Southampton Dermatology centre, Royal South

Hants Hospital.

The background to this rather unusual nursing

role was in 2000, when the Government pledged to

New Ways of Working and developing nursing roles.

With the advent of ‘Action on Dermatology’,

Southampton University Hospitals NHS Trust

(SUHT) looked at service delivery (2002), deciding

that with training ‘in house’, Registered Nurses could

take on this role to help improve the efficiency of the

service for our patients.

Nicky Crannage, Specialist Nurse Surgeon, set up

the service and training booklet, this was a new and

exciting role, she was trained by a Dermatology

Consultant within the Southampton Dermatology

Centre and also attended external courses, within a

few months Nicky was a fully fledged Dermatology

Nurse surgeon! The nurse led service was limited to

rashes and non-melanoma lesions, the procedures

performed were punch biopsies, curette and cautery,

incisional biopsies, shave biopsies and small ellipse

excisions, these were confined to trunk and

limbs only.

THIS ISSUE...Editorialpage 2

Journal digestpage 6

Melanoma- epidermiology,aetiology andpreventionpage 8

Suntan tabletsand injections

page 10

qualified as a State Enrolled Nurse

(SEN) in 1982, back in the days when

doctors were doctors, nurses were nurses

and surgeons - well they were just that!

Through a conversion course at Southampton

General Hospital I then qualified as Registered

General Nurse (RGN) in 1998.

My journey to Dermatology Nurse Surgeon has

taken many twists and turns, and eventually by some

happy accident this is my main job within the

DECEMBER 08

JANE JONES, Advanced Nurse Practioner

20096 - 7 February 2009PCDS Annual Irish MeetingCarton House Hotel, Maynooth,County KildareContact: debbielee@eircom.net

26 February 2009PCDS Dermoscopy MeetingManchesterContact: pcds@pcds.org.uk

27 March 2009PCDS Spring MeetingCardiff Marriot, CardiffContact: pcds@pcds.org.uk

25 - 26 April 2009PCDS Advanced Skin Surgery MeetingDurham Marriott Hotel, DurhamContact: pcds@pcds.org.uk

5 June 2009PCDS Basic Skin Surgery MeetingCrowne Plaza Hotel, LeedsContact: pcds@pcds.org.uk

6 - 7 June 2009PCDS Summer Meeting & AGMQueens Hotel, LeedsContact: pcds@pcds.org.uk

25 September 2009PCDS Autumn MeetingHilton Hotel, SouthamptonContact: pcds@pcds.org.uk

26 September 2009PCDS Basic Dermatology DayHilton Hotel, SouthamptonContact: pcds@pcds.org.uk

14 - 15 November 2009PCDS Scottish MeetingOld Course, St AndrewsContact: pcds@pcds.org.uk

Forthcoming Meetings

PCDS 12 Thorpe Road, Norwich NR11RY T01603 252525F01603 760070 pcds@pcds.org.uk www.pcds.org.uk

Company 5254647 VAT 875 1544 06

I

You needhands - cronichand eczema

page 12

Forthcomingmeetingspage 16

Continued on page 4

NURSE LEDMinor Surgery

measure lesion

marked out

EVERY PICTURE TELLS A STORY 2...The tick appeared to be dead butmay simply have been waitingbefore taking its blood meal. It wasremoved with a needle. On thisoccasion, the rule that everylesion must be submitted forhistology was disregarded, afterall we don’t want to abandonclinical judgment for tick boxmedicine!

3

allegedly overspent purchasers to reduce

secondary care referrals on purely financial or

contractual grounds. If GPs can be trained to do

things better and safer in the community so

that the need for secondary care referral is

reduced, then three loud cheers for that. That’s

why the PCDS promotes training in lesion

recognition and dermoscopy skills. That is

ethically as well as economically sound. But

given the ‘variable’ (a senior consultant I know

says ‘appalling’) level of GP lesion recognition

skills, the old adage ‘If in doubt-refer’ which

goes back to Hippocrates, must be defended as

safe and proper practice. By all means let’s

help reduce the doubts which contribute to

over-referral by education, but not by

economic pressure.

Who is fit to excise skin

cancers?

Once a skin cancer has been

competently diagnosed, who should

excise it? Answer-a properly

trained and audited

healthcare professional

working in a team who

can demonstrably do the job

properly. Why not nurses? In

Southampton University

Hospital Trust, we use

specialist nurses to do a lot of

this work, Hertfordshire (Julia

Schofield) and other trusts do the

same - initially out of necessity, but

now because it has been proven to work well.

This bulletin carries an item by my colleague

Sister Jane Jones on nurse provided skin cancer

surgery. I would value questions and comments

on this area and observations from what

happens down your way. I can understand why

GPs being told to stop excising BCCs might

fume at this, but ask yourself who you would

rather fit your (or your wife’s) IUCD - a doctor

who does 4 a year or a nurse who does 100 a

year as part of a team and is audited? Oh, and

costs half as much or less. Think about it.

Stephen Hayes

PS and what about GPs

practice nurses snipping off skin

tags etc? I am sorry to say that

some GPs are referring axillary

skin tags to my intermediate

dermatology service. I’m not

ashamed to do this menial

work, but why aren’t

they ashamed to ask

me? I am beginning to

hear of primary care

nurse surgeons and

would like to hear

of members’

experiences.

Please book early

and book often for

2009 PCDS events, see

you there.

EDITORIAL - STEPHEN HAYES The Society would like to

acknowledge support

from the following

members of the corporate

membership scheme.

How many dead?

Death is something

we can measure.

Death is not a matter

to be trivialised, but

we can possibly all

agree that, all other things being

equal, two deaths are twice as

bad as one, etc. If so, then in the

light of hard economic reality this

should inform, if not entirely

dictate, our healthcare resource

allocation. Or is resource

allocation decided by energetic

and well organised lobbying?

Today I read a letter from the chief

medical officer about carbon monoxide

poisoning, which kills fifty people a year in

the UK. I am sorry for every one of them. I

am getting my central heating renewed and

will remember to ask patients with

unexplained headaches and vomiting

about their household heating appliances,

but I do not remember receiving a letter

from Sir Liam about the eighteen hundred

and fifty people who died from malignant

melanoma in 2006.

