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Cosmetic dermatology should be an established part of the practice of dermatology. No ifs, ands, or buts. Patients want to look their best, and they have every right to achieve this goal.
Similar of knowledge and skills are required to deal with certain skin disorders and their corresponding cosmetic complaints. The field of cosmetic dermatology is growing as an overlap between the medical treatment of skin diseases and traditional cosmetology. This poses problems for dermatologists and other professionals, including regulation agencies. Dermatology should be able patients to benefit from all that is necessary for their care, whether that be surgery, drugs or cosmetics. There is no need to modify current regulations. A patient-orientated approach is advocated.
Physician assistants are physician extenders who can perform an invaluable role in dermatologic surgery and optimize physician efficiency. The well-trained physician assistant is a highly effective adjunct to patient evaluation and education and is capable of performing routine time-intensive procedures. When successfully integrated into a dermatologic surgery practice the physician assistant enhances patient care and satisfaction and permits the physician to focus on more complex medical decision-making and technically advanced procedures.
BACKGROUND: A positive temporal artery biopsy (TAB) is essential to the diagnosis of temporal arteritis. Both this relatively common disease and its prolonged treatment with corticosteroids are associated with serious sequelae. Therefore, accurate and timely diagnosis is critical. The dermatologic surgery literature lacks a description of this straightforward surgical technique, as TABs are most often performed by ophthalmologists. OBJECTIVE: As a service to our rheumatology department we began performing TABs on a same-day on-call basis in July 1996. METHODS: We have performed 45 TABs in a 22-month period using a simple, safe, time-efficient technique. We review the surgical anatomy and danger zone of the temporal region and potential complications. We describe the biopsy technique which aims at safely obtaining a greater than 2 cm segment of a peripheral branch of the superficial temporal artery (STA), identified preoperatively by doppler ultrasonography. RESULTS: The procedure was performed on the day requested in all cases. Intraoperative time ranged from 20 to 40 minutes. TAB established the diagnosis of temporal arteritis in 8 of 44 biopsies (18%) and in 7 of 35 patients (20%), including 1 of 9 patients in whom we performed bilateral TAB. One patient was diagnosed with small-vessel polyarteritis nodosa by TAB. The mean formalin-fixed length of the arterial specimen was 2.2 cm. The length did not vary between positive and negative specimens. There were no complications and the cosmetic results were excellent. CONCLUSION: TAB is a quick, safe, straightforward, and gratifying office procedure which dermatologic surgeons are very qualified to perform.
BACKGROUND: Porcine heterografting is a method that can be used to reestablish the protective integrity of skin after cutaneous injury. These grafts may be used in an assortment of clinical situations for chronic and acute wounds, burn injury, and partial- or full-thickness areas of skin loss. OBJECTIVE: The purpose of this article is to address the indications for using porcine heterografts in dermatologic surgery, the advantages and disadvantages of their use, and the technique of graft application. METHODS: Indications for porcine heterografts and the methodology of graft application are discussed. RESULTS: Porcine heterografts serve as a valuable tool in a variety of reconstruction settings in dermatologic surgery. CONCLUSIONS: Heterografts provide an inexpensive method to facilitate wound care and promote healing, and serve as an effective repair option for a variety of surgical defects.
BACKGROUND: The term evidence-based medicine (EBM) is increasingly being used. Physicians, journal editors, insurance companies, and patients are applying its tenets to clinical decision making. Although there are concerns about the overly zealous application of EBM to clinical situations, many of the basic concepts are important in improving decision making. OBJECTIVE: To define evidence-based medicine and to review potential problems in basing decision making entirely on less-than-ideal evidence. METHODS: We reviewed the EBM literature and looked for examples in dermatology of pitfalls in decision making based on poor evidence. RESULTS: Following a definition of EBM, we review problems inherent in anecdotes and uncontrolled trials, including the placebo effect. Examples of medical practice that have been altered by doing more rigorous studies are provided. CONCLUSIONS: Concepts of EBM as currently defined should be considered by dermatologic surgeons in assessing the available information for clinical decision making.
BACKGROUND: Laser eye protection has been designed to protect operators and patients from severe eye injuries. OBJECTIVE: To describe two cases in which lasers used for cutaneous therapy may have been associated with the induction of vitreous floaters, a subacute eye injury, in physicians operating these devices, and to review the theoretical feasibility of such injuries, prior reports of the same, and strategies for minimizing risk. METHODS: Report of two cases and review of the literature. RESULTS: Given the circumstantial evidence, it is possible that subacute vitreous injuries may be sustained by the operators of dermatologic lasers. Ex vivo experiments and previous case reports have demonstrated the possibility of laser-induced vitreous injury, including changes in vitreous conformation and vitreous hemorrhage, in the absence of permanent retinal deficits. It may be speculated that vitreous floaters are a milder manifestation of such subacute injuries. CONCLUSION: To the extent that vitreous floaters can multiply and presage the onset of severe retinal injury, the risk of their induction by dermatologic lasers should be minimized. Simple strategies and further research can help achieve this goal.
