure in 38% of patients and 24% of patients had lived abroad for more than 5 years. The delay to diagnosis in this age group is surprising and should perhaps be the target of education.

In an audit into the management of basal cell carcinoma in Scotland, Gudi et al.[26] generally found that basal cell carcinomas were managed appropriately according to the guidelines for the treatment of basal cell carcinoma as published by the BAD.[27] Few recurrent tumours in high-risk areas on the face were managed inappropriately with curettage and cautery and/or cryotherapy rather than surgical excision but some patients with multiple basal cell carcinomas or morphoeic basal cell carcinoma were not offered follow-up in secondary care.[26] PDT using MAL- PDT for superficial basal cell carcinoma was compared in an European multicentre study.[27] At 3 months the complete response rate did not differ significantly between MAL-PDT and cryotherapy but the cosmetic outcome of MAL-PDT was better. Even after 36 months of follow-up no treatment difference between MAL-PDT and cryotherapy, apart from cosmesis, could be found.[28]

In a similar study looking at nodular basal cell carcinoma, again from a multicentre European comparison, MAL- PDT was compared with excision. A trend for higher recurrence with MAL-PDT was found but cosmesis seemed better.[29] The use of PDT as the treatment of superficial basal cell carcinoma has pain as a main adverse event recorded at the time of treatment. Despite this, the routine use of PDT for superficial basal cell carcinoma was http://www.medscape.com/viewarticle/533355_print Page 3 sur 23 Updates from the British Association of Dermatologists Meeting 292/10/Thursday 07h37

shown to be effective and generally well tolerated although methods to minimize pain need more study. It may also be that MAL-PDT is more effective than conventional PDT for the treatment of superficial basal cell carcinoma.[30]

The development of skin cancers following solid organ transplantation is a growing issue, which was the subject of a symposium at the Royal Society of Medicine in 2005.[31] In a study from Ireland there was a biphasic increase in skin cancer in patients after renal transplant, with a steady increase in risk from 2 years after transplant reaching 200 times the risk by the time of 6 years after transplant. Similar types of skin cancer were reported as those already published but the risk of invasive squamous cell carcinoma increased 82-fold compared with the normal population, with male recipients particularly at risk in sun-exposed sites such as the scalp and ear.[32]

By contrast, skin cancer was not observed in a paediatric solid organ transplant group of patients who were 5-16 years[1] post-transplantation. Sunscreens were used regularly in only 83% of these transplant patients, including 77 of the 84 with skin types I-IV. Patients using a sunscreen had higher total benign naevus counts compared with those not using sunscreen. However, the authors felt it necessary to continue patient education regarding sun avoidance measures.[33]

The use of retinoids to prevent squamous cell carcinoma in organ transplant patients has been recognized for some time. In a study from London, Harwood et al.[34] used doses of 0·2-0·4 mg kg-1 daily for prophylaxis against squamous cell carcinoma. Most of the adverse effects were mild but in 25% of cases the retinoid dose was limited by symptomatic side-effects usually of the mucocutaneous type. Treatment significantly reduces squamous cell carcinoma development for at least 3 years and this effect may be sustained for 9 or more years with a generally well tolerated side-effect profile. The authors comment on the need for further studies to optimize the use of retinoids as a chemopreventative strategy in this high-risk population.

The information given to organ transplant recipients regarding sun avoidance and photoprotective measures does seem to get through, especially when this information is given in a dermatological setting.[35] Only prospective studies will establish whether the improved level of photoprotection will have a beneficial long-term effect on nonmelanoma skin cancer rates in this selected population.

In an interesting study comparing extracorporeal photopheresis (ECP) vs. methotrexate (MTX) used in the treatment of erythrodermic cutaneous T-cell lymphoma (CTCL), Wain et al.[36] randomly assigned patients to either ECP or MTX (maximum dose of 55 mg weekly). A total of 14 patients were enrolled, eight receiving ECP and six MTX. The study concluded that MTX and ECP were of similar efficacy in this erythrodermic CTCL group. However, patients who had undergone both treatments at some stage preferred ECP because it has fewer side-effects and because of the opportunity, while undergoing treatment, to meet other patients with similar problems.

Dermatopathology

There is an ongoing national debate as to the merits of specialized reporting in histopathology; national guidelines set standards for such reports.[37] In an audit from a district general hospital, Hill et al.[38] audited the effect of moving to specialized teams. Interestingly, hospital skin biopsies represented 20% of the histopathology workload. By moving to specialized reporting there was a slight shift of reporting from benign to malignant diagnoses but a reduction in changes in patient management. It was concluded that dermatopathology is a particularly complex area but that specialization meant that patients and clinicians could benefit from more precise reporting with fewer unnecessary investigations and a reduced potential for inappropriate treatment. Perhaps this is the way forward for the future?

Eccrine porocarcinoma is a rare tumour but is the commonest of the sweat gland carcinomas. In an audit from London, Shergill et al.[39] showed that the mean age of presentation was 67 years with a 2:1 female to male ratio. The commonest occurrence was on the lower limbs. Aggressive behaviour in eccrine porocarcinoma was not correlated with clinical appearance and histology. There does not appear to be a classical clinical appearance of an aggressive eccrine porocarcinoma as assessed on histological grounds.

Records in Manchester of sebaceous carcinomas were audited by Winhoven and Andrew.[40] This rare tumour usually occurs on the eyebrow and may be associated with Muir-Torre syndrome. This study confirmed the findings that sebaceous carcinomas usually arise on the facial areas of elderly patients. Mohs' micrographic surgery and wide local excision were the preferred treatment options but excision rarely achieved the generally accepted margins of 5-6 mm on such a tumour. The diagnosis of sebaceous carcinoma was not suspected clinically in any of the patients, probably because of poor awareness of this tumour among clinicians. It was

http://www.medscape.com/viewarticle/533355_print Page 4 sur 23 Updates from the British Association of Dermatologists Meeting 292/10/Thursday 07h37

commented that dermatopathologists can contribute to the management of this tumour by pointing out the need for wide excision margins.

Update for Dermatopathology

Dr Robin Reid from Glasgow gave a complex lecture on soft tissue tumours. He showed, through a series of cases, how markers such as cytokeratins could be used to categorize epitheloid-derived sarcomas. Dr David Slater, acknowledged expert in the field of dermatopathology, suggested at the end that many of these cases require the help and attention of a specialized pathologist in this area, and as a nonpathologist I (D.J.E.) certainly came away with that strong impression.

Dermatological Surgery

Digital myxoid cysts are a common problem presenting to dermatologists. In an open trial Lawrence[41] described a method by which a skin flap was raised to include the cyst and tissue from the cyst. The cyst was then simply incised, the contents drained and the flap sutured back into place. There was no osteocyte removal, skin excision or attempt to tie off the connection with the underlying joint. At previous BAD meetings Dr Lawrence had demonstrated eloquently how to inject the distal interphalangeal joint with methyl blue dye in order to identify the connection of one of these cysts with the underlying joint and tie it off. He now feels that this is not necessary and suggests that it is not attempted for toe joints.

From the same department Nayak et al.[42] described the 15-year experience of the surgical treatment of rhinophyma. The techniques of simple scalpel shave excision, dermabrasion and electrosurgery were compared in 12 patients. All had a good to excellent result with re-epithelization taking place in 2-6 weeks. The cosmetic result was similar for each of the three surgical modalities but dermabrasion produced problems with a potentially hazardous aerosol spray of blood; electrosurgery was felt to be the most satisfactory with better speed, ease of operation and control of haemorrhage.

Lipomas are traditionally treated by incision over the swelling followed by enucleation. A modification of the 'squeeze' technique was described. The margins of the tumour are drawn on the skin and local anaesthetic (LA) injected circumferentially. The lipoma is then infiltrated with either LA or normal saline until it is of a hard consistency. Through a small incision it is easy to separate the lipoma from the fibrous tissue using mosquito forceps and to squeeze the lipoma between the finger and thumb until it mushrooms out of the incision wound. Removal is then completed with scissors.[43]

With increasing numbers of patients prescribed anticoagulant and antiplatelet therapies for primary and secondary prevention of cardiovascularevents, dermatologists continue to face the dilemma as to whether to stop these medications preoperatively or to risk the complications of a cardiovascular event. This debate has raged for a number of years at BAD meetings. In a study conducted by a questionnaire to BAD members, there were nine patients who suffered complications on continued aspirin therapy and 11 on warfarin therapy. However, when medications were stopped four patients had suffered cardiovascular events, two suffered transient ischaemic attacks and one required admission for unstable angina. The literature was reviewed and, although it was stated that the lesion and the degree of anticoagulation must be considered, there is compelling evidence that patients can safely remain on their anticoagulation and antiplatelet agents for cutaneous surgery.[44]

In a prospective observational study to look for the complications of continued warfarin therapy, Blasdale et al.[45] found there was no significant increase in perioperative or postoperative bleeding when patients remained on warfarin but that there was moderate or severe postoperative bleeding in 7% of 60 patients on warfarin, statistically greater than in controls. There was no correlation between the international normalized ratio (INR) level and the frequency of haemorrhagic complications.

With the increasing use of botulinum toxin for axillary hyperhidrosis, a method by which the botulinum toxin can be evenly injected into the area of hyperhidrosis would be welcome. Jain[46] has developed a flexible silicone sheet with holes punched at 1-cm intervals. After defining the area of excess sweating using the starch iodine test, the silicone sheet grid can be positioned over the affected area and a skin marker pen used to mark the skin though the holes in the grid. This process takes only a few seconds after which the injections of botulinum toxin can be evenly distributed over the area.

The optimum treatment of Merkel cell carcinoma, a rare aggressive malignant neuroendocrine tumour, remains to be determined. In a retrospective clinical review of 28 histologically proven tumours, most underwent surgical

http://www.medscape.com/viewarticle/533355_print Page 5 sur 23 Updates from the British Association of Dermatologists Meeting 292/10/Thursday 07h37

excision but only 36% were documented as having at least 20-mm wide excision down to fascia, and adjuvant therapy to primary nodal basins was administered to 47%. Cumulative data suggests that a 20-30-mm wide excision, where possible, with adjuvant radiotherapy to the primary site and nodal basins may be the best treatment with chemotherapy as an effective palliative treatment both for locoregional disease or for systemic disease. The role of sentinel node biopsy, prophylactic lymph node dissection, adjuvant interferon therapy and adjuvant chemotherapy is unclear and these workers call urgently for national guidelines to ensure a consistent standard of care is offered to this group of patients.[47]

With increasing numbers of patients undergoing dermatological surgery, do we need to know the expectations of these patients? In a questionnaire interview of 50 patients undergoing day case skin surgery, the most frequent concerns of patients were scarring (33%), loss of function such as sight (21%), pain (19%) and return to normal physical activity (12%) with others including infective risk, bruising and the risk of skin cancer recurrence. Although these topics had been covered in an information leaflet sent out to the patients, the patients wanted to ask specific questions regarding their individual procedure and its associated risks. Many concerned about scarring thought it would be useful to see pictures of typical scars and the complications that might follow surgery. Some had not read the information leaflet, as they were worried it might provoke more anxiety or found it too detailed. The results of this study emphasize the need for verbal communication especially when carrying out skin surgery on our patients. There is no substitute for verbal one-to-one communication and although patient information leaflets can be helpful, verbal communication is probably more appreciated by the patients; it may be helpful to have clinical pictures of typical complications and scarring available.[48]

Update for Dermatological Surgery

Dr Richard Motley from Cardiff took us through the recent advances in surgery over the past year. He pointed out the history of Botox® in the treatment of migraine headaches but noted that unlike previous reports the facial flushing that occurs in acne rosacea does not seem to respond to botulinum toxin injections in the face.[49] There is still some hope for patients with largely vascular rosacea in the use of various vascular lasers.[50]

Interestingly in a discussion on split ear lobes it was noted that this problem did not correlate well with the weight of earrings used and it may well be that the problem is more related to allergy to the metal in the earring than to the sheer drag of earrings. Clinical presentation and histological study suggest that allergy to metals in the earring could lead to split ear lobe, whereas the constant pull by heavy earrings was probably more likely to result in a stretched ear lobe. The authors considered that the avoidance of the offending metal in the earring is indispensable to prevent recurrence of split ear lobe.[51]

It is well known that chronic lymphocytic leukaemia, the commonest adult leukaemia, accounting for around 30% of cases, is associated with a much increased risk of skin cancer. Despite the use of Mohs' micrographic surgery, recurrence rates were some 14 times more likely to occur in patients with basal cell carcinoma than in controls and some seven times more likely in those with squamous cell carcinoma.[52,53] Dr Motley proposed that this may be due to the cellular infiltrate from the chronic lymphocytic leukaemia cells surrounding the basal and squamous cell carcinomas. He felt that Mohs' micrographic surgery should be continued until a cell-free plane was achieved but a perceived problem with this could be that if the skin is infiltrated with many lymphocytes then a cell-free plane may not be achievable without a lot of tissue wastage!

