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Dermatologic problems are seen very often in the urgent care setting. Common acute problems such as urticaria, pruritus, and less common but potentially devastating dermatologic diseases will be discussed in this review. Emphasis will be placed on an efficient and cost-effective initial approach to diagnosis and treatment.
In February 1998 the first Dermatology Nursing Certification exam was administered to registered nurses. This added credential beyond licensure serves as a demonstration that Dermatology Nurse Certified (DNC) nurses have acquired a core body of specialized knowledge and adhere to specialized nursing standards. In addition to providing a sense of professional achievement, certification can serve other purposes: peer and collegial respect, documentation of advanced knowledge and skills, increased earning power, increased job satisfaction, and in the future, third-party reimbursement.
In opposition to intuitive and empirical approaches, rigorous medicine relies on two axes of development. Evidence-Based Medicine is currently put forward. However, it can not replace rational medicine rooted in physiopathological explanations. Dermatology does not escape such conceptual duality. Dermatopathology is one major pillar of rational dermatology. Such situation is jeopardized by health planners who deny the perennial skill of dermatologists and concede hegemony of dermatopathology to general pathologists.
Application of non-ionising radiation with or without photosensitizers is rather common in dermatology. Though the method itself was described in ancient times, its routine use in medicine based on scientific research started in the second half of the 20th century. Light can be used in three different patterns: phototherapy (UV-A or UV-B light), photochemotherapy (combination of psoralens with UV-A light) and photodynamic therapy (combination of photosensitizers with UV- and/or visible light). The following article deals with the photodynamic therapy or PDT. Using PDT implies the understanding of light dosimetry and calculation of light dose using different light sources and photosensitizers. The number of PDT sensitisers under investigation is rapidly increasing. The PDT itself, being a relatively new modality, quickly spreads its list of applications covering new indications in different areas of medicine. Though the main part of this list is made up of dermatological conditions, the use of PDT in other disciplines is also discussed to make dermatologists familiar with different aspects of the issue. PDT, like any treatment modality, has its benefits and adverse effects. The future of PDT is closely related to teamwork in physical, biochemical and clinical research which could provide better understanding of underlying mechanisms and help to create protocols for higher therapeutic efficacy.
A study carried out in an NHS trust showed that its dermatology nurses could safely undertake nurse prescribing. To be effective a formal system of nurse prescribing is required. This involves the compilation of a formulary for the nurse prescribers and the development of relevant treatment protocols. The introduction of nurse prescribing in a day-care unit led to improvements in the dermatology services available to the local population.
OBJECTIVE: To determine the proportion of dermatological patients who are offered evidence-based therapy in the routine dermatological practice. METHODS: For every patient seen for the first time at one of our tertiary hospital setting clinics between April and May 1999, the primary diagnosis and the primary intervention were recorded. For each primary diagnosis-primary intervention combination, evidence was searched for in electronic databases from January 1966 to December 1999. The proportion of patients who were offered evidence-based interventions was calculated as the main outcome measure. RESULTS: With a study sample of 136 patients, 61 different diagnosis-treatment couples were generated and 94 queries on electronic databases were performed (to account for "primary interventions" including more than 1 drug or treatment modality). Eighty-seven (64%) of 136 patients received evidence-based interventions. Evidence from randomized controlled trials was found for 69 patients (50.7% of the sample). Controlled studies lacking randomization or double blinding or including fewer than 20 patients per treatment group dealt with treatments offered to 14 patients (10.3%). The treatments offered to 4 patients (2.9%) were judged to have self-evident validity (ie, trials unanimously judged unnecessary). Symptomatic and supportive measures accounted for most interventions lacking substantial evidence (36% of the patients), but we had to include in this class other important treatment regimens, mainly for rare conditions. CONCLUSIONS: Most of the study patients received evidence-based care. However, published trials should be carefully appraised, and relevance of clinical end points should be evaluated together with methodological issues. More accessible, clinically oriented, evidence-based information sources are needed.
Antidepressant drugs can be an important component of the dermatologists' therapeutic armamentarium. When considering the use of psychotropic agents in dermatology two major factors should be considered: (1) the accurate diagnosis of the comorbid psychiatric disorder, and (2) the presence of proper indications for the use of antidepressant agents. Antidepressant drugs are used in the management of the psychiatric syndromes, which are most frequently comorbid with dermatologic disorders, i.e., Major Depressive Disorder, Obsessive-Compulsive Disorder, Body Dysmorphic Disorder, Post-traumatic Stress Disorder and Social Phobia. The antihistaminic and analgesic properties of some antidepressants such as doxepin and amitriptyline, are also of benefit in the treatment of some pruritic and neuralgic states. The specific guidelines, side effect profile, drug-drug interactions, and the most current indications should always be obtained for any particular antidepressant agent before it is prescribed.
