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Dermatology in-patient management greatly improves life quality.

The aim of this study was to measure the effect of in-patient management on the quality of life of adult dermatology patients, and to identify the diagnostic categories which show the greatest improvement. Over a 6-month period, all 230 patients admitted to the dermatology ward of the University Hospital of Wales were invited to complete a Dermatology Life Quality Index (DLQI) questionnaire on admission, and again 4 weeks after discharge. Two hundred and seventeen (93%) of these patients entered the study, and 181 (83.4%) returned both questionnaires. The mean DLQI on admission was 13.2 (standard deviation [SD] 7.6; n = 181), and 4 weeks after discharge it was 7.7 (SD 6.8; P < 0.001). Seventy-three per cent of the 181 patients showed improvement, 5.5% remained unchanged, and 21.5% worsened. Patients with psoriasis improved from 13.7 (SD 6.5) to 6.7 (SD 5.6; n = 63; P < 0.001), and those with eczema improved from 16.2 (SD 6.3) to 9.6 (SD 7.6; n = 56; P < 0.001). Patients with pruritus showed little improvement, as did those admitted for liver biopsy. Patients with psoriasis and severe eczema showed, overall, a significant decrease in impairment of life quality following in-patient treatment. Severe eczema has a greater adverse impact on the quality of life than severe psoriasis. The parameters for which most improvement was seen were those which were of most concern to the patients, i.e. their symptoms (score after discharge = 1.2; DS 0.9; P < 0.001) and their embarrassment (0.9; SD 1.0; P < 0.001).

Adolescent↗

Guidelines for prescribing azathioprine in dermatology.

Azathioprine has been available as an immunosuppressive agent for over 40 years, and current routine usage in dermatology is not restricted to licensed indications. Advances in understanding the metabolic fate of azathioprine have led to significant changes in prescribing practice and toxicity monitoring by U.K. dermatologists. The current state of knowledge concerning the use of azathioprine in dermatology is summarized, with identification of strength of evidence. Clinical indications and contraindications for azathioprine usage in dermatology are identified. Evidence-based recommendations are made for routine safety monitoring of patients treated with azathioprine, including pretreatment assessment of red blood cell thiopurine methyltransferase activity.

Azathioprine↗

Dermatological manifestations of autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy syndrome.

BACKGROUND: Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy syndrome (APECED; OMIM 240300) is a rare autosomal recessive disorder defined by a variable combination of endocrine failure, chronic mucocutaneous candidiasis (CMC), and dystrophy of the dental enamel and nails. APECED is caused by mutations in the autoimmune regulator gene (AIRE). Alopecia areata (AA) and vitiligo are diseases with autoimmune pathogeneses, and have been recognized as part of the APECED complex. There are rare reports of other cutaneous manifestations. OBJECTIVES: We sought to delineate the dermatological features of APECED in an Irish case series with emphasis on timing of their appearance and association with disease severity. Furthermore, we looked for evidence of genotype: phenotype correlation. Finally, we wanted to determine if the ectodermal changes described represent a primary ectodermal dysplasia or whether the ectodermal manifestations are secondary phenomena. METHODS: Irish patients with APECED were invited to attend a multidisciplinary clinic (Dermatology, Endocrinology, Dentistry and Ophthalmology) held in Our Lady's Hospital for Sick Children, Dublin. Clinical data were compiled from case notes and questionnaires. All patients had a detailed cutaneous examination. Blood samples were obtained for mutational analysis. RESULTS: Eighteen patients (seven males and 11 females) from 15 families were interviewed and examined. The mean age at diagnosis was 6 years (range 8 months-18 years). All patients had evidence of CMC, 13 (72%) had candidal onychomycosis or paronychia, six (33%) had AA and two had vitiligo. In the case of two patients the diagnosis was made on recognition of dermatological manifestations and confirmed by mutational analysis. Both patients developed Addison's disease on follow-up. CMC was an early feature, often predating diagnosis (10 of 18). AA and vitiligo presented later, and may reflect more severe disease in these cases. There was no correlation between the AIRE mutations identified on mutational analysis and the clinical presentation. We found no evidence of an isolated nail dystrophy or features consistent with a primary ectodermal dysplasia. CONCLUSIONS: APECED is a rare but complex and potentially life-threatening autoimmune disease. CMC is a common and early feature; diagnosis at this stage may pre-empt life-threatening endocrinological crises. It is important for dermatologists to be aware of this association as they are likely to be the earliest clinicians who encounter these children. AA and vitiligo in our series occurred in the setting of established disease. The term "ectodermal dystrophy" is misleading as the ectodermal features described in our series and in the literature are most likely to be secondary phenomena.