The dogma that digital anaesthesia should not include adrenaline dates from old literature well into the last century. Recent work, using LA containing adrenaline in surgery for Dupuytren's contracture instead of a tourniquet, suggests that the practice does not significantly increase the rate of digital ischaemia.[54] Despite evidence from the literature the present author remains cautious about the use of adrenaline in digital anaesthesia even with the possible advantage of decreased bleeding in these patients. This approach, based on the latest scientific data, may be difficult to defend in court but is probably reassuring for the dermatological surgeon to know.

The treatment of melasma is always very difficult. Dr Motley pointed out that Cleopatra applied sour milk to her face, while Arabian women used yogurt as a source of lactic acid in order to reduce melasma. Interestingly this treatment has re-emerged in the form of lactic acid applied to melasma, which has been found to be efficaciousin these patients. In a study from Baghdad, lactic acid, an alpha-hydroxy acid, was used at full strength (92%; pH 3·5) with chemical peels done every 3 weeks for up to six sessions until the desired response was achieved. Lactic acid was considered to be an effective and safe peeling agent for the treatment of melasma, with no significant side- effects.[55]

http://www.medscape.com/viewarticle/533355_print Page 6 sur 23 Updates from the British Association of Dermatologists Meeting 292/10/Thursday 07h37

Phototherapy

With three decades of total body photochemotherapy (PUVA) behind them, Farrant et al.[56] looked at the patients who had had more than 200 treatments with PUVA, that is, over the upper limit of the British Photodermatology Group Guidelines. Thirty patients had had more than 200 treatments, mostly for psoriasis. Three patients had developed squamous cell carcinoma, one of whom had died in consequence. Basal cell carcinomas were found in four individuals but no cases of malignant melanoma were found. From the practical point of view the group has instigated an annual follow-up of the five patients that they had discharged after high doses of PUVA and have marked the cover of all such notes with an alert sticker to identify this high-risk group.

In a study looking at the annual rates of adverse incidence following narrowband ultraviolet (UV)B and PUVA therapy, Martin et al.[57] showed that the number of adverse events in their department for all phototherapy treatments was 0·8% with the lowest percentage 0·6% for narrowband UVB. The majority of adverse events occurred in whole body treatments; bath PUVA was consistently recorded as having the highest rates.

In an intriguing study looking at the effect of obesity on potential overexposure to phototherapy, patients were simulated by the use of full laundry bags with readings taken from a built-in dosimeter. The built-in dosimeter was significantly affected by the amount of patient shielding, over-reading when the cabinet was empty and under- reading when the cabinet contained a 'large patient'. This could lead in the most extreme case to an overdose of 70% and the unit has decided to use a reduced starting dose [50% of minimal erythema dose (MED)] for very obese patients and a manual check of the dose rate displayed during the first treatment of any new patient.[58] This procedure clearly has practical implications for the practising dermatology nurse.

With the long-term outlook of TL01 phototherapy unknown at this moment, it is interesting to note that an increase in p53+ basal or suprabasal keratinocytes occurred in patients undergoing TL01 phototherapy for PUVA and occasionally these were arranged as inverted conical clones arising from putative stem cells, supporting the idea that chronic TL01 therapy might trigger cell growth and clonal expansion.[59] However, two studies have failed to show an increase in skin cancer incidence in patients receiving higher doses of TL01 phototherapy,[60,61] and one strongly suspects that only time will provide the answer to these questions.

The predominance of skin cancers on the lower legs of women has been attributed to the wearing of skirts. One group looked at the UVR reflected from the various surfaces including light paving stone, grit and tarmac. Light paving stones and grit reflected a greater portion of the UVR striking them than grass or a dark paving surface, and concrete reflected a greater amount of UVA while cobbles reflected more UVB. Wet surfaces and dark tarmac reduced UVR reflection. Designers and landscapers may take note of these findings.[62]

The UV transmission of commonly available sunglasses and their suitability as eye protection during PUVA therapy has long been an issue in dermatology. Modern sunglasses are manufactured mostly from polycarbonate plastic which is strong, inexpensive and an excellent UVA absorber. After transmission testing of glasses, Otman et al.[63] concluded that almost any modern sunglasses bearing a UV 400 tag will provide adequate UV protection and those of the wrap around style are probably preferable.

In a U.K. prospective clinicopathological study on erythropoietic porphyria (EPP), male sex, anaemia and total porphyrins were all significantly associated with abnormal liver function. The high frequency of anaemia with features of typical iron deficiency in men as well as women was an unexpected finding as iron deficiency in men is unusual and it suggested a fundamental defect in iron metabolism in EPP.[64]

Update on Photobiology

Dr Bilsland gave us an update on advances in photobiology largely made in the past year. The relationship between sun beds and melanoma has been controversial, with the intuitive expectation that there would be a causal relationship. Gallagher et al.[65] did a meta-analysis of 12 case-controlled studies on sun bed usage in melanoma. The results of this analysis indicate that there is a significantly increased risk of cutaneous melanoma after sun bed and sun lamp exposure. Perhaps we are getting closer to the answer to this burning question!

Dr Bilsland drew attention to a study suggesting that the addition of insecticides to sunscreens may lead to chemical incompatibility and that concurrent application of commercially available repellent and sunscreen products may result in significant synergistic percutaneous permeation of the insect repellent N,N-diethyl-m-toluamide (DEET) and the sunscreen oxybenzone. The possibility of increased absorption of the insecticide may be

http://www.medscape.com/viewarticle/533355_print Page 7 sur 23 Updates from the British Association of Dermatologists Meeting 292/10/Thursday 07h37

dangerous in children.[66]

In an interesting paper he noted that the early use of Finsen's light was used as a cure for lupus vulgaris. This treatment has been revisited using homogenate preparations from skin containing acid fast bacilli which have been shown to contain endogenous endorphins. The fluorescence of Mycobacterium tuberculosis indicated the presence of porphyrins. High performance liquid chromatography (HPLC) analysis of sonicated M. marinum showed that coproporphyrin III was present, which is highly suggestive that porphyrins are present in M. tuberculosis. This is a feasible reason to explain the efficacy of Finsen's light treatments, acting as the earliest instance of photodynamic therapy, in the treatment of skin tuberculosis.[67]

Psoriasis

Pathogenesis

Hampton and Reynolds,[68] from Newcastle, presented their data on β-catenin, a key regulator of mouse skin stem cell differentiation. It regulates keratinocyte transglutaminase transcriptional activation and increased nuclear β- catenin is found in the involved psoriatic epidermis. They studied six patients looking at β-catenin production and found that lithium, a known glycogen synthase kinase 3β inhibitor, caused inhibition of calcium-induced keratinocyte transglutaminase levels. They are the first workers to report keratinocyte transglutaminase 1 activation and involvement of the wnt/β-catenin signalling pathway in psoriasis. This sheds new light on the possible mechanisms underlying lithium-induced psoriasis.

Professor Griffiths' team from Manchester[69] have studied retinoid pharmacogenetics and vascular endothelial growth factor (VEGF) in chronic plaque psoriasis. They found that there were 'high VEGF producers' and 'low VEGF producers' and that the effects of retinoids on cell expression of VEGF are determined by cell type and genotype. It appeared that the presence of −460 VEGF single nucleotide polymorphism genotype had an important role in predicting the response of psoriasis to acitretin. It is likely that we will be hearing more about VEGF gene polymorphisms and also others that may be used as a prognostic factor for optimizing response to systemic retinoids and other drugs.

Epidemiology

Tobin et al.[70] from Dublin presented a poster on the prevalence of psoriasis in patients with alcoholic liver disease, as it is widely accepted that there is a relationship. They found a very high prevalence (10%) of psoriasis in patients with alcoholic liver disease. In the normal population it would be between 1% and 3%; further studies need to be established to look into this in more detail.

Poster 45 (P45) was very aptly labelled as such, as it was about the impact of moderately severe psoriasis on employment. Theoretically, psoriasis should not have any impact on employment unless the hands are very badly affected; however, this was not the case in this study presented by Cusack and Buckley[71] from Waterford. They sent out questionnaires to 120 patients with psoriasis and found that over 40% of the respondents avoided certain jobs because of the negative attitude or misconceptions about psoriasis in the workplace, or they would try to conceal their condition at work. Thirty per cent of respondents felt that psoriasis had influenced their career choice, 16% felt that psoriasis had affected their career progression and nearly 25% suspected this might have occurred. I am afraid that the conclusion was that moderately serious psoriasis has a negative impact on aspects of employment.

Management

There was one presentation on biological therapies for psoriasis, an international multi-centre study showing that infliximab produces a sustained, significant improvement in psoriasis over 50 weeks of continuous therapy. Infliximab was well tolerated and a clinically meaningful improvement of the Dermatology Life Quality Index (DLQI) was seen at 10 and 24 weeks compared with a placebo.[72] Time will tell whether the commissioners of healthcare following the NICE guidance will allow us to use this drug.

The monitoring of the toxicity of methotrexate still showed a wide variation. Two recent questionnaires have been undertaken. Collin et al.[73] from Solihull performed a nationwide survey for the British Association of Dermatologists, with a 71% response rate, looking at methotrexate prescribing and monitoring practices. They found a wide variation in current practice. Of the respondents 92% gave a test dose of between 2·5 and 5 mg and http://www.medscape.com/viewarticle/533355_print Page 8 sur 23 Updates from the British Association of Dermatologists Meeting 292/10/Thursday 07h37

following this 42% checked the blood count between 7 and 10 days and 43% at < 7 days; maximum marrow suppression usually occurs between 7 and 10 days. Procollagen type III N-propeptide (PIIINP) levels were widely used (59%) despite limited evidence of their utility. There were 49 deaths attributed to methotrexate use; four of these were following a liver biopsy. They called for clear guidelines for methotrexate prescribing and monitoring. Khan et al.[74] from Cardiff audited their own measurements of PIIINP assay in patients undergoing chronic methotrexate therapy. Their audit suggested that a significant hepatic fibrosis would be unlikely with normal PIIINP levels and they recommended that regular PIIINP estimation should replace the cumulative dose of methotrexate as an indicator for a biopsy; however, the exact abnormal threshold value for PIIINP before a liver biopsy should be undertaken has not been determined.

