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PubMed2001

Optical coherence tomography in dermatology: a review.

BACKGROUND/AIMS: Optical coherence tomography (OCT) is a non-invasive technique for morphological investigation of tissue. Since its development in the late 1980s it is mainly used as a diagnostic tool in ophthalmology. For examination of a highly scattering tissue like the skin, it was necessary to modify the method. Early studies on the value of OCT for skin diagnosis gave promising results. METHODS: The OCT technique is based on the principle of Michelson interferometry. The light sources used for OCT are low coherent superluminescent diodes operating at a wavelength of about 1300 nm. OCT provides two-dimensional images with a scan length of a few millimeters (mm), a resolution of about 15 microns and a maximum detection depth of 1.5 mm. The image acquisition can be performed nearly in real time. The measurement is non-invasive and with no side effects. RESULTS: The in vivo OCT images of human skin show a strong scattering from tissue with a few layers and some optical inhomogeneities. The resolution enables the visualization of architectural changes, but not of single cells. In palmoplantar skin, the thick stratum comeum is visible as a low-scattering superficial well defined layer with spiral sweat gland ducts inside. The epidermis can be distinguished from the dermis. Adnexal structures and blood vessels are low-scattering regions in the upper dermis. Skin tumors show a homogenous signal distribution. In some cases, tumor borders to healthy skin are detectable. Inflammatory skin diseases lead to changes of the OCT image, such as thickening of the epidermis and reduction of the light attenuation in the dermis. A quantification of treatment effects, such as swelling of the horny layer due to application of a moisturizer, is possible. Repeated measurements allow a monitoring of the changes over time. CONCLUSION: OCT is a promising new bioengineering method for investigation of skin morphology. In some cases it may be useful for diagnosis of skin diseases. Because of its non-invasive character, the technique allows monitoring of inflammatory diseases over time. An objective quantification of the efficacy and tolerance of topical treatment is also possible. Due to the high resolution and simple application, OCT is an interesting addition to other morphological techniques in dermatology.

Dermatology↗
PubMed1997

Determination of lactic acid and poly(lactic acid)s in a dermatological formulation by capillary electrophoresis.

A stability-indicating capillary electrophoresis (CE) method was developed to determine lactic acid at a level of 0.9% m/m in a dermatological formulation. This level includes up to 34% present in the form of poly(lactic acid)s. Current methods which involve treatment of samples with sodium hydroxide to hydrolyse the various lactic acid oligomers to free lactic acid cannot strictly be regarded as true measures of stability. The harsh hydrolysis conditions used can also lead to the generation of many degradation peaks from excipients such as natural extracts which can interfere with the detection of lactic acid in HPLC and CE methods. Application of indirect UV detection using 4-methoxybenzoic acid (p-anisate) as the background electrolyte and negative voltage polarity (detector towards anode) allows the direct quantification of the total available lactic acid from the monomer and the predominant linear oligomers in the raw material, i.e., the dimer (lactoyllactate) and the trimer. Tetradecyltrimethylammonium bromide was used as the electroosmotic flow modifier, lactic acid, lithium salt, as a calibration standard and butyric acid as an internal standard. A typical RSD for standard response using migration time-corrected peak area ratios was 1.17% (n = 9). Duplicate analysis of total lactic acid from two similar product placebos spiked with raw material gave average recoveries of 101.0 and 99.6%. The method, when applied to fully and partially hydrolysed raw material, showed good agreement (99.6%) with a standard titration assay for raw materials and was successfully applied to 5 month storage samples of a product. Advantages of the method include speed, simplicity, low consumption of reagents and no organic solvents.

Dermatologic Agents↗
PubMed2000

Rupert Hallam and the development of dermatology in Sheffield.

(Arthur) Rupert Hallam worked as a dermatologist in Sheffield from 1911 to 1944. Early in his career, he also specialized in diagnostic radiology and established this speciality in Sheffield. Hallam performed investigative work on the aetiology of papular urticaria and erythema multiforme, the prognosis of psoriasis, and the aetiology of chilblains. He was an original member of the British Association of Dermatologists from 1920 becoming president in 1935. He also helped to found the North of England Dermatological Society. He was an innovator in both clinical and administrative matters and was the first British dermatologist to develop a full-time training post in the specialty.