Adolescent↗

Dermatology Life Quality Index (DLQI)--a simple practical measure for routine clinical use.

A simple practical questionnaire technique for routine clinical use, the Dermatology Life Quality Index (DLQI) is described. One hundred and twenty patients with different skin diseases were asked about the impact of their disease and its treatment on their lives; a questionnaire, the DLQI, was developed based on their answers. The DLQI was then completed by 200 consecutive new patients attending a dermatology clinic. This study confirmed that atopic eczema, psoriasis and generalized pruritus have a greater impact on quality of life than acne, basal cell carcinomas and viral warts. The DLQI was also completed by 100 healthy volunteers; their mean score was very low (1.6%, s.d. 3.5) compared with the mean score for the dermatology patients (24.2%, s.d. 20.9). The reliability of the DLQI was examined in 53 patients using a 1 week test-retest method and reliability was found to be high (gamma s = 0.99).

Adolescent↗

Patient-physician consensus on quality of life in dermatology.

This study was undertaken in order to establish the correlation between physician-assessed and patient self-reported quality of life (QOL) when using a proposed Dermatology Life Quality Index (DLQI) in a random sample of 51 dermatological out-patients and in-patients. A substantial correlation was found between physician scores and DLQI (r 2 = 0.306, P < 0.001), suggesting that the DLQI can be used to assess QOL and general morbidity. Comparison of the observed and ideal patient-physician consensus suggests that patients with relatively benign or quiescent disease may over-estimate disease impact, while dermatological patients with more malign or aggressive disease may underestimate it compared with the physician estimate.

Adult↗

Seasonal variation of dermatologic disease in the USA: a study of office visits from 1990 to 1998.

BACKGROUND: Seasonal variation has been demonstrated in many diseases, including certain skin diseases. OBJECTIVE: To determine whether there is seasonal variation in dermatologic office visits in the USA. METHODS: Data on dermatologic office visits were obtained from representative visits to outpatient physicians in the USA from the National Ambulatory Medical Care Survey from 1990 to 1998. Office visit seasonality was examined for all skin conditions, and individually for the 15 most commonly diagnosed conditions. RESULTS: Office visits for skin conditions were seasonal (P = 0.002). The magnitude of variation can be roughly expressed by the following scheme: actinic keratosis (P = 0.0001) > acne (P = 0.0001) > folliculitis (P = 0.002) > dyschromia (P = 0.01) > seborrheic keratosis (P = 0.04) > psoriasis (P = 0.07) > seborrheic dermatitis (P = 0.09). Visits for skin cancer, not otherwise specified (skin cancer NOS), atopic dermatitis, cysts, common wart, wart, not otherwise specified (wart NOS), rosacea, contact dermatitis, and benign tumors showed no significant seasonal variations or trends. CONCLUSIONS: Dermatologic office visits are seasonal, with visits for individual diseases varying in their magnitude of seasonality. This seasonal variation may be a result of biological and nonbiological variables.

Humans↗

Dermatological manifestations in hepatitis B surface antigen carriers in east region of Turkey.