A study examined the response of patients with psoriasis whose skin cleared with TL-01 narrowband UVB therapy, according to skin types, MED and total dose received. They demonstrated that patients with psoriasis that did not clear had a lower MED, received a lower total dose of UVB TL-01 and were more likely to have Fitzpatrick skin types I or II. They also showed that patients who burnt during treatment had a lower MED than those who did not. The message from this presentation was that one has to be very careful with skin types I and II.[75]

Many of us have been using 0·1% tacrolimus ointment for flexural or facial psoriasis but the group from Liverpool[76] have undertaken a double-blind randomized single-centre study comparing clobetasone butyrate 0·05% ointment and tacrolimus 0·1% ointment. They found no significant difference between these two preparations which had similar efficacy and a comparable side-effect profile. Therefore if one were worried about skin thinning or the formation of striae then the use of tacrolimus ointment would be advised.

Eczema

Many of the presentations or posters concerning various aspects of eczema were presented in the British Society for Paediatric Dermatology session.

Adalat et al.[77] from Birmingham performed an up-to-date study on the prevalence, aetiological factors and treatment of napkin dermatitis. Their study confirms that napkin dermatitis is no longer a common clinical problem for secondary care practitioners and is now usually treated successfully in primary care. Approximately half of the patients had never experienced an episode of nappy rash. The use of disposable nappies is now almost universal and this was likely to have accounted for the decrease in the number of cases presenting with napkin dermatitis.

Beattie and Lewis-Jones[78] from Dundee audited the usefulness of the quality of life measures in secondary care for assessing the impact of atopic dermatitis on infants and their families, and the benefit of a consultation with a dermatology team. They showed that it was very useful to ask patients or their carers routinely to fill in the Infants' Dermatitis Quality of Life Index and the Dermatitis Family Impact. There was a beneficial effect for both infants and parents after the initial consultation by a dermatology team. This ties in nicely with a paper presented by Baron et al.[79] from Leeds who looked at the effect of dermatology consultations in secondary care on treatment, outcomes, and quality of life in adult patients with atopic dermatitis. They showed that adults seen in secondary care had a maximum improvement of atopic dermatitis measured by Severity Scoring of Atopic Dermatitis (SCORAD) after their initial consultation. Most dermatology departments are under pressure to reduce follow-ups so that they can increase the number of new patients seen. The findings suggested that a routine follow-up appointment was not required for many adults with atopic dermatitis. They would now offer an open appointment unless the risk of poor treatment compliance could be identified, and follow-up would be in a specialist nurse clinic where prescribed treatments could be demonstrated. Hon et al.[80] from Hong Kong presented a poster showing a poor correlation between subjective symptoms of children with atopic dermatitis and the disease extent and intensity as measured by SCORAD. This could be explained by the SCORAD not being reliable in children.

Hon et al.[81] also surveyed the use of traditional Chinese medicine in children with atopic dermatitis and found its use to be popular, but there was low parental awareness that traditional Chinese medicines may produce side- effects. They recommend that, because of the potential side-effects, we should enquire routinely about the use of Chinese herbal medicine. The same workers from Hong Kong[82] were unable to demonstrate the presence of corticosteroids in five popular herbal remedies used in traditional Chinese medicine, which is reassuring. However, one wishes sometimes that parents would use topical steroids on their children's skin to help control the symptoms. They also studied the clinical features associated with nasal carriage of Staphylococcus aureus in children with moderately severe atopic dermatitis and confirmed that S. aureus is an important pathogen and that cloxacillin has a favourable sensitivity profile for S. aureus in these children. The anterior nares is an important harbour for S. aureus and there was significant nasal carriage associated with high total objective SCORAD scores, extensive

http://www.medscape.com/viewarticle/533355_print Page 9 sur 23 Updates from the British Association of Dermatologists Meeting 292/10/Thursday 07h37

lesions and the presence of oozing and crusting and raised eosinophil counts.[83] Shah and Mohanraj[84] from Dewsbury continued to have problems with fusidic acid-resistant S. aureus in children, despite attempts by the hospital and community to reduce inappropriate prescribing of topical preparations containing fusidic acid. They recommended that in their area fusidic acid-containing preparations are inappropriate for use in children with atopic eczema.

Management

There was only one presentation on the use of topical tacrolimus in atopic eczema. Kirke and Taylor[85] from Newcastle upon Tyne presented their experience of this over a 1-year period. They used it in children with severe eczema in whom topical steroids had proved insufficiently effective. It proved to be effective for 65% of these patients; those who responded to treatment required continued, although often intermittent, use to maintain disease control. They stated that the long-term side-effects of this treatment are not yet known. Smith and Ormerod[86] presented a study of pimecrolimus cream 1% once daily as maintenance therapy for prevention of relapse in mild to moderate atopic dermatitis in adults; unfortunately this did not provide significant benefit compared with the control group. They are undertaking further studies to establish the most effective way of using pimecrolimus as a maintenance therapy.

Ladoyanni and Moss[87] from Birmingham presented the use of the SCORAD system to assess eczema severity in routine clinical practice. Their pilot study confirmed the benefit of using a validated eczema severity score in the management of atopic eczema. Nurses found it particularly useful; however, it is difficult and time consuming and probably not applicable to all patients with eczema.

Baron et al.[88] from Leeds presented a pilot study on hypnotherapy to treat adults and children with moderate to severe atopic eczema. This pilot study showed a marked improvement in the eczema and quality of life, anxiety and depression, and family impact, and these were maintained for a 12-month follow-up. In addition, patients enjoyed the sessions and found self-hypnosis a useful skill for the long-term management of their disease. A larger trial would be useful to evaluate whether this therapy is of real benefit.

Health Services Research

In recent years there has been a push from the Department of Health (DoH) to increase the numbers of general practitioners with a special interest (GPwSI) in various specialties, including dermatology, and this was reflected in four presentations on this subject. Schofield et al.[89] presented an audit of GPwSI against Department of Health guidance and found that some GPwSI posts were working well, but their results raised concerns about accreditation training, continuous professional development and the frameworks within which many GPwSI schemes have been implemented. In order to ensure high quality patient care, those commissioning dermatology GPwSI services should ensure that as a minimum the standards set within the DoH document are met. In a poster Schofield et al.[90] also presented concerns over the hidden resource of nonconsultant career grade dermatologists. These doctors are often very experienced and make a substantial contribution not only to service provision, but also to teaching and research. There was scope to maximize the potential benefit of this group of doctors, in particular in developing intermediate level service provision both in primary and secondary care. However, there was a great worry that at least 25% of them are considering leaving the specialty.

Community pharmacists were also included in the NHS plan to help with relieving pressure on GPs. Hafejee and Coulson[91] from Burnley surveyed community pharmacists in their area, of whom 19 of 20 replied. They found that community pharmacists receive even less dermatology teaching than medical students. They had high self- confidence in advising patients on common skin problems. This might be due to the fact that they were very experienced and would encounter only a narrow range of skin problems. They concluded that there needs to be more dermatology teaching for community pharmacists at both undergraduate and postgraduate levels if the new NHS plan for prescribing is to be realistic.

Dermatology Education

There is no doubt that dermatology training is always under threat in undergraduate and even postgraduate training schemes. Dr Kerr et al.[92] from Edinburgh presented a paper on the importance of teaching general practitioners dermatology at both undergraduate and postgraduate levels. Their survey concluded that dermatology was not only an essential part of the medical core curriculum but should be taught at postgraduate level as well. It should remain an essential part of the undergraduate medical curriculum and should be added to the list of specialties that http://www.medscape.com/viewarticle/533355_print Page 10 sur 23 Updates from the British Association of Dermatologists Meeting 292/10/Thursday 07h37

can be counted towards GP vocational training.

Clayton and Burge[93] from the Oxford region continue to define and validate the dermatological content of the undergraduate medical curriculum. They concluded that dermatological learning experiences should be threaded into a medical course at a number of stages with the content of the core curriculum broadly similar at different medical schools.

In a study from Bristol, Sansom and Shipley[94] have been developing an undergraduate teaching and learning curriculum in a clinical academy system. They found several key issues that were important: careful planning and involvement of all parties were crucial; individual student timetables required extra administration; there was a need to derive appropriate learning objectives and identify a course leader to evaluate equity of teaching and learning; and assessment was linked to teaching and learning. Regular meetings and feedback were required to inform and evaluate the course. Comprehensive documentation for quality assurance was vital. They also concluded that passing examinations was a good way of motivating students, which would be integral to the course. However, accreditation would continue to evolve supported by adequate resources and educational evidence.

The debate about the use of modern electronic technology for practicing the art of dermatology continues with studies looking at various aspects of this. Shaw and de Berker[95] from Bristol compared the data content and clinical value of electronic and paper referrals to a dermatology department and their study illustrated the strengths of e-referrals communicating demographic data and their weakness when telling us what is wrong with the patient; the latter still requires detailed clinical input from the referrer. Undue priority of the electronic over the clinical process may compromise understanding of patients' problems and their management. This study probably highlights the potential nightmare scenario with Choose and Book which is now being developed and brought into the NHS.

Watson et al.[96] from Edinburgh developed an e-mail advice service for general practitioners (GPs) and reviewed this after the first 12 months. It provided GPs with rapidly accessible advice on a wide range of dermatological problems; it offered an additional service to GPs but did not attempt to replace outpatient assessment as a means of diagnosis. It provided an insight into relevant areas to target GP education and may well have an effect on referral practice and perhaps reduce referrals.

Miscellaneous

Determining compliance in a patient is not always easy. Belgi and Finlay[97] from Cardiff developed the 'Yesterday Use' question to assess adherence with therapy. During consultation each patient was asked the standard 'Yesterday Use' question, 'Did you put any ointment or cream on your skin yesterday?' If they replied yes, they were asked how often they applied this yesterday. They assessed 272 consecutive patients and found that adherence after dermatology outpatients to prescribed topical treatments is poor. Forty per cent were not adhering to what was prescribed and 15% were partially adherent. This is a simple question, which will help us to identify those patients who are not adhering to prescribed treatment.

On the theme of poor patient compliance Dr Hon et al.[98] from Hong Kong asked the question: 'Why don't they come?'. The 'did not attend' rate was 20%, high by current NHS standards, now running at approximately 5%, but a few years ago it was up to 12% across the NHS. The most common reason for nonattendance was that the skin condition had already improved (46%) and, next, that 25% forgot the appointment. A long waiting time did not appear to be a common reason for nonattendance. This study was of paediatric new referrals and may reflect the fact that many skin conditions resolved spontaneously.

Lewis-Jones et al.[99] from Dundee looked at the quality of life of children with immediate allergy from natural rubber latex. It appeared to have a profound effect on the lives of the children and their parents. They were trying to validate the Quality of Life in Latex Allergy score for children and parents; however, further work is needed to develop and validate these questionnaires.