BACKGROUND: High-quality coding of patient clinical data is mandatory for an effective DRG classification to result in adequate allocation of funding for inpatient treatment. The aim of the study was to determine the effect of controlled documentation on patient clinical data and to ascertain the outcome of calculated DRG-based yields depending on higher coding quality of patient treatment. PATIENTS AND METHODS: In a prospective study, 1914 patient clinical records from the Department of Dermatology, University of Muenster, were captured using different documentation standards and the data was analysed. Grouping was performed on the basis of the Australian Refined DRG system v4.1. Dermatological patients were broken down into eleven groups based on principle diagnosis. RESULTS: As a result of a controlled documentation, case mix, case mix index and patient clinical complexity level (PCCL) value were increased within identical samples. Furthermore, it was shown that high-quality coding may result in exact and reasonable classification of patient clinical data. CONCLUSIONS: Different documentation standards may cause undesired effects on the monetary yields of in-patient treatment. It appears that high-quality coding and controlled documentation may guarantee adequate yields. FauIty. incomplete and (up)coding could be a potential economic risk for hospitals.
Two dermatologist friends, widely separated by geography, had the dream to build a virtual grand rounds that could connect colleagues around the world for diagnostic and therapeutic suggestions as well a intellectual stimulation. They recrulted 2 students and constructed the site over a summer vacation. Virtual Grand Rounds in Dermatology is a prototype for what can be launched by nonacademic practitioners with few resources. We envision Virtual Grand Rounds in Dermatology as a service to dermatologists who practice at a remove from university hospitals and tertiary referral centers, as well as to others who wish to collaborate with colleagues distributed over a wide geographical net. For us, this has been a voyage into a brave new world with many exciting vistas. It can be accessed online: http://www.vgrd.org.
The Foundation for International Dermatologic Education was organized to improve dermatological education and care in developing countries. The accomplishments of the foundation over the past 25 years are reviewed.
Technological advance in society and medicine has brought tremendous improvements and convenience but also a degree of depersonalization. The personal and pastoral aspects of medical practice, which are probably more important in helping patients toward health than we realize, are becoming increasingly stifled by health care systems which are increasingly "scientific," technological, and "efficient." Clinical practice in dermatology requires pastoral as well as technical skills, art as well as science, and yet the balance of current medical culture increasingly favors and encourages "science" over "art." In dermatology, this bias is evident in a reductionist focus of research, the move towards evidence-based medicine and the emergence of teledermatology. Although all these developments are extremely important and valuable, their effect on the doctor-patient relationship needs to be considered carefully. Increasingly rapid scientific advance is paradoxically providing diminishing returns for patients and the healing art is still very much in demand.
The current advancements in our understanding of cutaneous diseases should not obscure our appreciation for the past and the achievements of the founders of dermatology. Their observations, ideas, discoveries, and writings shaped the development of the specialty, influence daily practices today, and serve as the foundation for future research endeavors. This article reviews the history of outstanding contributions that were preserved in enduring landmark works on which the whole knowledge of skin diseases rests. From the earliest books written with meager prior information to the impressive 19th century texts and atlases providing significant advances, these volumes marked and recorded defining moments in the evolution of dermatology.
The referral pattern of acute dermatologic conditions is not well described in either outpatients or hospitalized patients. The aim of this study is to describe in more detail the skin diseases that were referred for evaluation in an acute outpatient clinic at Bispebjerg Hospital, Copenhagen. In a 3-month period in 2003 a total of 428 consecutive new patients were referred for various skin diseases that needed subacute and acute dermatological evaluation in a university hospital setting. Referral pattern, age ratio and sex ratio were examined retrospectively. Two hundred and twenty-five (53%) of the 428 patients were referred from other hospital clinics in the local area. Sixty-six (15%) were referred from private practising dermatologists and 64 (15%) from general practitioners in the City of Copenhagen. Referral information was not noted in 35 (8%) of the 428 patients. The most prevalent diagnoses were: unspecified eczema (10.7%), drug eruptions (6.3 %), psoriasis (6.3%), atopic dermatitis (5.6%), bacterial skin infections (4.0%), inflammatory skin disorders (3.7%), seborrhoeic dermatitis (3.5%), urticaria (3.0%), seborrhoeic keratosis (3.0%), toxic contact dermatitis (2.8%), ulcus cruris (2.8%), autoimmune diseases (2.8%), malignant skin tumours (2.5%), candidiasis (2.5%), pruritus/prurigo (2.5%) and viral skin infections (2.5%). The fact that drug eruptions are one of the leading causes of acute referral conditions probably reflects the proximity to other hospital settings, where a large number of patients receive several systemic medicaments for various conditions.