Melanoma continues to be our fastest

rising killer cancer and while they argue

about sun bed restrictions and try to find a

successful immunotherapy (and success to

them on both counts) not enough is

being done towards early

detection in primary care.

I continue to

teach a half day dermoscopy course for

GPs twice yearly with my senior colleague

and mentor Dr Catriona Henderson. The

PCDS plans to put 200 of her dermoscopy

images on line in 2009. At the most recent

class, I asked my usual question about how

many GP attendees had know a patient in

their practice die from melanoma; five

hands out of twelve went up. No GP had

had a patient die from cervical carcinoma.

The same question asked of 15 Isle of

Wight GPs at a dermoscopy talk a week

earlier produced a similar ration of five to

one. I like to ask this grim question, despite

the risk of a charge of gender stereotyping,

as it shows colleagues realistically that

cervical cancer, which we rightly use such

resources preventing and detecting early,

kills many fewer people than melanoma. It

seems to me that the key to saving life from

melanoma is earlier detection, which is

something that happens, or should

happen, in primary care. What about

levelling up early detection resources

across these two pathologies, death for

death? I have seen a few patients with

widely metastatic melanoma recently, and

it bothers me to think that more could

have been reasonably done to prevent it.

Train hairdressers?

I have seen several non melanoma skin

cancers of the scalp over the last year,

which were originally brought to their

patient’s attention by their hairdressers.

This makes me wonder if

we should approach the hairdressers’

professional body, assuming they have

one, and offer to design a simple guide to

detecting lesions which customers ought

to see their GP about. I remember a

melanoma detected on a patient’s back by

a physiotherapist, another by a doctor

who saw a worrying mole on the leg of a

fellow worshipper at church! Should we

open our lesion recognition workshops to

other personal care workers, including

hairdressers?

If in doubt, refer-fullstop.

By contrast, I have seen several horribly

neglected basal and squamous cell cancers

which you would have thought the cat

could have diagnosed. I’m talking about

chronically bleeding, indurated three and

four centimetre lesions on the head, on

patients who were either suffering

personality disorders or were in residential

care homes. The mind boggles. Of course

sometimes it is the patient who fails to

present themselves. At a time when public

servants are being put under the spotlight

over failing to detect obvious signs of child

abuse, surely elderly people in residential

care should not be blandly reassured that

their chronically bleeding scalp ulcer will

eventually get better with dressings, even

though it’s been growing for two years?

Working a session a week in a 14 day

wait hospital skin cancer clinic, yes I see a

lot of haemangiomas, seborrhoiec warts,

dermatofibromas and even

blackheads (and the

occasional curiosity-see

inside) which ideally

would not have been

referred, but on the other

hand there are the patients

with significant cancers who

have been incorrectly reassured

or otherwise delayed their

presentation. We must resist

pressure from PCTs or other

EVERY PICTURE TELLSA STORY 1This middle aged femalewas referred as a 14 dayskin cancer wait after anew deeply pigmentedlesion appeared on herneck. Dermoscopy wasinformative, turn to backpage...

includes a diagram, dimensions and site, medication (such as

anticoagulants and anti-platelet drugs and pre-op antibiotics where

indicated); the forms allow the doctor to specify single double or

treble slots and whether the procedure is for nurse, SPR,

consultant, GPSI or a specific team member. Unless otherwise

indicated by the clinician the margins are usually standard, BCC

and SCC 4mm, high risk SCC 6mm, MM and In-Situ Melanoma

2mm at initial excision and 1cm or 0.5cm around the scar line for

wide local excisions respectively.

In the year January 2007- December 2007 I carried out

approximately 870 procedures.

My excision rates were

50 Melanomas

- 48 were completely excised with 2 incomplete excisions.

21 Squamous Cell Carcin

- all were complete excisions

104 Basal Cell Carcinoma

- 4 were incompletely excised.

These incomplete excisions rates are comparable to those

achieved by the dermatologist surgeons and GPwSIs.

My vision for my role is to train a team of nurse surgeons for the

Department, and perhaps even provide an external course to train

nurses from around the area, and then to provide continuing

support in order for them to develop their own services.

I love my role and am proud and excited that nursing has

moved forward to allow me to perform dermatology minor surgery,

and also the skills I have learned over the past five years have now

been recognised within the Trust. This will allow me to further

develop and enhance the patient experience.

Jane Jones,

Advanced Nurse Practitioner

54

I really wanted to become a nurse

surgeon, but my role was Sister of the

Dermatology Day Centre, but fate played a

hand! The first Gulf War. Nicky was called

up for the RAF reserves, and the Dermatology

Centre needed to continue with the role. I

did not need to be asked twice! I

completed the training booklet within

threemonths and then started one list per

week.

Over the last five years my surgery has

gradually taken off to be my main role

within the Dermatology Centre. I usually

have five surgical lists weekly; these now

include all areas of the body, including

face and neck, large excisions,

wide local excisions of

Melanoma and small flap

repairs. I am currently hoping

to expand the role to include

full thickness skin grafts.

Local anaesthetic is

prescribed via ‘Patient Group

Directive’ (PGD); we normally

use 1% Lignocaine with

1:200,000 Adrenalin, 1% or 2%

plain lignocaine for extremities,

pregnant women, some

medication and Citanest for

those patients with allergy to

lignocaine.

There are some exclusion to

nurses performing surgery

including patients under 16,

patients having MI or stroke

within 3 months, patients on two anti-

coagulants and Warfarin INR being over 3.

Patients with pacemakers will need cold

cautery rather than uni-polar electro

cautery. Of course there are patients with

very complex medical problems that will be

discussed with the clinician prior to being

put onto a nurse list.

My role I believe is quite unusual, there

are nurses around the country that

perform minor surgery, however on

contacting other dermatology centres

there are few if any that perform the range

and complexity of dermatology surgery.

During the past five years I have been

instrumental in expanding the nurse

surgeon role, but of course none of this

would be possible without the continued

support and encouragement of all the

medical, nursing and management teams.

This has led to my recent promotion to

Advanced Nurse Practitioner, a role that I

am very proud to own!

Part of my role has been to train

another nurse surgeon (unfortunately left

the department) and to support Corrie

Dommerson, Nurse practitioner, (also just

promoted!) to continue her role as nurse

surgeon with less complex cases. I have

trained and supported SHO’s to enable

them to carry out small biopsies for our

ward-based patients, and regularly have both

nursing and medical students to observe.