Warwick Hospital's Department of Dermatology has undertaken a customer care survey of general practitioners about the quality of outpatient service.[100] One of the reasons for doing the survey was they might receive ideas on how to modify and develop the service better to accommodate the wishes of the local GPs. However, the responses and comments received showed that the GPs were very satisfied with the department and 99% of GPs considered an outpatients visit was the best way of dealing with the issues involved despite the huge potential for other modalities such as telemedicine in their enquiries. Those of us with an aversion to new ways of working will be relieved by this survey.

http://www.medscape.com/viewarticle/533355_print Page 11 sur 23 Updates from the British Association of Dermatologists Meeting 292/10/Thursday 07h37

On a pharmacy theme Dr Moss's team[101] at Birmingham Children's Hospital looked at outsourcing the pharmacy dispensing because of financial constraints and staffing difficulties in the hospital pharmacy. The advantages of this included patient satisfaction and cost savings of £17,000 per year. Disadvantages included a delay in prescription delivery especially over the weekends and three adverse events attributable in part to the lack of direct interaction between the patient and parent at the point of delivery.

Contact Dermatitis

Dr Darsow from Munich was the Prosser-White orator and gave an excellent talk on the atopy patch test.[102] This is patch testing atopic individuals with aero or food allergens. Most of the work has been done on aeroallergens but more is being produced on food allergens and also Malassezia furfur.[103] The theory behind the atopy patch test is that aero or food allergens can elicit eczematous skin lesions in patients with atopic eczema. They can do this in the absence of corresponding specific IgE antibodies, thus this is a delayed hypersensitivity rather than an immediate hypersensitivity reaction. He concluded that it can be used with high specificity to evaluate clinical relevance. He also recommended performing a combination of skin prick tests and specific IgE antibody measurements (RAST tests).

The strength of the para-phenylenediamine (PPD)-positive patch test was correlated with whether patients could continue dyeing their hair or not. A study from St John's Institute of Dermatology demonstrated that patients with a stronger patch-test reaction were more likely to have a clear history of reacting to hair dyes and were less likely to be still dyeing their hair.[104]

A multicentre study was presented of hairdressing allergens tested in the U.K. using the British Contact Dermatitis Standard Series, and various hairdressing series that individuals in the study had used.[105] Its purpose was to develop a British Contact Dermatitis Standard Hairdressing Series. The commonest allergens producing positive allergic patch tests were: diaminotoluenediamine (20%), ammonium persulphate (12%), nitro-4-phenylenediamine (9%), glycerine monothioglycolate (8%), 4-aminophenol (6%), 3-aminophenol (5%). The hairdressing series has now been developed following this study and is available on the British Contact Dermatitis Society website. The Swansea group reviewed hairdressing chemicals found in products currently used.[106] This showed that the existing hairdressing, standard and facial batteries would detect most allergens in hairdressing products; however, they did contain a wide range of nonstandard dyes, plant derivatives, sunscreens and preservatives which might occasionally cause sensitization reactions. This study highlighted the importance of testing the patients' own products. Laing et al.[107] from the Mater Hospital in Dublin reviewed allergic contact dermatitis in a cohort of hairdressers and showed allergic contact dermatitis in nearly 60% of these hairdressers. PPD was the highest at 51% and next were para-toluendiamine (23%) and nitro-4-phenylenediamine (18%). Permanent wave allergens such as glycerol monothioglycolate were found in nearly 24% of patients. Allergic contact dermatitis caused significant morbidity resulting in a career change in 66% of the patients in the cohort group. The authors emphasized that preventative measures to protect hands should be employed to reduce occupational sensitization in hairdressing.

Batchelor and Wilkinson[108] from Leeds studied recommended methods of photopatch testing, comparing the sensitivities of irradiation at 24 or 48 h. By and large patch testers tend to irradiate at 48 h whereas the photo light testers tend to irradiate at 24 h; the dosage was usually 5 J cm-2 UVA radiation This study suggested that 48-h occlusion of allergens before irradiation was more sensitive in detecting photoallergy, but before adopting this as a recommendation they suggest that it should be confirmed with a multicentre study. Walker et al.[109] from Manchester presented the case of a pharmaceutical worker who developed an occupational photoallergic dermatitis from manufacturing carprofen, the canine nonsteroidal anti-inflammatory drug. This happened despite wearing full protective clothing, including an air hood. No other workers had dermatitis. It involved her hands and spread to her arms, face and neck. She had a positive photopatch test to the tablet using 5 J cm-2 UVA. Ten controls were negative on testing. Carprofen is used in the management of canine arthritis and sensitivity has been reported to occur in dogs.

There were two reports of photoallergic contact dermatitis from benzophenone-3, which is the commonest photoallergen.[110] A 79-year-old woman had cheilitis caused by benzophenone-3 lip cosmetic and photoallergy from benzophenone-3 in a sunscreen.[111] Langan and Collins[112] reported benzophenone photoallergy in a 46- year-old woman, who was also allergic to lignocaine and prilocaine. This patient was misdiagnosed with cellulitis following various LA procedures. Undoubtedly contact allergy to LA goes unrecognized; probably allergy to lignocaine does get misdiagnosed as cellulitis.

http://www.medscape.com/viewarticle/533355_print Page 12 sur 23 Updates from the British Association of Dermatologists Meeting 292/10/Thursday 07h37

The Ukrainian President Yushchenko's plight was highlighted in a poster depicting the skin effects of his poisoning after having had dinner with the Ukranian security service chief. He had levels of dioxin (2,3,7,8-tetra chlorodibenzo-P-dioxin) 6000 times higher than normal. This was the second highest ever recorded in human history. With the Vietnam war 11 million tonnes of Agent Orange containing dioxin was used against the Vietnamese: high levels were found in the blood of local children.[113]

CS gas is increasingly being used by the police force in the U.K.; unfortunately unintended cutaneous reactions occur. Watson and Rycroft[114] from St John's Institute of Dermatology presented seven patients who had various cutaneous reactions ranging from three who developed allergic contact dermatitis to two patients with rosacea who showed the greatest susceptibility to the cutaneous effects of CS spray. Seborrhoeic dermatitis seems to have been triggered in one patient who was exposed to CS spray. Another patient developed a disfiguring leucoderma and dysthesia secondary to CS spray exposure. Affleck et al.[115] from Nottingham presented an epidemic of contact dermatitis from 1,2-benzisothiazolin-3-one (BIT) in operatives manufacturing adhesives and floor-levelling compounds. BIT is a well-recognized industrial allergen but of the five patients three also reacted to 5-chloro-2- methyl-4-isothiazolin-3-one/2-methyl-4-isothiazolin-3-one (MCI/MI), a chemically related compound. BIT and MCI/MI can both cause vesicular hand eczema.

White and White[116] from St John's Institute of Dermatology reported two cases of an allergic contact dermatitis from dicyclohexylmethane-4,4'-diisocyanate. Both patients acquired the problem occupationally in a company that made polyurethane prototypes. There are very few reported cases of contact allergy to this allergen. They found that petrolatum-based patch-test preparations of organic diisocyanates at low concentrations would possibly lead to false negative results, therefore increasing the chance of missing allergic contact dermatitis.

Keogh and Gawkrodger[117] from Sheffield presented seven cases of persistent post occupational dermatitis (PPOD); this was originally a term coined by Wall and Gebauer of Perth, Australia.[118] Their criteria for diagnosing PPOD was made up of the following: there was no immediate preceding dermatitis; the dermatitis was located virtually always on the hand; evidence of an occupational component, induced either by an irritant or allergic contact; and dermatitis that persisted despite withdrawal of the offending agent.

Gawkrodger and McMullen also presented a review of frictional dermatitis—an underrecognized problem. Their conclusions were that frictional irritancy is not an uncommon cause or exacerbating factor in contact dermatitis. It is not rare and deserves wider recognition.[119,120]

Stanway et al.[121] from Nottingham presented a multicentre study comparing the Trolab™ Compositae mix with the Chemotechnique™ Compositae mix and found that the Trolab™ mix was marginally better. This is probably due to the fact that although the mixes are almost identical, the Chemotechnique™ mix has the allergen parthenolide rather than feverfew extract. It was recommended that the Trolab™ Compositae mix should be used (diluted to 2% as it is presented at 6%). This will reduce the chances of active sensitization and should pick up most patients allergic to Compositae. However there was a debate about the routine patch testing of patients with extracts rather than pure allergens.

Katugampola et al. reviewed footwear allergens tested in the U.K.; this has led to the proposed 19 allergens of the British Contact Dermatitis allergen series.[122] Dr King's team from Liverpool presented two patients who developed chromium allergy from contact with leather sofas, although usually people develop chromium dermatitis from cement or leather shoes. No doubt these leather furnishings had sufficient hexavalent chromium to cause chromate allergy.[123] I have once seen a patient, described as an exotic dancer in the GP referral letter, who was allergic to leather clothing. His day job was that of a builder and he was sensitized to cement but he did have a widespread rash when he donned his leather gear (J.S.C.E.).

Takwale and Sansom studied nickel allergy in atopic patients and whether this correlated well with the history.[124] The results showed that metal sensitivity did correlate with a positive patch test to nickel or cobalt (50% of atopic and 78% of nonatopic patients). There was better correlation in the nonatopic group for patch tests and patch-test results with a positive and negative history of metal intolerance. Their impression was that patients with atopy who have a history of metal intolerance are not always demonstrably nickel allergic on patch testing.

Affleck and English[125] presented a poster on a patient with allergiccontact dermatitis from abitol in a temporary tattoo, which made a change from PPD-contaminated henna tattoos.

Hafejee et al.[126] from Burnley presented an unusual way of getting rid of tattoos by applying a paste from the http://www.medscape.com/viewarticle/533355_print Page 13 sur 23 Updates from the British Association of Dermatologists Meeting 292/10/Thursday 07h37

extracts of a nut obtained from a traditional healer. The nut originated from a Himalayan tree species Semecarpus anacardium commonly known as the marking nut tree. The paste was very irritant and produced a very effective destruction of the tattoo. The individual did not want to be patch tested so they were unable to find out whether he had been sensitized to the paste; maybe this is worthy of a comparison study with laser ablation of tattoos?

It is proposed that individuals exhibiting persistent post occupational dermatitis lose the capacity for the resolution of their condition upon removal of exposure to causative agents and subsequently develop persistent endogenous- like dermatitis which can be continual or intermittent.[127]

Blistering Diseases

Epidermolysis bullosa acquisita (EBA) is characterized on indirect immunofluorescence by dermal binding of immunoglobulin (Ig)G to the base of a salt-split skin preparation. It has clinical features, such as the mechanical induction of blisters, and the presence of milia and nail dystrophy, that distinguish it from bullous pemphigoid. Dermal binding of IgA in linear IgA disease (LAD) is uncommon, and Lally et al.[128] from Oxford presented the clinical and immunoblot findings of 17 patients with dermal binding disease out of 100 in their large series of patients with LAD. They sought to determine if the patients with dermal binding had clinical features that distinguished them from those with epidermal binding. Almost all LAD patients with dermal binding had mucosal disease; only one had localized disease and none had either scarring or milia. Infection and antibiotics were identified as triggers to disease flares in three of their patients. Immunoblotting was undertaken in the dermal binding group and in only two patients was the target antigen collagen VII, the target antigen in EBA. The clinical findings of the dermal binding group were indistinguishable from the classical epidermal binding group.