Dermatology↗
PubMed2003

Comparison of diagnostic accuracy for cutaneous malignant melanoma between general dermatology, plastic surgery and pigmented lesion clinics.

BACKGROUND: Since the 1980s there have been dedicated pigmented lesion clinics (PLCs) in the U.K. Important considerations when comparing the efficacy of the PLC with other referral clinics include diagnostic accuracy. OBJECTIVES: To compare the false-negative rate of clinical diagnosis (FNR) in the PLC with that in the other clinics of primary referral of malignant melanoma (MM) in the same geographical area. We have previously shown that certain clinical features are risk factors for diagnostic failure of MM. A further aim of this study was to correct for any differences in frequency of these factors in the melanoma populations between clinics and to estimate the false-positive diagnostic rate (FPR) in the PLC. METHODS: To compare the FNR between clinics, the case notes of all patients presenting with histologically proven cutaneous MM in Leicestershire between 1987 and 1997 were examined retrospectively. A false-negative diagnosis was defined as documentation of another diagnosis and/or evidence in the case notes that the diagnosis was not considered to be MM. The FNR was estimated as the number of false-negative clinical diagnoses/number of true-positive histological diagnoses. To estimate the diagnostic FPR, which was defined as the number of false-positive clinical diagnoses of MM/total number of positive clinical diagnoses, in the PLC, the outcome of 500 consecutive patients attending the PLC was surveyed. RESULTS: The case notes of 731 patients were available, of whom approximately two-thirds initially attended the PLC, one-fifth the General Dermatology clinics (D) and the remainder were divided approximately equally (one-twentieth each) between Plastic Surgery clinics (P), other clinics (O) and the surgery of the general practitioner (GP). The last was regarded as the primary referral clinic if the lesion were excised there prior to any referral. The FNR was lowest for the PLC, at 10%, compared with 29% (D), 19% (P), 55% (O) and 54% (GP) (P < 0.0001). Lesions with risk factors for diagnostic failure were under-represented in the PLC (P < 0.0001), the mean frequencies of the risk factors being 20% (PLC), 25% (D), 22% (P), 31% (O) and 30% (GP). Differences were not large but still could partially explain the lower FNR of the PLC. However, when the FNR was estimated for lesions exhibiting each of these risk factors, the PLC was found to have the lowest rate in every case (PLC vs. all clinics combined, P = 0.04 to P < 0.0001). The mean FNR for the risk factors combined was 18% (PLC), 45% (D), 50% (P), 68% (O) and 71% (GP). Also on logistic multivariable analysis of the PLC vs. all the other clinics on FNR and the above factors, the higher FNR of the other clinics retained significance (odds ratio 5.9, P < 0.0001). In the 500 patients surveyed separately in the PLC, the MM pick-up rate on biopsy was 32% and the diagnostic FPR was 41%. CONCLUSIONS: The FNR of MM was lower in the PLC than in the other clinics, while the pick-up rate for MM on biopsy and the FPR were acceptably low.

Aged↗
PubMed1998

An outbreak of methicillin-resistant staphylococcus aureus (MRSA) in a dermatology day-care unit.

We describe an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) in a dermatology day-care unit and the methods used to determine the mechanism of spread and control it. The epidemic strain had a characteristic sensitivity pattern and was typeable with phages 29, 80, 95, 47, 54 and 77, which was of considerable value in interpreting the epidemiological data. The method of spread was studied by examination of the medical and nursing records of patients who had acquired MRSA (to determine which members of staff they had encountered and which other MRSA-positive patients had been present in the department at the same time) and by the microbiological screening of all patients and staff. However, screening of all staff by nasal swabbing failed to identify carriage of the epidemic strain, while extensive swabbing of surfaces on the day-care unit also failed to show any evidence of MRSA in the environment. This suggests that the MRSA was most probably spread from patient to patient via the hands of staff, although there was also the possibility of direct transmission from patient to patient. Nine patients acquired the unique strain of MRSA and once acquired it proved difficult to eradicate, although in the majority, the infection did not appear to be clinically significant. However, in two patients MRSA contributed to a fatal outcome: these were the two most elderly patients and were the only two who were receiving systemic corticosteroids. The outbreak was brought under control with rigorous hygienic measures and the decision to discharge all patients with MRSA from the day-care unit. Repeat screening (swabs of nose, axilla and groin) of all day-care unit and in-patients 11 months after the last MRSA case showed no evidence of any residual MRSA infection in the day-care unit.