My role is cost effective for the

Department and Trust as obviously

my salary is lower than my

medical colleagues,

also I can be more available to perform ‘

one stop’ procedures as I have more

flexibility during my working week.

From a patient perspective many have

commented that they feel more relaxed

when they realise a nurse is going to carry

out their procedure.

I have seemed to have acquired a

regular client list, especially those with

multiple skin cancers or those undergoing

screening for melanoma, often patients

book their surgery with me and in fact one

of my patients refers to me as ‘The

Southampton Seamstress’!

The downside to the nurse surgeon

role is patients regularly come for their

booked surgery with extras! This means

generally having to retrieve a Consultant

from a busy clinic to confirm the diagnosis

and possible re-planning surgery, thus

possibly leading to both clinics becoming

delayed.

I attend the Dermatology Local multi

disciplinary skin cancer team (MDT)

fortnightly and the Specialist Skin Cancer

MDT annually, and keep records of all

surgery performed, excision margins

around lesions and histopathology, and

present audit in the same way as the

dermatologist surgeons and GPwSIs

attached to the department.

Decisions about surgery are made by

dermatology doctors who complete a

detailed surgical request form which

Jane cutting

into the jar

haemostasis achieved

deep sutures in

complete

Continued from front page

Journal Digest

76

o be the final arbiter of journal articles

suitable for inclusion in this bulletin

makes me feel a little like a judge on ‘Strictly

Come Dancing’ or ‘The X Factor’. Should this

article here be treated with Cowell like scorn

(however august it may be) or should I look

upon it with a kindly, Len Goodman

twinkle in my eye…

The first article guaranteed to be safe

from this week’s dance off comes from the

August edition of the BJD. It involves one

of the Society’s favourite subjects -

dermoscopy. Guiseppe Argenziano and his

team1 looked at different protocols for

dermoscopic monitoring of melanocytic skin

lesions. Sequential imaging is a useful strategy to reduce

unnecessary excisions whilst avoiding missing melanomas.

Compliance with such programmes will always be a

problem and it is suggested that the first revisit be at three

months to reinforce the need for such an approach. It is,

however, not something to be lightly undertaken - it

requires a dermoscope with a camera attached, image

editing software and an experienced operator.

More reassuring, for those of us who are keen

advocates of dermoscopy, is the study from Australia by

Vestergaard et al.2 This meta-analysis of data comparing

naked eye examination and dermoscopic examination. The

conclusion is unsurprising - that dermoscopy is more

accurate than naked eye examination for the diagnosis of

cutaneous melanoma when performed in a clinical setting.

The difference is quite significant and, in one of the studies

considered, specificity of excision was increased more than

four fold!

In the same issue, a second meta-analysis looked at a

comparison between biologic and non-biologic treatments

for moderate to severe psoriasis3. One conclusion was that

infliximab is the most effective agent currently available,

followed by adalimumab. However, more surprising was

the finding that the meta-analysis was limited by the lack

of comparative studies between biologic and non-biologic

therapies. In addition, few studies demonstrate long term

effectiveness of either methotrexate or fumaric acid esters.

The biologics place as final solutions seems to be under

threat from accumulated evidence.

October was a prime month for interesting articles - no

less than three pass my curiosity filter. The first is about

leptins and psoriasis4. Psoriasis is associated with both

obesity and cardiovascular disease but the reasons why

have been harder to elucidate. Leptin is a hormone

secreted (predominantly) from adipose tissue, it has also

been shown to induce proinflammatory cytokine

production -these cytokines are implicated in the

pathogenesis of psoriasis. It seems that leptin

may serve both as a marker for the severity of

psoriasis but alsomay contribute to chronicity in

the disease.

In a similar vein, the next article5

demonstrates that the risk factors for

cardiovascular disease and myocardial infarction,

along with other vascular diseases, occur more

frequently in patients with psoriasis - is this due

to psoriasis itself, or the treatments that we use?

More work is needed…

Finally (for October at least) there is a report6

looking at the long term effects of narrow band

ultra violet - B therapy (NB-UVB). These are, by

necessity, early reports as the use of NB-UVB is a

relatively recent innovation. However, compared

to PUVA treatment of the same duration, there is

no increase in melanomas or non-melanoma skin

cancers. This is reassuring for the treatment of

many skin diseases, but longer term data is

needed as many skin cancers grow/evolve very

slowly.

November brings us another couple review articles that

the BJD seems to do so well. For those who are interested

in arresting the march of time, there is a review article on

minimally invasive cosmetic procedures7. Here you will find

details of botulinum toxin therapy, intradermal fillers -

including bovine, human and porcine collagen, hyaluronic

acid, autologous fat, calcium hydroxyapatite,pol-L-lactic

acid and silicone. There are also a myriad of chemical

peels. I remain unconvinced (after all, gravity always wins8)

but at least we can be better prepared for the questions

that seem to come with increasing frequency. The second

article is a fine piece of work detailing the evidence base for

all current treatments for the diagnosis of vitiligo9. There is

also a detailed guide to diagnosis and a discussion of the

T natural history of this disease. I commend it to the society.

So there you are, a personal trawl through the BJD. The

last sequin has been sewn, and the last note has been sung.

All opinions are my own, any errors are probably mine as

well! But remember… keep reading!