In another study from the Oxford group, Desai et al.[129] looked at the prevalence of circulating antibodies to the basement membrane zone in a series of patients with leg ulcers. Immunoblot analysis against epidermal extract was performed to determine the target antigen, antibody class and antibody titre in 93 patients with chronic leg ulcers, 95 patients with well characterized bullous pemphigoid and 61 healthy controls. Eighty-one per cent of the patients with leg ulcer had antibodies to either bullous pemphigoid (BP) antigen 180 or 230 at a titre of 1:10; 88% of the patients with pemphigoid and, surprisingly, 59% of healthy controls had positive antibodies! BP 180 was the commonest target antigen, with IgA class antibodies predominating in the leg ulcer group. Recurrence and chronicity of the leg ulcer was associated with a more frequently positive antibody. Chronic antigen exposure in leg ulcers is presumably the reason for the development of the antibody. Perhaps there is a state of natural autoreactivity in patients with leg ulcer. The results obviously question the pivotal role of BP 180 antibodies in the pathogenesis of pemphigoid.

Acne and Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is one of a dermatologist's major challenges as it has major consequences for quality of life and is notoriously resistant to therapy. The observation that tumour necrosis factor (TNF) antagonists used to treat Crohn disease had a dramatically positive effect on a patient with concomitant HS, led Cusack and Buckley[130] from Waterford, Ireland to assess the efficacy of etanercept in a series of six patients with hidradenitis. All had failed to respond to conventional therapies including high-dose antibiotics, isotretinoin and rifampicin. Etanercept 25 mg subcutaneously twice weekly resulted in an improvement in self-assessed disease activity in excess of 60% and an improvement in quality of life. No infective adverse events were experienced, but withdrawal of therapy resulted in fairly rapid recurrence. Continued therapy has resulted in remission in all cases. Kaur et al.[131] from Birmingham investigated the effect of dapsone in HS. Hyper-reactive neutrophils have been demonstrated in HS that cause tissue destruction by the release of superoxides. Six patients used dapsone at doses of 50-100 mg daily; all patients experienced benefit from this treatment, responding 4-12 weeks after initiation. All experienced recurrence of HS on discontinuation of dapsone, so all have remained on therapy with a follow-up duration of 15 months. This is certainly a cheaper alternative to TNF antagonists, but blood monitoring is frequent at initiation and adds to cost and patient inconvenience.

Disruption to quality of life in acne was highlighted in a poster from dermatologists in Stoke and Bolton.[132] The disparity between clinical severity and patient's subjective rating was re-emphasized. Patients who thought that their acne was serious had less belief in their control of their acne and had higher levels of anxiety and depression. This did not correlate with either clinical severity or acne duration.

Contrasting with the introduction in the U.K. of the Pregnancy Prevention Programme for use of isotretinoin for acne in women is the ease at which prescription-only drugs can be obtained from internet pharmacies (without the purchaser committing any offence). With minimal effort using four common search engines, Torley et al.[133] from http://www.medscape.com/viewarticle/533355_print Page 14 sur 23 Updates from the British Association of Dermatologists Meeting 292/10/Thursday 07h37

Norwich identified 12 online pharmacies (in the U.S.A., Canada and India as well as in unidentified locations) capable of providing isotretinoin without prescription. Alarmingly, only five gave 'on screen' warnings of teratogenicity, and only three gave details of other adverse effects.

Morphoea and Lichen Sclerosus

The prognosis of male genital lichen sclerosus (LS) has received scant attention in the literature. Shah[134] from Dewsbury followed the progress of 50 men with penile LS over a 1-year period. At initial presentation to his male genital dermatoses clinic, 20% required immediate surgical referral, and a further 16% needed surgery within a year of presentation. Of those referred for surgery, 75% were symptom free after circumcision, two patients required ongoing urethral dilatation for meatal disease, and 60% of his sufferers gained significant benefit from topical steroid therapy alone, even those who had long-standing disease. Alarmingly, two patients of his series developed squamous cell carcinoma, one patient rapidly succumbing.

The long-term follow-up of women with LS has been addressed in the BAD guidelines series; it is suggested that yearly follow-up and examination be undertaken. Balasubramaniam and Lewis[135] audited the rate of follow-up by general practitioners after discharge from secondary care. Twenty-six percent of patients had not been seen for 2 years after discharge, and 38% had never seen their GP at all. Seventeen percent had seen their GP specifically about their LS but had not been examined. Interestingly 82% of patients were receiving ongoing therapy for their LS!

The link between LS and organ-specific autoimmune disease was revisited by Kaushal et al.[136] In a large study of 286 adult women with LS, 18% were noted to have coexisting thyroid disease and 8% vitiligo. The authors reflect on the role of extracellular matrix protein 1 antibodies in the pathogenesis of all three diseases.

Morphoea can be an inconsequential disease in childhood, but it may be progressive and have severe sequelae, both functional and cosmetic. The combined experience of the Great Ormond Street, Royal Free and Padua University departments in the evaluation and treatment of difficult morphoea was presented.[137] Assessment was performed clinically, by overlapping clinical and thermographic images, and by laser Doppler flowmetry. Interestingly, Doppler flowmetry was useful in assessing the false positive thermographic images that are seen in areas of skin atrophy. Disease activity was suppressed using pulsed methylprednisolone, followed by oral prednisolone (0·5-1 mg kg-1 day-1) and weekly methotrexate with folic acid supplementation. Prednisolone was tapered over 6-12 months and methotrexate tapered over 1-3 years. Disease activity correlated well with the results of the imaging methods. This was a useful presentation of how to manage the minority of morphoea patients in whom treatment can go wrong!

Hair and Appendages

Hormone replacement therapy (HRT) in the menopause has had negative press recently because of its association with an increased risk of breast cancer. It is commonly believed that HRT has a role with antiandrogens in the management of female pattern hair loss. In a large study of 230 women, Ali et al.[138] of the Oxford group correlated the scalp and facial hair status of two groups of women—those that were receiving HRT and those that had never had any. Women on HRT had a lower objective facial hair score, but HRT was not protective towards preventing female pattern hair loss. Indeed, there was a significant correlation found between HRT use and female pattern hair loss after the age of 60 years. In some instances this was found to be associated with the use of tibolone and premarin, both of which have mild androgenic activity.

Acquired progressive kinking of the hair is a condition described in men where a progressive kinking and twisting of the scalp hair shaft develops; this may be a harbinger of male pattern baldness. Ali et al.,[139] in a large study of the ageing female scalp, found acquired progressive kinking in 7% of postmenopausal women. This was most evident in those with an elevated body mass index. A small number had female pattern hair loss and over half had evidence of frontal recession.

Alopecia areata can be a sudden devastating shock to sufferers. In a revealing survey of chronic Scottish patients, a few important lessons were learnt. Most patients did not feel that the current allocation of two NHS acrylic wigs a year is sufficient; 32% of patients supplement this allocation by buying some of their own pieces. Most patients (90%) had consulted alternative practitioners for treatment; almost a quarter had spent in excess of £1000. Although the treatments had helped them 'as individuals' they had seldom effected hair regrowth. Hospital consultants received criticism for lack of sympathy and lack of knowledge about the allocation and provision of wigs.[140] http://www.medscape.com/viewarticle/533355_print Page 15 sur 23 Updates from the British Association of Dermatologists Meeting 292/10/Thursday 07h37

Anhidrosis is a symptom that patients seldom report, and is a sign we seldom look for. Colleagues from Lucknow,[141] India, alerted us to the problem of acquired idiopathic generalized anhidrosis. In a series of eight male patients, all presented with a history of heat, light and exercise-induced itch. On exercise a transient, papular and urticated eruption developed, suggesting cholinergic urticaria. A starch-iodine test showed complete anhidrosis. Skin biopsy revealed different findings—either duct blockage, a lymphocytic hidradenitis or normal appearances. The patient with the lymphocytic hidradenitis responded to oral steroids and azathioprine. The authors advise considering this condition in patients with cholinergic urticaria; they suggest performing a starch-iodine test and, if abnormal, a skin biopsy.

Drug Eruptions

Nicorandil (Ikorel®), a potassium channel activator used for angina prophylaxis and treatment, is becoming increasingly recognized as a cause of perianal ulceration. Three cases from Belfast were presented by Cooke et al.[142] In all cases, the ulceration was painful and developed many months after nicorandil introduction. Oral ulceration is better recognized; one patient had experienced this. Recognition is imperative as ulceration persists until the drug is stopped; on cessation healing may be rapid.

Hydroxyurea usage is increasing as it is now used more frequently in polycythemia rubra vera and sickle cell disease, and a wide variety of cutaneous problems have been attributed to it, including a dermatomyositis-like eruption on the hands and face, painful lower leg ulcers, squamous cell carcinoma, actinic keratoses and pigmentary changes. Low-dose hydroxyurea (1-1·5 g day-1) in psoriasis may be less likely to produce adverse reactions. Dogra et al.[143] from Chandigarh, India, reported their experiences in Indian patients. Lesional skin pigmentation was reported after only a few months of therapy in 31% of patients; generalized pigmentation was less frequent. Nail pigmentation with longitudinal bands, lunula pigmentation or diffuse plate pigmentation was noted. Diffuse hair loss was seen in 10% of patients. Skin pigmentation resolved rapidly on drug discontinuation.

Infections and Infestations

It is good to see the positive effect of audit! Rose et al.[144] of Leeds were instrumental in highlighting the inadequacy of antibiotic use for cellulitis in their Accident and Emergency Department. Of Accident and Emergency consultations 3% are for cellulitis; before the audit only 12% of cases were treated with appropriate antibiotics at appropriate doses (flucloxacillin plus penicillin V or amoxicillin, or erythromycin or clarithromycin in penicillin- sensitive patients). After the audit, and dissemination of the results at Medical Grand Rounds, guidelines were altered, and a repeat audit showed 88% appropriate antibiotic use. This resulted in an admission rate that fell from 32% to 4%, although I wonder if other factors also contributed to this.

Delayed breast cellulitis is an erythematous cellulitis-like eruption that is becoming more recognized as a complication of conservative breast cancer surgery. Stevenson et al.[145] from Warwick drew attention to this condition that develops between 3 weeks and 3 months after partial mastectomy. Clinical findings range fromerythema,swelling with a peau d'orange appearance, and even bruising. Clinically, infective cellulitis and carcinoma erysipeloides were considered. Biopsies, blood counts and cultures did not indicate infection. Antibiotics were given to two patients without benefit. The authors speculate that altered lymphatic function may predispose to infection in some cases and in others that the lymphatic disturbance caused the erythema without overt infection.

Head lice remain a refractory problem and the popular desire to avoid 'chemical' treatments is growing. Downes et al.[146] have investigated the use of a cosmetically elegant coconut emulsion in the treatment of pediculosis capitis. The agent was very effective at clearing the initial infestation with three 20-min applications, and patients followed on by using the emulsion as a normal cosmetic shampoo. Remarkable rates of eradication and low rates of reinfestation make encouraging news for coconut farmers!

Update

In the interesting talk by Dr Steve Katz from the National Institutes of Health (NIH), he showed the NIH complex at Bethesda, Maryland. NIH scientists conduct their research in laboratories located on the main campus in Bethesda, and in several field units across the country and abroad. He declared that the funding of the NIH was 29 billion dollars per annum, of which 85% went to investigators outside the NIH. This compared with 40 billion dollars of research per annum in the US conducted by pharmaceutical companies. The NIH tended to look at 'gap areas' and target these areas of scientific need by placing money in them and explained that by so doing the NIH could guide

http://www.medscape.com/viewarticle/533355_print Page 16 sur 23 Updates from the British Association of Dermatologists Meeting 292/10/Thursday 07h37

researchers to where the money was.