BACKGROUND AND DESIGN: Various cutaneous disorders associated with hepatitis B virus infection have been reported so far. Almost all of them were some peculiar eruptions or some disorders mainly based on immune complex reaction. OBJECTIVE: The aim of this study was to compare the frequency of all dermatological disorders other than genetic ones in hepatitis B surface antigen (HBsAg) carrier patients and controls in our geographical area. METHODS: Examinations were made on 88 hepatitis B carriers and 84 control patients, including entire skin surface, and oral and anogenital mucosa, and all the manifestations that could be seen were noted down. RESULTS: While the number of HBsAg carrier patients with dermatological disorders was 62 (70.75%), it was only 24 (28.57%) in control patients. This seems statistically important: Yates' corrected chi-square test = 28.5; P = 0.0000001; odds ratio = 6.0 (2.94 < odds ratio < 12.2). The prevalence of oral lichen planus and pitted keratolysis in HBsAg carrier group was significantly higher than that of controls. We found the duration of positivity was not important statistically in the development of the dermatological disorders. CONCLUSIONS: HBsAg positivity may induce or cause proneness to oral lichen planus and pitted keratolysis with some mechanism that needs to be elucidated.

Adult↗

Quality of life before and 6 weeks after treatment in a dermatological outpatient treatment unit.

BACKGROUND: Dermatological disease affects quality of life to a great extent. Treatments are time-consuming and many patients have problems adhering to treatment. Attending an outpatient unit regularly during an intensive treatment period may enable patients to cope with their illness, adhere to treatment and thus improve their quality of life. OBJECTIVE: To study the effect on quality of life of 6 weeks of regular treatment in the outpatient unit in the County Hospital of Jönköping, by means of a questionnaire and interviews. METHODS: The Dermatology Life Quality Index (DLQI) was distributed to 50 consecutive patients with psoriasis, atopic dermatitis or pruritus attending our outpatient treatment unit. Nine of the patients were interviewed during treatment about factors that might influence their quality of life. RESULTS: The DLQI scores before treatment indicated a low quality of life. Women were more affected than men. After 6 weeks of treatment there was a clear improvement, with a 57% reduction in the scores. The answers from the interviews indicated important areas of concern such as withdrawal from public places, adoption of special clothing habits and concern about personal relationships. CONCLUSION: Dermatological diseases have an important influence on patients' quality of life. Attending an outpatient treatment unit was in this series of cases associated with improved quality of life as measured with the DLQI.

Activities of Daily Living↗

Efficacy of double gloving as a protection against blood exposure in dermatologic surgery.

Double gloving has been widely suggested as a means of decreasing exposure to blood and other body fluids. However, most dermatologists do not routinely follow this practice when performing surgical procedures because it reduces manual dexterity and increases costs. To determine whether double gloving should be routinely practiced in dermatologic surgery, pairs of sterile surgical gloves worn during weekly UCLA dermatologic surgery clinics were collected over a period of 3 months and examined for perforations. The procedures gloves were used for ranged from excision of benign lesions, lasting 15 minutes, to hair transplants, lasting 3 hours. Upon completion of the procedures, 8 (5.5%) of 144 pairs of single gloves, 2 (3.7%) of 54 pairs of double inner gloves, and 3 (5.5%) of 54 pairs of double outer gloves were found to have perforations. There were no instances of both the double outer and the double inner gloves having perforations when worn on the same hand. This suggests that double gloving offers a protective advantage by providing extra protection for both the surgeon and the patient during dermatologic surgery.

Blood↗

Camouflaging techniques and dermatologic surgery.

BACKGROUND: Skin appearance alterations as a result of dermatologic surgical procedures may produce temporary or permanent cosmetic defects. Basic camouflaging cosmetics and techniques can restore self-confidence and allow the surgical patient to resume social contact. OBJECTIVE: This paper presents the dermatologic surgeon with a basic understanding of the principles and techniques employed in cosmetic camouflaging. METHODS: Evaluation of surgical scars and healing tissue in terms of contour and pigmentation defects accompanied by an understanding of complementary colors provides the basis for cosmetic camouflaging. A variety of commercial products are available to meet specific patient needs. RESULTS: Cosmetic camouflaging can merely hide postsurgical erythema following laser resurfacing, dermabrasion, and face peeling or provide a cover for permanent scarring. CONCLUSION: An understanding of cosmetic camouflaging is essential to the dermatologic surgeon.

Cicatrix↗

Analysis of Chinese herbal creams prescribed for dermatological conditions.