Julian Peace

1 Argenziano, Mordente, Ferrara, Sgamboto, Annese and Zaludek -Dermoscopic monitoring of melanocytic skin lesions: clinicaloutcome and patient compliance vary according to follow-upprotocols. BJD 2008 159;331-336.2 Vestergaard, Macaskill, Holt and Menzies - Dermoscopycompared with naked eye examination for the diagnosis ofprimary melanoma: a meta-analysis of studies performed ina clinical setting. BJD 2008 159;669-676.3 Schmitt, Zhang, Wozel, Meurer and Kirch - Efficacy andtolerability of biologic and nonbiologic systemic treatments formoderate-to-severe psoriasis: meta-analysis of randomisedcontrolled trials. BJD 2008 159;513-526.4 Bozkurt, Sav, Tulunay, Elbasi and Ergun - Serum leptin levels, skin leptin andleptin receptor expression in patients with psoriasis. BJD 2008 159;820-8265 Kaye, Li and Jick - Incidence of risk factors for myocardial infarction and othervascular diseases in patients with psoriasis. BJD 2008 159;895-890.6 Hearn, Kerr, Rahim, Ferguson and Dawe - Incidence of skin cancers in 3867patients treated with narrow-band ultraviolet B phototherapy. BJD 2008 159;931-9357 Ogden and Griffiths - A review of minimally invasive cosmetic procedures. BJD2008 159;1036-10508 Yorke, Greenwood, Greenwood, O’Brien and Selway - Fake Plastic Trees.Radiohead 1995 - The Bends.9 Gawkrodger, Ormerod, Shaw, Mauri-Sole, Whitton, Watts, Anstey, Ingham andYoung - Guideline for the diagnosis and management of vitiligo. BJD 2008159;1051-1076.

Melanoma98

Rising incidence,

mortality plateau

The global incidence of melanoma

continues to rise, but the number of

deaths has been roughly stable for some

30 years. There were 1,859 UK deaths in

2006. The additional melanomas are

mostly thin lesions. It would be nice to

think our efforts have prevented a rise in

deaths due to picking lesions up earlier;

however, the review reminds us that some

thin and in situ melanomas seem to

develop very slowly and may not become

invasive if left. The assumption that there is

an inevitable linear progress from

superficial spreading to nodular invasive

lesions seems logical but has a scanty

evidence base, since we cannot watch thin

melanomas to see how they grow. It would

be nice to have this evidence, but I cannot

imagine volunteers for such a trial!

Evidence based medicine has limits, and as

with cervical cancer,

there is

no way to know what in situ malignancy

would do without intervention.

Risk factors for melanoma

What are the risk factors for melanoma?

Most of what we think we know is based

on population studies and statistics rather

than direct evidence. Actinic keratoses are

a risk marker for melanoma risk, with

patient who have AKs having a two to four

fold increased risk. The incidence of

melanoma in Queensland, Australia is four

times the UK incidence. There are good

reasons from population studies for

putting most of the blame on sunshine,

but Dr Bataille tells us that the relationship

between sunlight and melanoma is

complex. Sunburn in childhood is

considered significant, but the distribution

pattern between men and women (trunk in

men, legs in women) is not so

straightforwardly related to patterns of

dress as we thought, since this distribution

is found across the world in populations

where clothing and sun exposure are

different. Statistical analysis of studies

corrected for skin type suggest that host

response to sunlight is more significant

that dose alone. In other words, its

sunlight plus genetics, but not as

simple as that.

Sun beds

The contribution of sun beds is

discussed. We tend to assume that

they are ‘A Bad Thing’, but studies

are divided between those which

show no difference, and others which

show a small increased risk. I heard a

senior clinician recently assert that four

local patients had died from sun bed

induced melanoma. But how do you

separate the effects of natural and

artificial UV? Or causal from casual? Sun

bed users also sunbathe. It is considered,

as with natural UV, that damage done

under the age of 20 is of particular

significance. Surely it is rational to support

restrictions of sun bed usage in the under 18s.

Atypical naevus syndrome

A Meta analysis of studies showed that

patients with 100 or more naevi had an

increased risk of melanoma up to 20 fold.

The atypical mole syndrome is defined as

over 100 naevi with at least two odd

looking lesions over 5mm and moles in

unusual places e.g. buttocks, soles of feet,

breasts in females, ears. It is present in

some 2% of the UK population - these

individuals are at significantly higher risk

and should see a dermatologist, but its not

clear how often or for how long. In the

hospital department where I work, we get

high quality total skin photography of

these people, give them a copy of the prints

and get them to check their skin against

the pictures three monthly and report any

change. I am told by my mentor that there

is evidence of benefit from mole

mapping, and have seen a couple of

cases where it has paid off, but the

review does not mention mole

mapping.

The signs of worrying change in a

mole were discussed, I won’t bore

readers by repeating the ABCDE

basics, but was glad to see the old text

book signs of bleeding and itch debunked.

Itch in my book is a worthless sign, since

many harmless lesions itch (a traumatised

wart is the itchiest of the lot, followed by a

cosmetic naevus the patient wants excised!)

and most melanomas don't. Bleeding is a

late and deeply ominous sign we don’t

want to see.

Melanoma genetics

Genetic factors are singificant, with

number of moles largely determined by

genes as twin studies show.

Polymorphisms in the melanocortin one

receptor (MRC1) gene appear to

determine individual susceptibility, which

is why fair skinned red haired people with

thousands of freckles people have higher

risk. The most significant phenotypic

predictor is the number of moles, which

seems to be genetically determined. About

a quarter of melanoma families have

mutations in the tumour suppressor gene

CDKN2A/p16 on chromosome 9p21.

Genetic screening is not done routinely,

but we must take heed of family histories.

Of course, the biggest genetic factor is skin

type, dark skinned patients rarely get

melanoma, and if they do it is usually palm

or sole.

Pregnancy and hormones

Women tend to do better than men for

melanoma survival even when Breslow

thickness is taken into account, suggesting

that an X linked gene expression or

hormonal factor affects survival. On the

latter point, the anecdotal effect of

pregnancy on melanoma is mentioned. I

remember 'one of my old teachers' told me

of a patient whose melanoma had

fatally developed metastases

during pregnancy, but a Meta

analysis of 5000 women cited here

showed no effect attributed to

pregnancy, oral contraception or

HRT.

Primary prevention-no

hard evidence as yet

No study evidence from anywhere in the

world can show that melanoma incidence

has been reduced by advice on sunbathing

and sun beds etc. The vitamin D issue was

raised, suggesting that here might be

harms from excessive sun avoidance. I have

often wondered how many suicides are

prevented by sunlight; certainly my

mood is depressed by prolonged

grey skies and lifted by blue skies

and sunlight. I am typing this

on my new mini laptop on a

ferry on the east Solent, off to

maybe catch a melanoma or

two on the Isle of Wight. I

always pick a seat on the sunny

side of the boat and am looking

east with pleasure at the brightly

illuminated vapour trails which reflect the

coming sunrise. I will continue to advise

my patients that sun should be treated like

alcohol-enjoy in moderation if you wish,

but be wise and don’t get drunk or burned.