In a fascinating lecture on the rationale behind systemic reviews, Sir Iain Chalmers explained that there are situations where both clinicians and patients are uncertain about the way forward after having looked rigorously at the data. Systemic review helps to turn over stones to see where further research is necessary. He pointed out that Bradford Hill, the father of medical statistics in the U.K., suggested that for any research project we need to know why the researcher started the research, how they did it, what they got and, crucially, what it means. The results of the research needs to be set in context rather than simply reported blindly. It should not be assumed without consideration that new research is needed in a particular area and the development of a database such as that held by the clinical trials network led by Professor Hywel Williams is a major step forward in looking at nonindustry-sponsored research.

On the subject of research, refreshingly, Sir Iain Chalmers pointed to the fact that all NHS consultants should make it part of their expected medical practice to do clinically based research in the NHS and should demand of their managers and the NHS the facilities to carry out crucial research to answer clinically relevant and important questions. Indeed, unless the public begins to demand unbiased, reliable estimates of the effects of treatment from researchers and health professionals, there is a real possibility that the next 'milestone' in the history of controlled trials may be a gravestone.[147]

In their joint presentation during a lunch time session Dr Nick Simpson and Dr David Shuttleworth gave us a brief overview of how to deal with management. David Shuttleworth commented that reading the Health Service Journal may be of more benefit to hospital consultants these days than reading the British Journal of Dermatology. Many of the delegates to the session found it slightly depressing, realizing that dermatology often falls below the radar of their managers. One of the delegates, however, pointed out that, as around 10% of the work of a hospital is dermatology, we do have considerable leverage, for example, in terms of waiting lists and also can play the ace card of skin cancer. In his 'survival guide', Dr Nick Simpson pointed out that information about our service is power and that we need to find out where the data are held in the Trust and work with those who control and compile the data, both to make sure that the information is accurate and that those collecting the data understand our work load. It was also pointed out that it would be a good tactic to stop the 'them and us' approach and to get managers on our side by engaging with them on strategy days away from the Trust where the dermatologists can influence who comes to the meeting, the agenda and write up the minutes of the meeting. Clearly to this end the building of personal contacts is of high importance.

…And finally,

The group from Southampton, Morgan et al.,[148] analysed the publication rate of abstracts at the annual BAD meeting. They used the PubMed database to search for each of the authors' names for the abstracts from the main plenary session of the BAD, the registrars' forum, clinical pathological cases and the Bristol Cup posters. In 2001, of the 131 presentations, 51 had been published by December 2004. Most went to the BJD (34%) and Clinical and Experimental Dermatology (15%). By the time this review is published the editor notes that this group will have published their abstract as a letter in the BJD!! However, please note that an abstract at the BAD meeting should by no means raise your expectations of a publication in the BJD where standards rise year on year!!

CLICK HERE for subscription information about this journal.

References

1. Bataille V, Hunter S, Schofield J, James N. Concordance in the diagnosis of skin lesions between plastic surgeons and a dermatologist using digital imaging with referral: an Action on Plastic Surgery pilot site project. Br J Dermatol 2005; 153 (Suppl. 1):74. 2. McCormack SKA, Smith M, Doherty VR. Melanoma assessment clinic: e-referral for the 21st century? Br J Dermatol 2005; 153 (Suppl. 1):45. 3. Collin B, Zaki I. Two-week-wait clinics work. Br J Dermatol 2005; 153 (Suppl. 1):46. 4. Patalay R, Leslie K, Tan E, Garioch J. An audit of the 2-week skin cancer referrals, are we prepared for 2005? Br J Dermatol 2005; 153 (Suppl. 1):45-6. 5. Brown SJ, Thirlaway CJ, Lawrence CM. A 6-month prospective study of the incidence and management of dermatological malignancies in an NHS teaching hospital. Br J Dermatol 2005; 153 (Suppl. 1):74. 6. Haniffa MA, Lloyd J, Thirlaway C, Laurence CM. The role of a skin-imaging device as a diagnostic aid in http://www.medscape.com/viewarticle/533355_print Page 17 sur 23 Updates from the British Association of Dermatologists Meeting 292/10/Thursday 07h37

the melanoma screening clinic. Br J Dermatol 2005; 153 (Suppl. 1):74-5. 7. McKenna DJ, Dolan OM, McCallum D. Digital dermoscopy in combination with digital body mapping photography for the screening and follow-up of patients with multiple atypical melanocytic naevi. Br J Dermatol 2005; 153 (Suppl. 1):26-7. 8. McCormack S, Doherty VR. The challenge of nodular melanomas. Br J Dermatol 2005; 153 (Suppl. 1):27. 9. Glass D, Batta K, Tatnall FM. Malignant melanoma mimicking Bowen's disease: a report of three cases. Br J Dermatol 2005; 153 (Suppl. 1):27. 10. Ragnarsson-Olding BK, Kanter-Lewensohn LR, Lagerlof B et al. Malignant melanoma of the vulva in a nationwide, 25 year study of Swedish females: clinical observations and histopathological features. Cancer 1999; 86:1273-84. 11. Ravat FE, Rytina E, Hall PN et al. Histological and clinical clearance of vulval melanoma with imiquimod and possible association with lymphatic spread. Br J Dermatol 2005; 153 (Suppl. 1):68. 12. Eedy DJ. Introducing controversies in dermatology: sentinel lymph node biopsy for cutaneous melanoma— a useful technique or a waste of time? Br J Dermatol 2004; 151:267-8. 13. Medalie NS, Ackerman AB. Sentinel node biopsy has no benefit for patients whose primary cutaneous melanoma has metastasized to a lymph node and, therefore, should be abandoned now. Br J Dermatol 2004; 151:298-307. 14. Morton DL, Cochran AJ. The case for lymphatic mapping and sentinel lymphadenectomy in the management of primary melanoma. Br J Dermatol 2004; 150:308-19. 15. Russell-Jones R. Sentinel node and survival in melanoma. Br J Dermatol 2005; 153:1093-5. 16. Gutzmer R, Al Ghazal M, Geerlings H, Kapp A. Sentinel node biopsy in melanoma delays recurrence but does not change melanoma-related survival: a retrospective analysis of 673 patients. Br J Dermatol 2005; 153:1137-41. 17. MacKie R, Moyes C, Bray C et al. Sentinel-node biopsy in melanoma—the west of Scotland experience. Br J Dermatol 2005; 153 (Suppl. 1):5. 18. Thein M, Abu-Sitta G, McAndrew L et al. Melanoma micrometastases identified in sentinel lymphadenectomy: a 4-year experience at Barts and The London Trust skin cancer centre. Br J Dermatol 2005; 153 (Suppl. 1):71. 19. Moyes CB, Blessing K, MacKie RM. Histopathological review of sentinel lymph nodes for cutaneous melanoma. Br J Dermatol 2005; 153 (Suppl. 1):72. 20. Bataille V, Boniol M, De Vries E et al. Sunbed use and melanoma: a multi-centre case-control study of melanoma in Europe. Br J Dermatol 2005; 153 (Suppl. 1):2. 21. Chua S, Leslie K, Levell N. Audit of cutaneous squamous cell carcinoma management. Br J Dermatol 2005; 153 (Suppl. 1):24-5. 22. Foley P, Freeman M, Vinciullo C et al. Photodynamic therapy using methyl aminolaevulinate with cryotherapy in actinic keratosis: an Australian study. Br J Dermatol 2005; 153 (Suppl. 1):29. 23. Szeimies RM, Karrer S, Radacovic-Fijan S et al. Photodynamic therapy using topical methyl aminolaevulinate photodynamic therapy compared with cryotherapy for actinic keratosis: a European prospective, randomized study. Br J Dermatol 2005; 153 (Suppl. 1):30. 24. Morton C, Horn M, Leman J et al. A placebo controlled European Study controlling methylaminolaevulinate photodynamic therapy with cryotherapy and 5-fluorouracil in patients with Bowen's disease. Br J Dermatol 2005; 153 (Suppl. 1):30. 25. McCormack SKA, Kemmett D. Basal cell carcinoma in patients under 50 years of age. Br J Dermatol 2005; 153 (Suppl. 1):26. 26. Gudi VS, Ormerod AD, Gupta G. Management of basal cell carcinoma in Scotland. Br J Dermatol 2005; 153 (Suppl. 1):25. 27. Telfer NR, Colver GB, Bowers PW. Guidelines for the management of basal cell carcinoma. British Association of Dermatologists. Br J Dermatol 1999; 41:415-23. 28. Basset-Séguin N, Ibbotson S, Emtestam L et al. Methyl aminolaevulinate photodynamic therapy vs. cryotherapy in primary superficial basal cell carcinoma. Br J Dermatol 2005; 153 (Suppl. 1):29. 29. Rhodes LE, De Rie M, Enström Y et al. A randomized European comparison of MAL-PDT and excision surgery in nodular basal cell carcinoma. Br J Dermatol 2005; 153 (Suppl. 1):28-9. 30. Morton CA, Fraser C, Leman JA, Smith B. Effects of protocol variation on response rate of superficial basal cell carcinoma to topical photodynamic therapy. Br J Dermatol 2005; 153 (Suppl. 1):25. 31. Eedy DJ. Summary of inaugural meeting of the Skin Care in Organ Recipients Group, UK, held at the Royal Society of Medicine, 7 October 2004. Br J Dermatol 2005; 153:6-10. 32. Moloney EJ, Comber H, O'Lorcain P et al. A cohort study of cancer patterns in renal transplant recipients in Ireland. Br J Dermatol 2005; 153 (Suppl. 1):3. 33. Thomson MA, Milford D, Baumann U et al. Skin surveillance of a UK paediatric transplant population. Br J Dermatol 2005; 153 (Suppl. 1):3. 34. Harwood CA, Ismail F, Leedham-Green M et al. Low-dose retinoids in the prevention of cutaneous http://www.medscape.com/viewarticle/533355_print Page 18 sur 23 Updates from the British Association of Dermatologists Meeting 292/10/Thursday 07h37