OBJECTIVE: This guideline has been developed in order to recommend the correct and safe usage of isotretinoin (Roaccutane) in the treatment of acne and related conditions. Aspects such as correct dosage related to the patient's weight and the minimal requirement in relation to blood tests and physician visits have been addressed. OPTIONS: Isotretinoin is known to be the treatment of choice for severe acne. Familiarity with the drug has lowered the threshold for its use in lesser degrees of acne, particularly when scarring is occurring and other options outlined in the guideline have failed or are either unsuitable or not tolerated. OUTCOMES: Severe acne causes permanent physical damage and frequently equally severe psychological damage. The correct use of isotretinoin increases the chance of complete cure, thus maximising the chance of meeting the patient's expectations. EVIDENCE: Studies have shown that the patient may expect the chance of permanent cure to be between 60% and 80% at a dose ranging from 0.5 to 1 mg/kg body weight per day for a period of 16-20 weeks. Recent evidence suggests that a cumulative dose of 120 mg/kg body weight during the course at a daily dose of 0.75 mg/kg body weight or greater may be more important than the duration of treatment. VALUES: The National Dermatology Working Group consisting of 11 consultant dermatologists, all with considerable experience in the use of isotretinoin therapy for acne, using the current literature as back-up, reached consensus on the contents of the document. The document was presented to the Congress of the South African Dermatology Society in May 1997. It was subsequently sent to all registered dermatologists in South Africa for comment. BENEFITS, HARM AND COSTS: Correct use of isotretinoin will often effect cure and at worst considerably improve acne. Side-effects due to hypervitaminosis A, while almost inevitable, are uncomfortable rather than dangerous. The potential for teratogenicity is stressed. Isotretinoin is an extremely expensive drug, but studies have shown that it is cost-effective when compared with prolonged treatment with other modalities in what is usually a chronic condition. RECOMMENDATIONS: The optimal dosage recommended is a cumulative dose of 120 mg/kg body weight with a daily dose as close to 1 mg/kg body weight as possible. Isotretinoin is used for severe acne, lesser degrees of acne where scarring is seen, and in patients who do not respond to or cannot tolerate other treatment modalities. VALIDATION: This guideline is similar to those recommended by other groups outside South Africa. It has been scrutinised by all the practising dermatologists in the country. It is endorsed by the Medical Association of South Africa.
We developed a general model to assess patient activity within the primary and secondary health-care sectors following a dermatology outpatient consultation. Based on observed variables from the UK teledermatology trial, the model showed that up to 11 doctor-patient interactions occurred before a patient was ultimately discharged from care. In a cohort of 1000 patients, the average number of health-care visits was 2.4 (range 1-11). Simulation analysis suggested that the most important parameter affecting the total number of doctor-patient interactions is patient discharge from care following the initial consultation. This implies that resources should be concentrated in this area. The introduction of teledermatology (either realtime or store and forward) changes the values of the model parameters. The model provides a quantitative tool for planning the future provision of dermatology health-care.
A short review is given of the development of dermatology and venerology in Byelorussia. The scientific activity of Professor Andrej Procopchuk (1896 - 1970), who was the founder of the scientific school of dermatology and venerology in Byelorussia, was of prime importance in this respect
The present study was undertaken to describe patterns of dermatological drug utilization in a tertiary hospital in Delhi by measuring WHO delineated drug use indicators. Six hundred and six prescriptions of dermatology out-patients were analyzed and the data collected were used to evaluate the following drug use indicators: average number of drug per prescription, average consultation time, percentage of drugs prescribed by generic name, percentage of encounters with an antibiotic prescribed, percentage of encounters with an injection prescribed and percentage of drug prescribed from the essential drugs list or formulary. The average number of drugs per prescription +/- SD was found to be 2.6 +/- 1.2, average consultation time +/- SD was 4.4 +/- 2.6 minutes, percentage of drug prescribed by generic name was 6.98, percentage of encounters with an antibiotic and injection prescribed were 46.86 and 6.76 respectively and 23% of the total drugs prescribed were from Delhi State Essential Drugs Formulary.
The department of dermatology has developed a broad clinical activity with a particular expertise in oncology, allergology, psoriasis and gynecological dermatology. Research has also been developed in these areas.