Secondary prevention

saves lives

The benefits of primary prevention are

elusive, but there are clear and present

benefits from secondary prevention, i.e.

early detection. For this to work, we are

reminded, education of both public and

health professionals is vital. As the authors

write, “Being able to recognise a

melanoma early is an important skill for

primary healthcare practitioners.”

Population screening is not cost free: as

well as the economic cost, there is patient

anxiety, increased excision of benign

lesions, and diversion of scarce resources

from other priorities to consider. The

incidence of melanoma is still relatively low

and population screening is of doubtful

cost effectiveness. There is consensus on

the need for patients with atypical mole

syndrome to be seen by dermatologists

and better public education and lesion

recognition skills in the community.

In conclusion

As the second part of this series shows (I

will comment on this for the next bulletin)

outcomes in metastatic melanoma

continue to be appalling. There is good

evidence that picking up lesions early

through better education of patients and

practitioners is saving lives, and could save

more. Primary prevention has not been

achieved on a measurable scale, although

it is rational to give advice on excessive UV

exposure. Such advice is likely to do more

good if targeted on higher risk people

(redheads, sun worshippers and atypical

mole syndrome) and of course mothers of

such people. Although melanomas are

treated by specialists, the lives are saved by

early detection. The greatest potential for

that to happen is in Primary Care, and

that’s our job.

Stephen Hayes works in a skin cancer

clinic in Southampton

Melanoma-epidemiology, aetiology, and prevention

A clinical review of the latest evidence on melanoma has been

published in a two part series on the BMJ-BMJ 2008;337:a2249. Part 1

deals with aetiology and prevention. The main author is Dr Veronique

Bataille of Hertfordshire, who has lectured on melanoma for the PCDS.

I have reviewed and commented on this for the PCDS.

Two melanomason face

query BCC and two melanomas -awaiting biopsy

melanoma on the back

10 11

Working together

We had some introductions to main areas

of concern from Chairman Dr Mark

Goodfield. He told us that the BAD usually

had an annual strategy day, but this year

had wanted to involve other 'stakeholders'

(I don’t think he actually used that word,

but in modern NHS speak I think that was

what was meant). He restated the primary

aims of the BAD which were to address the

needs of all patients with skin disease and

ensure a consultant led service, which

allowed for and included a number of

service models but was ‘unapologetically’

based on the primacy of a strong secondary

care dermatology establishment. Among the

BAD's aims were to set and maintain

standards of care and promote research

and education. In pursuit of these goals,

today's strategic working party was headlined

'partnerships in dermatology' and the views

of other protagonists had been sought.

95% of dermatology care

already in community

Dr Steve Jones from the Wirral, kicking

off, reminded us of the old model where

GPs managed most problems and referred

to hospital those patients they could not

‘sort’ This was being supplemented or

replaced by a range of models of varying

levels of acceptability, with issues like

choice, accreditation, cost effectiveness

and integration rather up in the air. My

friend Julian (Peace) and I smiled at each

other as Dr Jones acknowledged that 95%

of dermatology care took place in the

community and always had done (which

as he rightly said made the demands of

some PCTs to ‘move 80% of dermatology

into the community’ look rather silly).

Some intermediate schemes worked well

and could be supported, others fell short.

Good intermediate care service models

existed, but many schemes depended on

one ‘specific individual’ with succession

planning and training issues unresolved. A

very fair point, and one which applies to

my own service. Dr Jones stressed that the

BAD was willing to support and promote

high quality intermediate dermatology

services, but training, quality and clinical

governance matters must be seen to be

satisfactorily resolved in each case. The

PCDS would happily support this

reasonable stance.

Hearing the patients’

voice

Dr Chris Archer led a discussion on

education, intentionally raising more

questions than providing answers with

helpful contributions from the floor. We

heard from Andrew Langford of the Skin

Care Society (SCC) that patients should be

more involved in education and should be

invited to speak at dermatology

conferences much more often. Jennifer Viles

of the Vitiligo Society also recommended

that there should be more ‘hearing the

patient's voice’. Patients’ representatives

would like to have more of a say on

education committees. We will take this

back to the PCDS committee.

Accreditation-call for

firm and fair rules

The thorny and current issue of

accreditation of non-consultants in

dermatology was discussed, with the BAD

wanting to see mandatory nationwide

standards enforced. Both individuals and

services should be signed off as fit for

purpose with consistent application of

‘firm rules’. It was noted that patient

satisfaction surveys, although tending to

favour community services, were a ‘soft’

measure, with the possibility of high levels

of satisfaction from easy access and

parking in a smaller setting, regardless of

the medical outcome. Hospitals were

always marked down for various reasons

which did not reflect on the standard of

care. One sees the point of this, but on the

other hand we had just heard from patient

representatives who said they wanted more

of a say! It just goes to show how difficult

it is to wisely balance all the different rights

and wrongs of healthcare delivery together.

Which underlined what a good idea it was

to be all talking together in Fitzroy square

on this December day.

I made the point later that we GPSIs

were all for standard setting and

opportunities to learn, work in partner-

ship, demonstrate our competency and

willingness to integrate, keep up to speed,

do audit etc, but standards must be

realistic as well as firm and where

appropriate some local flexibility rather

than rigid regulation might avoid doing

more harm than good.

Communication

David Eedy from Craigavon talked

succinctly on communication, and how

easy it was to get this wrong, not least

through hastily composed and posted

emails (Julian and I shared a wry and

knowing smile over this!). He showed us

the front page of the BAD's soon-to-be-

relaunched web site. He drew attention to

the fact that ALL doctors currently felt got

at, pushed around, besieged and constantly

reorganised, which inevitably led to

anxiety, conflict and stress. This could lead

to unhelpful communications between

health care professionals. He felt we ought

to be in regular and sympathetic dialogue,

of which this working party was an example.

Bravo BAD for organising and hosting it.

£700 a session?