OBJECTIVE: To determine whether Chinese herbal creams used for the treatment of dermatological conditions contain steroids. DESIGN: 11 herbal creams obtained from patients attending general and paediatric dermatology outpatient clinics were analysed with high resolution gas chromatography and mass spectrometry. SETTING: Departments of dermatology and clinical biochemistry. MAIN OUTCOME MEASURE: Presence of steroid. RESULTS: Eight creams contained dexamethasone at a mean concentration of 456 micrograms/g (range 64 to 1500 micrograms/g). All were applied to areas of sensitive skin such as face and flexures. CONCLUSION: Greater regulation needs to be imposed on Chinese herbalists to prevent illegal and inappropriate prescribing of potent steroids.

Administration, Topical↗

Antibiotic-resistant Staphylococcus aureus in dermatology and burn wards.

Staphylococcus aureus isolated between 1967 and 1975 from the nose and skin lesions of patients in dermatology wards and from the burns of patients in a burns unit in Birmingham showed a high incidence of multiple antibiotic-resistant strains in both environments. Over 20% of the strains isolated from patients on admission to the dermatology wards were multiresistant. Resistance to benzylpenicillin, tetracycline, erythromycin, and fusidic acid was common in the dermatology wards; a smaller proportion of strains were resistant to lincomycin, and few (since 1972 none) were resistant to methicillin; resistance to novobiocin and chloramphenicol was uncommon. In the burns unit, fusidic acid resistance was uncommon, but resistance to benzylpenicillin, tetracycline, erythromycin, novobiocin, neomycin, methicilin, and lincomycin was common. Several of the antibiotics to which resistance was common in the burns unit were rarely if ever used there; strains resistant to these antibiotics probably remained common in the ward through the frequent use of other antibiotics, especially erythromycin, to which these strains were also resistant.

Anti-Bacterial Agents↗

Imaging of pulmonary-cutaneous disorders: matching the radiologic and dermatologic findings.

Dermatologic lesions are often associated with pulmonary disorders and vice versa. Diseases with pulmonary and cutaneous manifestations can be divided into four major categories: (a) congenital and developmental disorders with cutaneous-pulmonary manifestations (Ehlers-Danlos syndrome, generalized elastolysis, yellow nail syndrome, neurofibromatosis, hereditary hemorrhagic telangiectasia); (b) primary dermal diseases with associated pulmonary manifestations (septic vasculitis, malignant melanoma, Kaposi sarcoma); (c) primary pulmonary diseases with associated cutaneous manifestations (tuberculosis, Pseudomonas pneumonia, mycoplasmal pneumonia, adenocarcinoma, metastasis); and (d) cutaneous-pulmonary conditions (multisystem disorders) (progressive systemic sclerosis, systemic lupus erythematosus, Wegener granulomatosis, sarcoidosis). A series of selected cases is used to illustrate the radiologic and dermatologic features of conditions that affect both the lung and dermal tissue. Specific emphasis is placed on the dermatologic manifestations of disease. Diagnosis of a pulmonary-cutaneous disorder requires familiarity with the morphologic appearance of the cutaneous lesion.

Adult↗

Psychosomatic liaison service in dermatology. Need for psychotherapeutic interventions and their realization.

BACKGROUND: Empirical investigations examining the psychosocial distress and need for care of dermatology patients are rare. Little is known about the use of psychotherapeutic interventions in routine care. OBJECTIVE: To evaluate the psychosocial distress of dermatological inpatients, the need for psychotherapeutic interventions and their realization in the framework of a psychosomatic liaison service. METHODS: 86 patients from one unit at the University Dermatology Clinic in Freiburg underwent psychodiagnostic interviews and completed self-rating instruments, elucidating mental disorders, psychosocial distress, coping methods, quality of life, treatment motivation and psychotherapeutic interventions. RESULTS: Using ICD-10 criteria, mental and behavioral disorders were diagnosed in 46%; most frequent were mood and anxiety disorders. Professional assessment indicated a need for psychotherapeutic treatment in 51%, while 28% of the patients wished for psychotherapy; actual intervention occurred in 38%. CONCLUSIONS: The need for psychotherapeutic treatment can only be handled within the framework of a liaison service in close collaboration with care givers.