The purpose of this research was to evaluate different parameters that can influence in vitro drug release from topical dermatological drug products such as creams, gels, and ointments. In vitro release from topical dermatological drug products was carried out by using a static diffusion cell, a synthetic membrane, and an appropriate receptor medium. The receptor medium was mixed by means of a magnetic bar rotated at 400 rpm. Experiments were designed to evaluate the influence of (i) receptor media, (ii) different lots of synthetic membranes, and (iii) agitation on drug release. Release experiments were also carried out to study inter- and intralot variability. The in vitro release test was used to evaluate the marketed glucocorticoid products. Among the parameters studied, the receptor medium was found to be the most important and critical variable that influenced drug release. The release rate ranged between 0.61 and 2.68 micrograms/cm2/min0.5 for betamethasone dipropionate, depending on the percentage of ethanol in the receptor medium. The drug release was not influenced by agitation or by different lots of synthetic membranes. Very small inter- and intralot variability was observed. These experiments establish the ruggedness of the in vitro diffusion cell test system used for the drug release measurements.
A survey of all MD-PhD residents in dermatology in the United States was conducted to evaluate the factors important to them in making career pathway decisions. Twenty-six MD-PhDs responded to the survey representing a 90% response rate. Although essentially all entered dermatology with the intention of pursuing a career in academic medicine, 77% percent thought they would be in academic medicine 5 years post-residency. Factors explored for a negative influence on entrance into academic medicine post-residency were 1) financial concerns, 2) length of training, 3) research hiatus due to clinical training, and 4) eligibility for existing funding mechanisms.
The American Food and Drug Administration (FDA) bioequivalent guidance of topical dermatological corticosteroids in 1995 (the Guidance) requires measurement of the skin blanching response with a chromameter for evaluation of cutaneously applied corticosteroid formulations. The Japanese government decided to apply the same guidelines in 2003, despite there having been no reported trial for the yellow-skinned races. The purpose of this study was to obtain basic data of corticosteroid-induced skin blanching response measured with a chromameter on yellow-skinned races. Four studies were performed according to the Japanese version of the Guidance for Industry using a chromameter on the forearms of healthy Japanese volunteers. This involved: (i) a validation study of proper duration of treatment exposure (dose duration); (ii) a comparison study of two dermatological corticosteroid products that represented different potency classes; (iii) inspection of reproducibility using right and left forearms; and (iv) study of seasonal difference. We showed that: (i) the same medication can give different values of ED(50) (the dose duration required to achieve 50% of the fitted areas under the effect curves [AUEC](max) value) under different dose durations; (ii) ED(50) do not always represent the potency of the corticosteroid; (iii) the results of AUEC at maximum duration were similar, but AUEC at an approximate ED(50) duration time varied widely; and (iv) the results of AUEC were different according to season. In conclusion the dose duration relationships, determination of the AUEC(max), and the ED(50) could be obtained on yellow-skinned races using the FDA method. However, negligible differences were found in our study regarding dose duration, reproducibility and seasonal change.
A comprehensive survey of the dermatology out-patient service, including private practice, was undertaken by the medical staff of the Department of Dermatology, in Edinburgh. The unit serves a population of 1,171,000 in the south-east region of Scotland. One thousand two hundred and thirty-two new patients and 1587 follow-up patients were seen in 1 month. Ninety-five per cent of new referrals were from general practitioners and the remaining 5% were from hospital doctors. Benign tumours (19.3%), viral warts (16.9%) and dermatitis/eczema (16.7%) accounted for over half of all new consultations. The routine waiting time for a clinic appointment was 5 weeks, but 9.5% of new patients were seen within 3 weeks of referral and a further 6.5% within 48 hours. Minor surgical procedures, excluding the treatment of viral warts, were carried out on 22% of new patients.
Non-attendance at out-patient clinics, although common, has received relatively little attention. A prospective study was undertaken to assess the extent of the problem of non-attendances of newly referred dermatological patients in a single dermatological out-patient clinic over a 12-month period. The overall non-attendance rate was found to be 19%. There were no apparent significant differences between the groups of attending and non-attending patients when compared statistically. A survey of those patients who failed to attend suggested that inadequate communication between the hospital and patients (17%) and patients forgetting their appointment date (23%) may be factors that are amenable to administrative changes.