We also heard fromDr Ansley the treasurer

about the BAD’s finances, which appeared

to be in good shape. I had not realised

how generously our senior colleagues have

been supporting various dermatological

charities. The economic downturn,

changing relationship with the NHS and

academia, plus tightening of rules on

sponsorship seemed likely to constrain

future cash flow. During talks about

money it was mentioned from the floor

that the payment of GPSIs was not subject

to national agreement (true) and was

secretive, with GPSIs receiving from £250

up to £700 a session. Dr Peace and I pointed

out that this upper figure was unknown to

us and in no way reflected what we and

other GPSIs we knew of were earning. We

believe that a good GPSI deserves to be

rewarded at a similar rate to a good GP,

taking legitimate expenses into account.

Excessive rewards at this extreme upper

level are rotten value for health pounds

and cause justified unhappiness - not least

to GPSIs on realistic remuneration.*

Peer group discussion

After this power packed introductory

session led by BAD representatives, we

went into 'peer groups' (primary care,

nursing, patient reps, BAD regions and

hospital non consultants) and thrashed

out our main issues before presenting

them to the main group at a pre-lunch

plenary session. The BAD conference team

took these thoughts and sorted them into

four areas for discussion by the afternoon

groups, who talked for 45 minutes and

then fed back into a general discussion.

National dermatology

partnership

The groups discussed data, accreditation,

a national skin forum and education. I was

on the national skin forum group and we

had a really good talk with general

agreement that all parties (especially

patients) had a lot to gain from the setting

up of a body which could discuss issues

together and speak with a united voice on

skin problems. A body of this sort had

been set up in the form of the English

Council on Dermatology but due to

various difficulties this had folded. It was

felt by Dr Goodfield that lessons had been

learned and the group felt it was in

everyone's interest to go forward with

some kind of national skin forum. There

was wide agreement with this, hopefully we

will hear more in due course. The PCDS

would wish to be fully involved. Such a

body with a diverse membership would not

always reach agreement on every issue,

and a fair constitution would be required

to resolve matters and prevent any one

group pushing its agenda too far, but there

was no doubt that we could easily reach

agreement on many big issues, which

should benefit patients though improved

advocacy to the media, spending bodies

and Parliament.

Best bang for buck

- educate GPs better!

The group which discussed education fed

back that there was a need for better

education across the board, including

patient education, but that the best 'bang

for buck' would be from better educating

GPs since most dermatology consultations

took place in GP surgeries. Music to our

PCDS ears! The problem of Quality Outcome

Frameworks (QOFs) was raised. QOFs

take upmuch energy, and there is no derma-

tology QOF, so effort is diverted from

dermatology to other areas which ‘pay

better’. This is an issue the PCDS and SCC

have raised before without success. Perhaps

better advocacy through an inclusive

national skin partnership would help.

On GPSIs, there was talk about the

need to 'break down walls’, meet together

and publicise successful initiatives. The

concerns of non consultant career grade

doctors (the use of the term 'non career

grades' by one speaker was surely an

unintentional slip) were raised, with the

difficulties these often unsung doctors

faced with career progress brought to the

group. The deplorably low salaries of

clinical assistants were also mentioned.

Some doctors feel aggrieved at the

perceived high wages of GPSIs. This forum

was not the place to resolve these issues,

nor is this report, but let us acknowledge

the legitimate concerns of hard working

colleagues. We also heard from hospital

dermatology trainees about the uncertainties

they faced in a time of incessant and often

bungled reorganisation (sorry, change). I

wonder if Barak Obama would have won

the US presidential election on a platform

of ‘reorganisation’ rather than ‘change’.

Data collection-boring

but powerful

The data group reported back that data

collection was of course a dreary chore we

all loathed, but gave us powerful tools to

use as leverage for resources and training

etc. There were already too many forms:

simplification and incentives were needed.

Good quality data could be used for

recertification, appraisal, resource manage-

ment and political lobbying.

We finished and went our ways on

time. My experience of the day was of a

very welcome example of health care

professionals across the whole area of skin

disease together with skin patients’

representatives working together in a spirit

of friendly co-operation and mutual

respect, hopefully sorting out a few

misunderstandings and building bridges,

and, dare I say it, hope?

The PCDS will let you know as soon as

we hear any more about the proposed new

joint body for dermatology, whatever its

name might be. Please bear in mind that

will be one more responsibility for your

committee. New volunteers are always

welcome and the more of us there are, the

less each one has to do.

Stephen Hayes

PS thanks are due to the BAD for

hosting such an excellent day of co-

operative listening at Fitzroy square. Lunch

was pretty outstanding too.

*PPS if anyone knows of GPSIs being

paid £700 a session please let me know.

Depending on where it is, I will either

whistle blow that this about three times the

going rate, or offer to do it myself for £500!

PARTNERSHIPS IN DERMATOLOGY - BAD STRATEGY WORKSHOP, 6 DECEMBER

epresentatives of various skin care groups assembled as guests of the British Association of

Dermatologists (BAD) at their Fitzroy Square headquarters on a pleasantly sunny (am I allowed to say that

in a dermatological publication?) early winter’s day to discuss strategy. About 20 invited delegates represented

regional and key members of the BAD, pharmacist, nursing and patient representative groups, the PCDS, the All

Party Parliamentary Group on Skin (APPGS), dermatology trainees and non consultant dermatology doctors.

R

1312

No single causative factor for hand

eczema has been identified. Instead, it is

thought that the condition has a multi-

faceted aetiology, with genetic

predisposition, dysregulated immune

responses, atopy, and contact with skin

irritants and allergens identified as

causative factors.5

Severe, chronic hand eczema is

characterised by a thickening, scaling, and

drying of the skin, accompanied by signs of

inflammation. This can present a

significant physical and emotional burden

for the patient, as itching, painful fissures

and blisters become commonplace, and

manual dexterity is severely limited. Such a

highly visible disease is also associated

with a significant social stigma.5

“I was constantly embarrassed by my

eczema, because people were quite shocked when

they saw it. When I went into a shop I would

hand over a note to pay, and then try and

take the change with my thumb and forefinger

so I didn’t show the sales assistant my palm.

When the sales assistant did see my palm,

they would be very taken aback and shocked

by the scales and cuts. It looked like I had

been dragging barbed wire through my hands.

Even shaking hands was a struggle. Men

like to give each other a strong handshake

when they greet each other - I used to flinch

with the pain.”

Stephen, 46-year-old CHE sufferer

What effect does CHE

have on patients?