Adolescent↗
PubMed2001

From blacklist to beacon, a case study in reducing dermatology out-patient waiting times.

At its worst our dermatology department had a waiting list for routine appointments of 57 weeks. As a result we started to lose contract income and consequently were unable to replace a retiring consultant. The service faced fragmentation and loss of the inpatient ward. Using a series of internally planned and driven initiatives it was possible to retrieve the situation. Our efforts were recognized by a national waiting list Beacon award in 1999. This study describes the methods used to increase new patient throughput, reduce demand and hence reduce waiting time for new patient appointments. Change was achieved only when medical, nursing staff, general practitioners, managers and health authorities were involved in the process. The changes needed to be led by a consultant enthusiast and managed effectively. There remains a constantly increasing demand for the service and reducing the waiting list simply invites a further increase in referral. In a resource-limited health care system the provider must be able to limit demand by using agreed referral exclusion criteria in order to balance supply and demand.

Ambulatory Surgical Procedures↗
PubMed2002

Cytokine blocking agents in dermatology.

Cytokines are intercellular messengers that have an important role in the development and maintenance of cutaneous inflammation. The primacy of cytokines in eliciting cutaneous immune responses makes them a highly attractive target for new biological response modifiers. Targeting of cytokines is still in its infancy for therapy of skin disease. However, blocking tumour necrosis factor alpha by infliximab or etanercept has shown particular promise, especially in the management of psoriasis. Anecdotally, this approach is also effective for a variety of dermatological conditions including pyoderma gangrenosum and Behçet's syndrome. We review the current and prospective roles of cytokine blocking agents in the treatment of skin disease.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed2003

The current status of nurse prescribing in dermatology.

This review describes the current status of prescribing by nurses and other nonmedical staff in the UK with particular emphasis on issues affecting secondary care dermatology departments. We discuss background issues of how the process has evolved, the requirement for this initiative and its assessment, the terminology applied to different groups of prescribers, and training issues.

Community Health Nursing↗
PubMed2003

Cyclosporin: applications in small animal dermatology.

Cyclosporin has been increasingly used for the treatment of skin diseases in small animals. Reported uses include the treatment of atopy, cutaneous lupus erythematosus, feline acquired alopecia resembling pseudopelade of humans, pemphigus erythematosus, pemphigus foliaceus, perianal fistulae and sebaceous adenitis. In addition, cyclosporin has been used anecdotally for several other skin diseases. Few side effects have been noted at doses therapeutic for dermatologic diseases. Current suggestions for monitoring, and the value of trough cyclosporin serum concentrations for prediction of toxicity and efficacy are discussed.

Administration, Oral↗
PubMed2004

[Online bedside teaching: multimedia, interactive and case-based teaching scenarios in dermatology].

The MeduMobile project or Mobiler Campus Charité was started in the beginning of 2003 to evaluate new, multimedia supported teaching and learning scenarios. The project focuses especially on acute and rare diseases to which students usually have are very limited access. During the teaching sessions the MeduOnCall team and the academic teacher communicate with the students who are equipped with individual notebooks through a wireless net. In dermatology the MeduMobile project focused in summer 2003 and winter 2003/2004 on bedside teaching. Despite some technical difficulties in the beginning the project was well received by teachers and students. The possibility of simultaneous online searches by Internet as well as the possibility to include photographs depicting the course of the skin disease was felt to be one of the main advantages of this project. Based on these positive experiences an attempt will be made to integrate the project further into the regular teaching of the Charite.