BACKGROUND: The aim of this study was to characterize the medical activity of a dermatology emergency room and to compare it with 1) outpatients, scheduled visits to the same department and 2) visits to community dermatologists in private practice. METHODS: All the 500 patients who attended the emergency room in one month and all the 411 patients with scheduled appointments during one week within the same period were included prospectively. The clinical diagnoses were recorded and compared between the two groups using chi square and linear correlation tests. Data on the diagnoses made by community dermatologists in private practice were obtained from another study. RESULTS: In the emergency room, 4 diagnoses accounted for 71.4 of all visits: infections (29 p. 100), dermatitis (23.8 p. 100), rashes (11 p. 100) and urticaria (7.6 p. 100). In scheduled visits the 4 leading diagnosis were cancer and precancerous lesions (28.7 p. 100), dermatitis (11.7 p. 100), fungal infections (8.3 p. 100) and acne (7.1 p. 100). There was no correlation (r=0.14; p=0.6) between the 16 more prevalent diagnoses in the emergency room and the prevalence of the same diagnoses in scheduled visits in the hospital department. The emergency diagnosis were also not correlated with those seen in private practice (r=0.21; p=0.4). Seven percent of emergency room consultants were hospitalized. COMMENTS: Skin disorders encountered in the dermatology emergency room differ from those seen both in the outpatient hospital department and in community private practice.
Measuring patient satisfaction is regarded as one of the principal methods for obtaining patients' evaluation of services they receive. During the last decades more interest has been devoted to inpatients' preferences and needs. Surveys on patient satisfaction may provide information to hospitals about areas where improvement is needed. In this survey, 648 questionnaires were completed by dermatological inpatients and were analyzed for overall satisfaction and seven satisfaction determinants. Background factors and clinical parameters were considered. Emotional support was recognized as a critical area. "Coordination of care" and "information and education" were identified as the most relevant determinants for overall patient satisfaction. The Hospital Management, taking into account the results, planned training in order to improve personnel's communication skills. This study confirms that patient satisfaction analysis is a useful instrument also among dermatological inpatients, and satisfaction is a valid measure of quality of health care.
INTRODUCTION: The official policy of the French National Health Insurance system is to deny reimbursement for drugs prescribed for off-label indications. The objectives of this study were 1) to quantify the use of off-label prescriptions by physicians from a hospital department of dermatology in France; 2) to characterize these off-label prescriptions; 3) to assess data from the literature on the appropriateness of these off-label prescriptions. PATIENTS AND METHODS: For each patient consulting between February 1 and April 1, 2001, the symptom or the disease that was treated and the type of prescription were recorded on standard forms. RESULTS: Eighty six percent of prescriptions were labelled, 14 p. 100 were off-labelled. Inflammatory and hypersensitivity dermatoses were the most frequent indications of off-label prescriptions (26 p. 100). Treatments which most frequently corresponded to off-label prescriptions were topical corticosteroids and methotrexate. Examination of the literature showed that 70 p. 100 of the off-label prescriptions were not based on strong data from evidence-based-medicine. Many off-label prescriptions were made by the most graduate physicians. DISCUSSION: This study showed a great number of off-label prescriptions in dermatology. These prescriptions were often related to rare diseases that were managed by senior dermatologists. These off-label prescriptions were rarely in accordance with data from evidence-based-medicine.
This article deals with a number of newer drugs now being employed in dermatology. The great beneficial role of corticoids both topically and systematically for various inflammatory dermatoses is now amply proved. The addition of a corticoid to a conventional acne lotion renders it much more effective. Nystatin for monilial infections is especially effective in a powder form. For systemic use Griseovulvin, now becoming available, is the most interesting current development in dermatology. Presumably, it is highly effective against ringworm of the hair, nails and skin. The role of synthetic antimalarials in treating chronic discoid lupus erythematosus and light sensitivity eruptions also is firmly established.
BACKGROUND AND OBJECTIVES: Exposure of family medicine residents to dermatology is inconsistent. We encourage residents to record skin lesions using digital photographs, which are made into posters displaying clinical information. METHODS: Residents submit diagnoses for each poster, and correct diagnoses are then posted. A semiannual 10-case quiz compares the scores of participating residents with nonparticipants. RESULTS: On the first three semiannual quizzes, participants and nonparticipants have scored, respectively, 68% and 48%, 73% and 55%, and 77% and 65%. CONCLUSIONS: Residents' ability to make dermatologic diagnoses improved from participation in an inexpensive, easily administered program using digitally displayed skin problems.
We report a retrospective study of all scabies cases collected in the department of Dermatology of Charles Nicolle Hospital during a 8 year-period (1993-2000). 148 cases of scabies were collected with a mean incidence of 144 new cases/year (65-204). Diagnosis was made clinically in all cases. Parasitological exam was done in case of doubtful diagnosis. Our purpose is to try to define an epidemio-clinical profile of scabies in Tunisia and to estimate the incidence of this parasitosis through our dermatological consultation with reviewing the literature data.