CHE patients suffer significant disability

with profound occupational, economic,

medical and social consequences because

they can not use their hands normally. It is

reported that one patient in five takes

prolonged sick leave6 resulting in high

socio-economic and individual patient

burden.

In a Danish survey,7 occupational hand

dermatitis led to prolonged (more than

five weeks per year) sick leave in nearly 20%

of the patients and nearly a quarter of

them reported they had lost their job at

least once during the past 12 months due

to their disease.

Another important factor is the social

stigma associated with this visible skin

disease. Hands are an important tool for

communication and expression and hand

eczema can result in major psychosocial

problems.8 Severe disease is also

associated with a significantly lower

quality of life.9 One observational study in

Sweden which evaluated over 1,200

patients with hand eczema found that 80%

experienced some kind of social or

emotional disturbance including sleep and

mood disturbances and handicap in

leisure activities and occupation.8

Current treatment options

The significant impact of CHE on the

individual’s well being and social

functioning calls for a concerted effort on

the part of the patient and their Health

Care Professional to bring their condition

under control.

Treatment should focus on the

adequate use of emollient preparations to

help moisturise and protect the skin barrier

and/or the use of topical steroids of an

appropriate potency to ameliorate the

overt signs and symptoms.

Steps should be taken where possible

to identify and eliminate any exogenous

causative factors such as skin irritants and

allergens, which the individual’s history

suggests may aggravate their condition. An

accurate profile of reactions to potential

irritants can be established through patch

testing with likely allergens.

Where such interventions prove

ineffective in managing the condition

adequately and the patient’s CHE has

proved severe and unresponsive to

treatment with potent corticosteroids,

referral should be considered to a

dermatologist.

In such patients treatment options

become more limited.5 The effects of

phototherapy and immunosuppressants

(e.g. methotrexate, ciclosporin, and

mycophenolate mofetil) may show variable

benefits, and toxicity issues may preclude

long-term use (particularly ciclosporin).5

“I have tried all sorts of treatments, but

nothing really works and my hands are never

clear. Sometimes they will get a bit better for

four or five days, just dry and rough without

any cracks, but this never lasts longer than a

week, and then they just crack again.

Currently, I use a steroid cream and

moisturisers plus a tape to put over the

cracks.”

Doreen, 67-year-old CHE sufferer

An introduction to

alitretinoin

Earlier this year, alitretinoin

(Toctino®▼), a naturally occurring, oral,

vitamin-A derivative, was granted a licence

in the UK for treating adults with severe

chronic hand eczema (CHE) that is

unresponsive to treatment with potent

topical corticosteroids.

Licence approval was based on results

from a clinical development programme

which included the Benefit of Alitretinoin

in Chronic Hand Eczema (BACH) trial.

This was a 24-week, double-blind,

placebo-controlled, Phase III study

involving 1,032 patients with severe,

chronic CHE including subjects who were

unresponsive to potent, topical

corticosteroids.10, Patients were

randomised to receive a once-daily, oral

dose of 30mg alitretinoin; a once-daily,

oral dose of 10mg alitretinoin; or placebo

for 12 or 24 weeks. The study’s primary

endpoint was the proportion of patients

whose hands were rated as clear or almost

clear by the Physician’s Global Assessment.10

‘You need hands’…so wha t happens when y o u c a n ’ t u s e t h e m ?C H R O N I C H A N D E C Z E M A A N D I T S S U B S T A N T I A L N E G A T I V E P A T I E N T I M P A C T

Chronic hand eczema - a common and debilitating condition Hand eczema is a very

common dermatological condition that can have a significant social impact on the affected individual.1 It is

estimated to affect approximately 10% of the general population and up to 30% of high-risk occupational

groups such as nurses and hairdressers.2,3 Hand eczema normally presents as a chronic, relapsing condition

with periods of acute ‘flare-up’. Approximately 7% of patients with hand eczema suffer a severe, chronic form

of the disease, and for these patients, treatment response rates are low and prognosis is poor.4

Continued on page 14Erythema

Hyperkaratosis

Fissures

Vesicles

14

When compared to placebo, both

doses of alitretinoin evoked statistically

superior efficacy. Forty-eight per cent of

patients in the alitretinoin 30mg group

and 28% of patients in the alitretinoin

10mg group achieved clear or almost clear

hands, compared with only 17% of the

placebo group (P<0.001 and p=0.004

respectively).10

During a six-month, post-treatment

observational period, up to 65% of the

total alitretinoin responders did not

relapse to a severity which required re-

treatment. Of those who did relapse, up to

80 per cent achieved clear or almost clear

hands following a second course of

alitretinoin treatment.10

In the BACH trial, the most frequently

reported adverse events were headache,

flushing, and increased blood lipid levels.

These events were both dose-dependent

and reversible.5,10

Alitretinoin belongs to the retinoid

class of drugs and should only be

prescribed by dermatologists or physicians

with experience of using systemic retinoids

who understand the risks including the

serious risk of teratogenicity if used during

pregnancy and the appropriate monitoring

requirements (e.g. triglyceride and

cholesterol levels).

In view of the teratogenic risks Basilea

Pharmaceuticals, the manufacturers of

alitretinoin, has developed a Pregnancy

Prevention Programme (PPP). It is

important to note that alitretinoin is

strictly contraindicated in women of

childbearing potential unless all the

requirements of the PPP as outlined in the

SPC are fulfilled. The materials associated

with the PPP and a copy of the SPC can be

found at: http://www.toctino.co.uk

Key Points

• Chronic hand eczema is an extremely

distressing and socially debilitating

disease, and effective treatment options

are limited.