squamous cell carcinomas in organ-transplant recipients: a 16-year retrospective study. Br J Dermatol 2005; 153 (Suppl. 1):3-4. 35. Ismail F, Mitchell L, Casabonne D et al. An audit of compliance with advice given on sun-protection measures among renal-transplant recipients. Br J Dermatol 2005; 153 (Suppl. 1):23-4. 36. Wain EM, Whittaker SJ, Russell-Jones R. A randomized, open, crossover study to compare the efficacy of extracorporeal photopheresis with methotrexate in the treatment of erythrodermic primary cutaneous T-cell lymphoma. Br J Dermatol 2005; 153 (Suppl. 1):10. 37. Royal College of Pathologists Standards and Minimum Datasets for Reporting Cancers. Minimum Dataset for the Histopathological Reporting of Common Skin Cancers. http://www.rcpath.org/resources/pdf/skincancers2802.pdf (accessed 5/1/06). 38. Hill CH, Alsop R, Bedlow A et al. Does specialised reporting work? An audit of outcomes from dermatopathology multidisciplinary team meetings. Br J Dermatol 2005; 153 (Suppl. 1):64. 39. Shergill B, Khorshid SM, Cerio R. Eccrine porocarcinoma: an underdiagnosed skin cancer. Br J Dermatol 2005; 153 (Suppl. 1):65. 40. Winhoven SM, Andrew S. Sebaceous carcinoma: a review of 15 cases. Br J Dermatol 2005; 153 (Suppl. 1):65. 41. Lawrence CM. Skin excision and osteophyte removal is not required in the surgical treatment of digital myxoid cysts. Br J Dermatol 2005; 153 (Suppl. 1):5. 42. Nayak N, Ormond PJ, Lawrence CM. Surgical management of rhinophyma: a 15-year experience. Br J Dermatol 2005; 153 (Suppl. 1):75. 43. Varma K, Morris A, Motley R. Treatment of lipoma by the Cardiff 'inject-and-squeeze' technique. Br J Dermatol 2005; 153 (Suppl. 1):75-6. 44. Degiovanni CV, Coburn P. Perioperative management of patients on warfarin and aspirin therapy undergoing cutaneous surgical procedures: a survey of current practice and complications. Br J Dermatol 2005; 153 (Suppl. 1):78-9. 45. Blasdale C, Ormond PJ, Laurence CM. Continuation of warfarin therapy may lead to increased postoperative bleeding complications in dermatology surgery patients. Br J Dermatol 2005; 153 (Suppl. 1):78. 46. Jain S. A new multiple site marking grid for botulinum toxin application in the treatment of axillary hyperhidrosis. Br J Dermatol 2005; 153 (Suppl. 1):30. 47. Kaur MR, Marsden JR. Primary cutaneous Merkel cell carcinoma: a clinical review of 28 cases. Br J Dermatol 2005; 153 (Suppl. 1):78. 48. Herath D, Emerson RM. What expectations do patients have about skin surgery? Br J Dermatol 2005; 153 (Suppl. 1):77. 49. Kranendonk SK, Ferris LK, Obagi S. Botulinum toxin for the treatment of facial flushing. Dermatol Surg 2005; 31:491. 50. Gupta AK, Chaudhry MM. Rosacea and its management: an overview. J Eur Acad Dermatol Venereol 2005; 19:273-85. 51. Raveendran SS, Amarasinghe L. The mystery of the split earlobe. Plast Reconstr Surg 2004; 114:1903-9. 52. Mehrany K, Weenig RH, Pittelkow MR et al. High recurrence rates of basal cell carcinoma after Mohs' surgery in patients with chronic lymphocytic leukemia. Arch Dermatol 2004; 140:985-8. 53. Mehrany K, Weenig RH, Pittelkow MR et al. High recurrence rates of squamous cell carcinoma after Mohs' surgery in patients with chronic lymphocytic leukemia. Dermatol Surg 2005; 31:38-42. 54. Denkler K. Dupuytren's fasciectomies in 60 consecutive digits using lidocaine with epinephrine and no tourniquet. Plast Reconstruct Surg 2005; 115:802-10. 55. Sharquie KE, Al-Tikreety MM, Al-Mashhadani SA. Lactic acid as a new therapeutic peeling agent in melasma. Dermatol Surg 2005; 31:149-54, discussion 154. 56. Farrant PBJ, Herath D, Price M. Three decades of whole body PUVA therapy: the consequences. Br J Dermatol 2005; 153 (Suppl. 1):20. 57. Martin JA, Laube S, Edwards C et al. Study to define annual rates of adverse events for narrowband UVB and psoralen ultraviolet A phototherapy. Br J Dermatol 2005; 153 (Suppl. 1):92. 58. Thomas CL, Wilson FJ, Edwards C et al. Built-in dosimeters in ultraviolet phototherapy cabins have potential to cause overexposure to obese patients. Br J Dermatol 2005; 153 (Suppl. 1):93. 59. Jasim ZF, McKenna KE, Robson T et al. p53 expression in psoriatic epidermis treated with ultraviolet B TL- 01; influence of dose and skin types. Br J Dermatol 2005; 153 (Suppl. 1):92. 60. Man I, Crombie IK, Dawe RS et al. The photocarcinogenic risk of narrowband UVB (TL-01) phototherapy: early follow-up data. Br J Dermatol 2005; 152:755-7. 61. Black RJ. Retrospective study of patients receiving multiple courses of TL01 phototherapy. Br J Dermatol 2005; 153 (Suppl. 1):20. 62. Razzaq T, Wright JCH, Hart G, Wright AL. Reflection of ambient solar ultraviolet radiation by common urban surfaces. Br J Dermatol 2005; 153 (Suppl. 1):21. http://www.medscape.com/viewarticle/533355_print Page 19 sur 23 Updates from the British Association of Dermatologists Meeting 292/10/Thursday 07h37

63. Otman SGH, Edwards C, Taylor DK et al. The ultraviolet transmission of commonly available sunglasses: an update on their suitability for use in eye protection in photochemotherapy. Br J Dermatol 2005; 153 (Suppl. 1):92. 64. Holme SA, Anstey AV, Badminton NM, Elder GH. UK prospective clinicopathological study on erythropoietic protoporphyria. Br J Dermatol 2005; 153 (Suppl. 1):11. 65. Gallagher RP, Spinelli JJ, Lee TK. Tanning beds, sunlamps, and risk of cutaneous malignant melanoma. Cancer Epidemiol Biomarkers Prev 2005; 14:562-6. 66. Gu X, Wang T, Collins DM et al. In vitro evaluation of concurrent use of commercially available insect repellent and sunscreen preparations. Br J Dermatol 2005; 152:1263-7. 67. Møller KI, Kongshoj B, Phiipsen PA et al. How Finsen's light cured lupus vulgaris. Photodermatol Photoimmunol Photomed 2005; 21:118-24. 68. Hampton PJ, Reynolds NJ. β-catenin regulates keratinocyte transglutaminase transcriptional activation, and increased nuclear β-catenin is found in involved psoriatic epidermis. Br J Dermatol 2005; 153 (Suppl. 1):9. 69. Young HS, Summers AM, Read I et al. Retinoid pharmacogenetics and vascular endothelial growth factor in chronic plaque psoriasis. Br J Dermatol 2005; 153 (Suppl. 1):9-10. 70. Tobin AN, Norris S, Kirby B. Prevalence of psoriasis in patients with alcoholic liver disease. Br J Dermatol 2005; 153 (Suppl. 1):34. 71. Cusack C, Buckley C. Impact of moderate/severe psoriasis on employment. Br J Dermatol 2005; 153 (Suppl. 1):34. 72. Reich K, Nestle F, Ortonne JP et al. Infliximab produces a sustained, significant improvement in psoriasis over 50 weeks of continuous therapy. Br J Dermatol 2005; 153 (Suppl. 1):4. 73. Collin B, Srinathan S, Finch TM. Methotrexate prescribing and monitoring practices among consultant dermatologists. Br J Dermatol 2005; 153 (Suppl. 1):5-6. 74. Khan S, Subedi D, Chowdhury MMU. Audit of aminoterminal type III procollagen peptide assay in methotrexate therapy for psoriasis. Br J Dermatol 2005; 153 (Suppl. 1):31. 75. Jasim ZF, McKenna KE. Treatment of psoriasis with ultraviolet B TL-01; response according to skin types, minimal erythema dose and total dose received. Br J Dermatol 2005; 153 (Suppl. 1):7. 76. Kleyn CE, Woodcock D, Sharpe GR. The efficacy of 0·1% tacrolimus ointment compared with clobetasone butyrate 0·05% ointment in patients with facial, flexural or genital psoriasis. Br J Dermatol 2005; 153 (Suppl. 1):33. 77. Adalat S, Wall D, Goodyear HM. Study of the prevalence, aetiological factors and treatment of napkin dermatitis. Br J Dermatol 2005; 153 (Suppl. 1):82-3. 78. Beattie PE, Lewis-Jones MS. An audit of the usefulness of quality-of-life measures in secondary care for assessing the impact of atopic dermatitis on infants and their families and the benefit of taking a consultation with a dermatology team. Br J Dermatol 2005; 153 (Suppl. 1):82. 79. Baron SE, Morris PK, Dye L et al. The effect of dermatology consultations in secondary care on the treatment outcome and quality of life of adult patients with atopic dermatitis. Br J Dermatol 2005; 153 (Suppl. 1):8. 80. Hon KLE, Leung TF, Fok TF. Subjective symptoms do not correlate well with disease extent or intensity in children with atopic dermatitis. Br J Dermatol 2005; 153 (Suppl. 1):89. 81. Hon KLE, Mar KC, Leung TF, Fok TF. A survey of traditional Chinese medicine use in children with atopic dermatitis attending a paediatric clinic. Br J Dermatol 2005; 153 (Suppl. 1):90. 82. Hon KLE, Lee WYV, Leung TF, Fok TF. Corticosteroids are not present in five popular herbs in a traditional Chinese method of formulation for atopic dermatitis in children. Br J Dermatol 2005; 153 (Suppl. 1):90-1. 83. Hon KLE, Lam MCA, Leung TF et al. Clinical features associated with nasal Staphylococcus aureus colonisation in children with moderate to severe atopic dermatitis. Br J Dermatol 2005; 153 (Suppl. 1):88. 84. Shah M, Mohanraj M, Continuing problems with fusidic acid, resistant Staphylococcus aureus in children. Br J Dermatol 2005; 153 (Suppl. 1):88-9. 85. Kirke SN, Taylor AEM. A 1-year experience of the use of topical tacrolimus for atopic dermatitis in the paediatric dermatology population. Br J Dermatol 2005; 153 (Suppl. 1):83. 86. Smith CH, Ormerod AD. Pimecrolimus cream 1% once-daily maintenance therapy for the prevention of relapse of mild to moderate atopic dermatitis in adults. Br J Dermatol 2005; 153 (Suppl.1):37. 87. Ladoyanni E, Moss C. A pilot study of SCORAD to assess eczema severity and routine clinical practice. Br J Dermatol 2005; 153 (Suppl. 1):37. 88. Baron SE, Layton A, Goulden V. A pilot study of hypnotherapy to treat adults and children with moderate to severe atopic dermatitis. Br J Dermatol 2005; 153 (Suppl. 1):37-8. 89. Schofield JK, Irvine A, Jackson S et al. General practitioners with a special interest (GPwSI) in dermatology: results of an audit against Department of Health (DH) guidance. Br J Dermatol 2005; 153 (Suppl. 1):1. 90. Schofield JK, Jackson S, Irvine A et al. Nonconsultant career grade doctors in dermatology: a hidden http://www.medscape.com/viewarticle/533355_print Page 20 sur 23 Updates from the British Association of Dermatologists Meeting 292/10/Thursday 07h37