Adult↗

Review of teleconsultations for dermatologic diseases.

BACKGROUND: Telemedicine has been increasingly used in some areas to provide consultation for isolated populations that might otherwise have difficulty accessing specialty care. Little information exists on what types of patients or diseases are being seen in dermatology telemedicine consultation services. OBJECTIVE: To review our consultations done over a regional telemedicine network with an emphasis on looking at what type of patient, cutaneous diseases, and diagnostic or therapeutic recommendations were made. RESULTS: Between August 1992 and December 1997, 796 teleconsultations were done. The most common diagnoses made were eczemas, follicular based diseases, skin infections, and skin tumours. Steroids were the most commonly recommended therapy, along with antibiotics, antihistamines, and antifungal therapy. Diagnostic recommendations commonly made were a skin biopsy and potassium hydroxide preparation. CONCLUSIONS: Common skin problems were seen by our dermatology teleconsultation service. A significant number of diagnostic biopsies and potassium hydroxide preparations were recommended. The efficacy of telemedicine in the delivery of dermatologic care is reviewed.

Adolescent↗

The Cornwall dermatology electronic referral and image-transfer project.

An evaluation of a store-and-forward electronic referral system was carried out in Cornwall to gauge its effectiveness in prioritizing dermatological patients needing secondary care. A dermatologist classified patients to be seen according to need based on information on the electronic referral form along with an image of the skin condition. Initial findings indicated that patients were more accurately triaged in at least 50% of cases and that 25% of patients did not require an outpatient dermatological appointment. Dermatologists rated image quality at 7.5 on a 10-point scale. This low-cost system has potential for more appropriate clinical management of dermatological patients in both primary and secondary care.

Computer Communication Networks↗

Ocular and dermatologic health effects of ultraviolet radiation exposure from the ozone hole in southern Chile.

OBJECTIVES: This study sought to investigate numerous reports emanating from Punta Arenas, Chile (population 110,000, latitude 53 degrees S), that associated acute ocular and dermatologic disease in humans and animals with excess ultraviolet-B (UV-B) exposure in the setting of the thinning of the ozone column. METHODS: Ophthalmologic and dermatologic records in Punta Arenas were systematically reviewed to enumerate sentinel diagnoses potentially associated with UV-B exposure, ocular examinations on representative animal populations were performed, and the ambient UV-B exposure in the region during the time of maximal thinning was estimated. RESULTS: No increase in patient visits or conditions attributable to UV-B exposure was seen for periods of known ozone depletion compared with control periods. Although ambient UV-B exposure was 1.6 to 2.3 times the habitual exposure on individual days, this excess exposure conferred only a 1% increase in annual exposure on the region. CONCLUSION: This study does not support existing lay reports of ocular and dermatologic disease in humans and animals that had been associated with the ozone hole over southern Chile.

Animals↗

Important drug interactions in dermatology.

Drug interactions can occur at any step from absorption to elimination of a drug, and can induce adverse as well as beneficial effects. Since systemic drugs are increasingly available and important in the treatment of dermatological diseases, a variety of possible interactions between concomitantly administered drugs have to be considered by dermatologists. The xenobiotic-metabolising enzyme system cytochrome P450 (CYP) is involved in the metabolism of many drugs, regulating their plasma concentrations and activities. Furthermore, the adverse effects of many drugs depend on the basal activity and inducibility of particular CYP isoenzymes in an individual patient. Since drug therapy in dermatological practice is of increasing complexity, and an increasing number of potent systemic drugs have become commonly used therapeutic agents, this review focuses on the following topics with the aim of optimising dermatological drug therapy. In the first section, all the different types of drug interactions that can occur through pharmacokinetic and pharmacodynamic mechanisms are introduced briefly, and then discussed systematically with special reference to drugs important for dermatologists. Then, the network of drug interactions that may occur from absorption to elimination is presented. The most important drug interactions mediated by CYP isoenzymes are listed. Finally, the importance of pharmacogenetics for the development of new drugs and its potential impact on the optimisation of individual therapy regimens is discussed.

Absorption↗