Case-Control Studies↗
PubMed2004

[Prevention and regeneration of barrier disturbances in occupational dermatology].

Over the past 10 years primary, secondary and tertiary prevention of occupational skin disorders has been shown to be successful, documented with appropriate statistical methods. Interventional strategies are the main features of secondary and tertiary prevention, now well-established in occupational dermatology. Primary prevention is best accomplished by health education measures, both in the form on individual counseling and seminars. This overview reviews the scientific background of hand eczema with respect to barrier damage and repair and then considers the options for individualized and focused prevention. Special anatomical features of the interdigital space and palms, as well as functional disorders, such as palmar hyperhidrosis, are discussed. The importance of barrier regeneration is considered in light of the role of an acid pH, the epidermal calcium gradient and aspects of percutaneous absorption. The effects of anti-oxidants are considered, and new bioengineering methods which rely on physiologic measuring techniques are reviewed.

Dermatology↗
PubMed2004

[Health economic studies in dermatology--review of the literature, evaluation and practical aspects].

BACKGROUND: Health economic studies attempt to objectivity treatment results to place them in economic. These studies summarize both physician care and other medical services to allow a more rational use of limited resources and are of great value. METHODS: The health economic studies in the literature were analyzed by the conducting countries, financing, the study period and the interval until publication. A quantitative comparison to other specialties in medicine was performed. On the basis of a checklist of basic criteria, a qualitative assessment of the studies was performed to rate the significance. RESULTS: The number of studies showed a fivefold increase. A third of the dermatological studies (n = 71) were conducted in the United States, 23.94% in Great Britain, 9.86% in Sweden and 35.23% in other countries. The interval until publication was 0 to 9 years. CONCLUSIONS: The increase in the number of studies may be explained by the growing demand for clarification of the economical situation. Reasons for the significant differences between different countries might be the financing of the studies or the nature of the dominant health care system. Whereas American studies are predominantly sponsored by pharmaceutical companies, the ones in Great Britain and Sweden are supported by public authorities. The long delays in publishing may be accounted for by long review periods and by difficulties in transferring large amounts of data in international studies. Particularly the introduction of the DRG system in Germany has increased demands for cost-effective action on the basis of well-founded and high-quality health economic studies.

Cost-Benefit Analysis↗
PubMed2003

Solar keratoses: analysis in a dermatological practice in Australia.

Two hundred consecutive patients with solar keratoses (SK) seen in a private dermatology practice had on average 61.9 SK compared with eight reported in the general population. Non-melanoma skin cancer was present in 41% of patients and 17% had squamous cell carcinoma (SCC). The ratio of basal cell carcinoma to SCC in the cohort was 1.7:1. The commonest site of SK was the upper limbs but the greatest density of lesions was on the face, particularly the nose. Squamous cell carcinomas were most commonly found on the upper and lower limbs. Basal cell carcinomas were most common on the head and neck.

Adult↗
PubMed2002

Incidence and risk factors for thalidomide neuropathy: a prospective study of 135 dermatologic patients.

Thalidomide is effective in several cutaneous diseases. Peripheral neuropathy is the most important adverse event limiting its use. Its incidence rate and its relation to thalidomide doses remain unclear. We prospectively monitored 135 patients treated with thalidomide for various dermatologic diseases for 2 y in order to estimate the annual incidence rate and risk factors for neuropathy. Patients underwent standardized neurologic examination and nerve conduction studies prior to, and regularly during treatment. Risk factors for neuropathy were assessed using a Cox proportional-hazards model. Clinical and electrophysiologic evidence of a thalidomide-induced neuropathy were present in 25.2% of the patients; however, when considering all potential cases, this rate reached 55.6%. The incidence rate was maximal during the first year of treatment (20%). The risk of neuropathy was related to the daily dose whatever the duration of treatment (p<10-3). Considering a daily dose < or =50 mg per day as reference, the relative risk for thalidomide neuropathy was 8.2 for a daily dose comprised between 50 and 75 mg per day and 20.2 for a daily dose >75 mg per day (p<10-3). No neuropathy occurred for daily doses < or =25 mg per day. The neuropathy was subclinical in nearly a quarter of patients with such an adverse event. These data confirm the high rate of thalidomide neuropathy and identify the daily dose as the main risk factor. The risk of neuropathy seems to be negligible for doses less than 25 mg per day, whatever the duration of therapy.