resource. Br J Dermatol 2005; 153 (Suppl. 1):46. 91. Hafejee A, Coulson I. Community pharmacists' role in patients with common skin problems: what is happening now? Br J Dermatol 2005; 153 (Suppl. 1):46-7. 92. Kerr OA, Walker J, Boohan M. Importance of training general practitioners in dermatology at both undergraduate and postgraduate level. Br J Dermatol 2005; 153 (Suppl. 1):1-2. 93. Clayton R, Burge SM. Defining and validating the dermatological content of the undergraduate medical curriculum. Br J Dermatol 2005; 153 (Suppl. 1):2. 94. Sansom IE, Shipley DR. Developing dermatology undergraduate teaching and learning in a clinical academy system. Br J Dermatol 2005; 153 (Suppl. 1):43-4. 95. Shaw LJ, de Berker DAR. Comparison of the data content and the value of electronic and paper referrals in dermatology. Br J Dermatol 2005; 153 (Suppl. 1):1. 96. Watson AJ, Kemmett D, Donald J. Twelve-month review of a novel dermatology e-mail advice service for general practitioners. Br J Dermatol 2005; 153 (Suppl. 1):44. 97. Belgi AS, Finlay AY. The Yesterday Use Question to assess adherence with therapy in dermatology outpatients. Br J Dermatol 2005; 153 (Suppl. 1):47-8. 98. Hon KLE, Leung TF, Ma KC, Fok TF. Why don't they come? Reasons for new referral non-attendance at a pediatric dermatology centre. Br J Dermatol 2005; 153 (Suppl. 1):91. 99. Lewis-Jones MS, Dawe RS, Lowe JG. Quality of life of children with type 1 latex allergy and their parents: use and primary validation of the QoLLA-C and QoLLA-P questionnaires. Br J Dermatol 2005; 153 (Suppl. 1):83-4. 100. Amirtha Vani BP, Charles-Holmes R, Humphreys F et al. Evaluation of the dermatology outpatient service: a general practioners' questionnaire survey about the quality of outpatient consultations. Br J Dermatol 2005; 153 (Suppl. 1):44-5. 101. Lim SPR, Dyoss M, Kelly T et al. Outsourced pharmacy dispensing: an option for hospital dermatology departments? Br J Dermatol 2005; 153 (Suppl. 1):47. 102. Darsow U, Ring J. Atopy patch test. Br J Dermatol 2005; 153 (Suppl. 1):56. 103. Johansson C, Sandström MH, Bartosik J et al. Atopy patch test reactions to Malassezia allergens differentiate subgroups of atopic dermatitis patients. Br J Dermatol 2003; 148:479-88. 104. Ho SGY, White IR, Ryecroft RJG et al. Analysis of para-phenylenediamine allergic patients in relation to strength of patch-test reaction. Br J Dermatol 2005; 153 (Suppl. 1):61-2. 105. Katugampola RPK, Statham BN, English JSE et al. A multicentre review of the hairdressing allergens tested in the U.K. Br J Dermatol 2005; 153 (Suppl. 1):56-7. 106. Katugampola RPK, Statham BN. A review of allergens in current hairdressing products. Br J Dermatol 2005; 153 (Suppl. 1):61. 107. Laing ME, Powell FC, Sullivan DO, Keane FM. Review of allergic contact dermatitis and its impact in a cohort of hairdressers. Br J Dermatol 2005; 153 (Suppl. 1):57. 108. Batchelor RJ, Wilkinson SM. Photopatch testing: a 4-year retrospective review of cases using the 24- and 48-hour irradiation protocols. Br J Dermatol 2005; 153 (Suppl. 1):56. 109. Walker SL, Ead RD, Beck MH. Occupational photoallergic contact dermatitis in a pharmaceutical worker manufacturing carprofen, a canine nonsteroidal anti-inflammatory drug. Br J Dermatol 2005; 153 (Suppl. 1):58. 110. Darvay A, White IR, Rycroft RJG et al. Photoallergic contact dermatitis is uncommon. Br J Dermatol 2001; 145:597-601. 111. Veysey EC, Orton D. Photoallergic contact cheilitis due to oxybenzone lip cosmetic. Br J Dermatol 2005; 153 (Suppl. 1):60. 112. Langan SM, Collins P. Photocontact allergy to oxybenzone and contact allergy to lignocaine and prilocaine. Br J Dermatol 2005; 153 (Suppl. 1):60. 113. Eedy DJ. President Yushchenko's post-'dioxin dinner' drama. Br J Dermatol 2005; 153 (Suppl. 1):51. 114. Watson KMT, Rycroft RJG. Unintended cutaneous reactions to CS spray. Br J Dermatol 2005; 153 (Suppl. 1):57-8. 115. Affleck AG, English JSE, Hughes D. Occupational allergic contact dermatitis from 1,2-benzoisothiazolin-3- one (Nibocide BIT 10) in operatives manufacturing adhesive and floor levelling compounds. Br J Dermatol 2005; 153 (Suppl. 1):58. 116. White JML, White IR. Allergic contact dermatitis from dicyclohexylmethane-4,4'-diisocyanate: two cases. Br J Dermatol 2005; 153 (Suppl. 1):58-9. 117. Keogh SJ, Gawkrodger DJ. Persistent post-occupational dermatitis: report of seven cases. Br J Dermatol 2005; 153 (Suppl. 1):59. 118. Wall L, Gebauer KA. A follow-up study of occupational skin disease in Western Australia. Contact Dermatitis 1991; 24:241-3. 119. Gawkrodger DJ, McMullen E. Frictional dermatitis: an under recognised irritant contact eruption that particularly affects the fingers. Br J Dermatol 2005; 153 (Suppl. 1):59. http://www.medscape.com/viewarticle/533355_print Page 21 sur 23 Updates from the British Association of Dermatologists Meeting 292/10/Thursday 07h37

120. McMullen E, Gawkrodger DJ. Frictional dermatitis: an under recognised irritant contact eruption that particularly affects the fingers. Brit J Dermatol 2006; 154:154-6. 121. Stanway A, English J, Omerod A et al. Trolab™ Compositae mix versus Chemotechnique™ Compositae mix. Br J Dermatol 2005; 153 (Suppl. 1):57. 122. Katugampola RP, Statham BN, English JSC et al. A multicentre review of footwear allergens tested in the U.K. Br J Dermatol 2005; 153 (Suppl. 1):60. 123. Kleyn CE, Patel T, Wilson NJE, King CM. Two patients with chromate allergy from contact with leather furnishings. Br J Dermatol 2005; 153 (Suppl. 1):63. 124. Takwale A, Sansom JE. Metal sensitivity: a poor indicator of nickel allergy in atopic individuals. Br J Dermatol 2005; 153 (Suppl. 1):61. 125. Affleck AG, English JSC. Allergic contact dermatitis from abitol (dihydroabietyl alcohol) in a temporary tattoo. Br J Dermatol 2005; 153 (Suppl. 1):63. 126. Hafejee A, Coulson IH, Lakshiminarasimin P, Leon C. Traditional tattoo treatment trauma. Br J Dermatol 2005; 153 (Suppl. 1):62. 127. Sajjachareonpong P, Cahill J, Keegel T et al. Persistant post-occupational dermatitis. Contact Dermatitis 2004; 51:278-83. 128. Lally A, Chamberlain A, Allen J, Wojnarowska F. Dermal binding linear IgA disease: is this the IgA equivalent of epidermolysis bullosa aquisita? Br J Dermatol 2005; 153 (Suppl. 1):7. 129. Desai N, Allen J, Ali I et al. Leg ulcers: the prevalence and significance of antibodies to the basement membrane zone. Br J Dermatol 2005; 153 (Suppl. 1):11. 130. Cusack C, Buckley C. Etanercept: effective in the management of hidradenitis suppurativa. Br J Dermatol 2005; 153 (Suppl. 1):4. 131. Kaur MR, Gupta S, Taibjee S, Lewis HM. Hidradenitis suppurativa treated with dapsone; a case series of six patients. Br J Dermatol 2005; 153 (Suppl. 1) 39-40. 132. Hassan JA, Richards HL, Grogan SC, Yates VM. Illness perceptions and distress in patients with acne. Br J Dermatol 2005; 153 (Suppl. 1):41. 133. Torley D, Patalay R, Leslie KS. Buying isotretinoin on the worldwide web. Br J Dermatol 2005; 153 (Suppl. 1):48. 134. Shah M. Prognosis of lichen sclerosus in male patients. Br J Dermatol 2005; 153 (Suppl. 1):36. 135. Balasubramaniam P, Lewis FM. Long-term follow-up of patients with lichen sclerosus: does it really happen? Br J Dermatol 2005; 153 (Suppl. 1):36. 136. Kaushal G, Ali I, Cooper S et al. Lichen sclerosus, thyroid disease and vitiligo: is there a link? Br J Dermatol 2005; 153 (Suppl. 1):35. 137. Harper JI, Sampaio C, Visentin MT et al. Morphoea (localised scleroderma): assessment of disease activity and evaluation of treatment using systemic steroids and methotrexate. Br J Dermatol 2005; 153 (Suppl. 1):6. 138. Ali I, Dawber RPR, Wojnarowska F. Does hormone replacement therapy protect against female pattern hair loss and hirsutism? Br J Dermatol 2005; 153 (Suppl. 1):22-23. 139. Ali I, Dawber RPR, Wojnarowska F. Is there a female counterpart to acquired progressive kinky hair disease? Br J Dermatol 2005; 153 (Suppl. 1): 23. 140. Smith M, Schofield OMV. Alopecia areata: learning from patients. Br J Dermatol 2005; 153 (Suppl. 1):21- 22. 141. Saraswat A, Saraswat M. Is acquired idiopathic generalized anhidrosis a rare untreatable entity? Br J Dermatol 2005; 153 (Suppl. 1):42-43. 142. Cooke NS, Tolland JP, Walsh M et al. Nicorandil-associated perianal ulceration. Br J Dermatol 2005; 153 (Suppl. 1):38. 143. Dogra S, Kaur I, Kanwar AJ, Kumar B. Spectrum and course of mucocutaneous adverse effects of hydroxyurea in patients with psoriasis. Br J Dermatol 2005; 153 (Suppl. 1):32. 144. Rose RF, Kamath RP, Baron SE et al. Improving the management of cellulitis in the Accident and Emergency department. Br J Dermatol 2005; 153 (Suppl. 1):48. 145. Stevenson O, Bedlow A, Harries S et al. Delayed breast cellulitis: a bacterial infection or a skin response to lymphoedema? Br J Dermatol 2005; 153 (Suppl. 1):48-49. 146. Downes AMR, Connolly M, Stafford KA et al. A family-based trial of a coconut-derived emulsion shampoo for head-lice control. Br J Dermatol 2005; 153 (Suppl. 1):40. 147. Chalmers I. Comparing like with like: some historical milestones in the evolution of methods to create unbiased comparison groups in therapeutic experiments. Int J Epidemiol 2001; 30:1156-64. 148. Morgan CJ, Dyer JP, Cooper A, Friedmann PS. Publication rate of abstracts presented at the annual meeting of the British Association of Dermatologists. Br J Dermatol 2005; 153 (Suppl. 1):31.

Reprint Address

http://www.medscape.com/viewarticle/533355_print Page 22 sur 23 Updates from the British Association of Dermatologists Meeting 292/10/Thursday 07h37

Correspondence: David J. Eedy. E-mail: [email protected]

D.J. Eedy, J.S.C. English* and I.H. Coulson†

Craigavon Area Hospital Group Trust, 68 Lurgan Road, Portadown, BT63 5QQ, U.K. *Department of Dermatology, Queen's Medical Centre, Nottingham, NG7 2UH, U.K. †Department of Dermatology, Burnley Hospital, Lancashire, BB10 2PQ, U.K.

Conflicts of interest: D.J. Eedy has received fees for speaking and chairing meetings for 3M Pharmaceuticals and is an advisor to Novartis (UK). J.S.C.E. and I.H.C. have no conflicts of interest to declare.

http://www.medscape.com/viewarticle/533355_print Page 23 sur 23