Adult↗
PubMed1999

Periorbital rejuvenation: a review of dermatologic treatments.

BACKGROUND: The periorbital region serves as a barometer of chronologic and environmental age and, as such, patients often seek its cosmetic rejuvenation. OBJECTIVE: The purpose of this article was to review the dermatologic treatments available for periorbital skin rejuvenation. METHODS: Topical retinoic and glycolic acid preparations, chemical peels, botulinum and collagen injections, dermabrasion, and laser resurfacing procedures for periorbital skin rejuvenation were reviewed. The relative benefits and risks of each treatment were detailed. RESULTS: Minimal photodamage with mild rhytides should be responsible to topical acid therapy and superficial peels, whereas moderate wrinkling and photodamage generally require medium-depth peels, collagen injections, or erbium:YAG laser resurfacing. Deeper rhytides and more extensive cutaneous photo-damage usually necessitate CO2 laser resurfacing and botulinum injections. CONCLUSIONS: Proper patient selection and assessment of aging severity are critical to determine the best therapeutic option.

Botulinum Toxins, Type A↗
PubMed2001

Iontophoresis as a tool for anesthesia in dermatologic surgery: an overview.

One of the biggest challenges of performing dermatologic surgery procedures is to minimize pain. Not only will the experience of each patient be enhanced by increased comfort, but the medical and aesthetic results achieved by the physician will be facilitated as well. Iontophoresis is the use of electrical impulses to drive molecules into the skin. Anesthetic agents are one type of medicine that can be delivered in such a way. There is a tremendous potential for the applications of iontophoresis to be expanded. As our understanding of the technique increases we will be able to modify the skin's surface as well as the individual agents we wish to transport.

Anesthetics, Local↗
PubMed2002

Dermatologic surgery in geriatric patients: psychosocial considerations and perioperative decision-making.

BACKGROUND: Dermatologic surgery, both for cutaneous malignancies and for management of the visible signs of photodamage, is frequently performed on older persons. OBJECTIVE: To review common psychologic and physiologic limitations among the elderly that may affect their ability to tolerate cutaneous surgery and to outline a stepwise approach for management of these conditions during the perioperative period. METHODS: Literature review, MEDLINE (1966-2001) search, and personal experience. RESULTS: Communication with patients, their families, and their physicians, management of patients' underlying medical problems, and special sensitivity to patients' cognitive and physiologic limitations can minimize perioperative risk during cutaneous surgery in the elderly. CONCLUSION: Given appropriate physician management, elderly patients can usually safely undergo cutaneous surgery.

Aged↗
PubMed2002

Recurrence rates of primary nonmelanoma skin cancers treated by surgical excision compared to electrodesiccation-curettage in a private dermatological practice.

BACKGROUND: The incidence of nonmelanoma skin cancer, the most common form of cancer in the United States, continues to increase. It is important that physicians know what treatment modalities will be the most efficacious. OBJECTIVE: The purpose of this study was to compare recurrence rates by treatment modality for primary basal and squamous cell carcinomas in a private dermatological practice. METHODS: Between June 1993 and December 1994, 268 consecutive primary nonmelanomic tumors were treated by surgical excision or electrodesiccation and curettage in our practice. The charts of the 191 patients treated were retrospectively reviewed, and recurrence data were compared by treatment modality. RESULTS: The recurrence rates between the two types of treatment were not found to be significantly different. CONCLUSION: In contrast to other studies reported from academic centers in which surgical excision has been found to have lower recurrence rates than tumors treated with curettage and electrodesiccation, this study found recurrence rates for two treatments to be approximately the same.

Aged↗