• The emergence of the new vitamin A

derivative, alitretinoin, provides skin

specialists with a valid option for treating

patients with severe CHE that is

unresponsive to treatment with potent

topical corticosteroids

Dr Jonathan ML White

Consultant Dermatologist, Department of

Cutaneous Allergy, St John’s Institute of

Dermatology, St Thomas’ Hospital, London

Dr White is a member of Basilea’s

medical advisory board panel in respect of

Toctino and has spoken at a Basilea-

sponsored meeting. Basilea Pharma-

ceuticals are sponsors of the PCDS

References1 Diepgen TL, Agner T, Aberer W et al. Management ofchronic hand eczema. Contact Dermatitis 2007; 57(4):203-210.2 Smit HA, Burdorf A, Coenraads PJ. Prevalence of handdermatitis in different occupations. Int J Epidemiol 1993;22(2):288-293.3 Meding B, Jarvholm B. Hand eczema in Swedish adults -changes in prevalence between 1983 and 1996. J InvestDermatol 2002; 118(4):719-723.4 Diepgen T. Emerging treatment strategies for severe,chronic hand eczema. European Dermatology Review 2007;Extract:1-2.5 Ruzicka T. Meeting an unmet need in chronic hand eczema- the role of alitretinoin. European Dermatology 2008; 3:17-18.6 Meding B. Epidemiology of hand eczema in an industrialcity. Acta Dermato-Venereologica 1990; Suppl 153, 1-437 Cvetkowski R, Rothman K, Olsen J, Mathiesen B, Iversen L,Johansen J and Agner T. Realtion between diagnosis onseverity, sick leaveand loss of job among patients withoccupational hand eczema. Brit J Dermatology 2005; 152:93-988 Meding B, Swanbeck G. Occupational hand eczema in anindustrial city. Contact Dermatitis 1990, 22:12-239 Cvetkowski R, Zachariae R, Jensen H, Olsen J, Johansen J,Agner T. Quality of life and depression in a poluation ofoccupational hand eczema patients. Contact Dermatitis 2006;54:106-11110 Ruzicka T, Lynde CW, Jemec GB et al. Efficacy and safetyof oral alitretinoin (9-cis retinoic acid) in patients with severechronic hand eczema refractory to topical corticosteroids:results of a randomized, double-blind, placebo-controlled,multicentre trial. Br J Dermatol 2008; 158(4):808-817.

ELIDEL®:Tough on eczema,

not on skin

In mild to moderate eczema where topical steroids can be a problem,1

ELIDEL® delivers rapid relief from itch.2 ELIDEL®’s low potential to cause skin atrophy3 means it can be used on sensitive face and neck areas in both adults and children over two years old.1

UK Abbreviated Prescribing Information. Elidel® 1% cream (pimecrolimus). Please refer to the ELIDEL®

Summary of Product Characteristics for full prescribing information. Presentation: Whitish, homogenouscream containing 1% w/w pimecrolimus. Indications: Mild or moderate atopic dermatitis (eczema) inpatients aged 2 years and over where treatment with topical corticosteroids is either inadvisable or notpossible: short-term treatment of signs and symptoms of atopic dermatitis and long-term intermittenttreatment for prevention of progression to flares. Dosage and administration: ELIDEL cream should beinitiated by physicians experienced in the treatment of atopic dermatitis. Discontinue if no improvement after6 weeks or disease exacerbation. Adults and children aged 2 years and over: apply a thin layer of cream tothe affected skin twice daily. Rub in gently and completely. Continue until signs and symptoms have resolved,then discontinue. ELIDEL cream may be used on all skinareas, excluding mucous membranes. For long-termintermittent treatment, apply at first signs and symptoms to prevent progression to flares. Continue until signsand symptoms have resolved, then discontinue. Treatment should be intermittent, short-term and notcontinuous. Emollients can be applied immediately after using ELIDEL cream. Elderly patients: Clinicalstudies did not include sufficient numbers of patients aged 65 years and over to determine whether theyrespond differently from younger patients. Contraindications: Hypersensitivity to pimecrolimus, othermacrolactams or excipients of ELIDEL cream. Precautions: May cause mild and transient application sitereactions e.g. warmth and/or burning sensation. Avoid contact with eyes and mucous membranes. Ifaccidentally applied to these areas, cream should be thoroughly wiped and/or rinsed off with water. Containscetyl alcohol, stearyl alcohol and propylene glycol, which may cause skin reactions/irritation. ELIDEL shouldnot be used in patients with congenital or acquired immunodeficiencies or in patients on therapy that causesimmunosuppression. Do not use concomitantly with topical corticosteroids or other anti-inflammatoryproducts. Cases of malignancy, including cutaneous and other types of lymphoma, and skin cancers havebeen reported. However, patients with atopic dermatitis treated with ELIDEL have not been found to havesignificant systemic pimecrolimus levels. Long-term effect on the local skin immune response and on theincidence of skin malignancies is unknown. ELIDEL should not be applied to potentially malignant or pre-malignant skin lesions, or to areas affected by acute cutaneous viral infections (herpes simplex, chicken pox).Clear infections at treatment sites before application. Increased risk of herpes simplex virus skin infection andeczema herpeticum. If herpes simplex virus skin infection develops, discontinued ELIDEL until the infectionhas cleared. Increased risk of skin bacterial infections (impetigo) in patients with severe atopic dermatitis. Not

recommended in patients with erythroderma or Netherton’s syndrome. Do not apply under occlusivedressings. Not recommended during pregnancy or breast feeding. In patients with extensive disease,administer vaccinations during treatment-free intervals. Avoid excessive exposure of skin to ultraviolet light.Avoid therapy with PUVA, UVA or UVB during treatment. Undesirable effects: Application site reactionsreported by 19% of ELIDEL patients and 16% of patients in the control groups. These reactions generallyoccurred early in treatment, were mild/moderate and of short duration. Very common ( 1/10): application siteburning. Common ( 1/100, <1/10): application site reactions (irritation, pruritus, erythema), skin infections(folliculitis). Uncommon ( 1/1,000, <1/100): furuncle, impetigo, herpes simplex, herpes zoster, herpessimplex dermatitis (eczema herpeticum), molluscum contagiosum, skin papilloma, application site disorderssuch as rash, pain, paraesthesia, desquamation, dryness, oedema, and condition aggravated. Quantitiesand basic NHS price (excl. VAT): 30g tube, £19.69; 60g tube, £37.41; 100g tube, £59.07. Marketingauthorisation number: PL 0010/0659. ® denotes registered trademark. Legal category: POM. Fullprescribing information is available on request from: Novartis Pharmaceuticals UK Ltd., Frimley BusinessPark, Frimley, Camberley, Surrey GU16 7SR. Telephone (01276) 698370. Fax (01276) 698449. Date ofpreparation: 10th September 2007.

References:1. ELIDEL® SmPC. Novartis Pharmaceuticals UK Limited. 2. Meurer M, Fartasch M, Albrecht G, et al. Dermatol 2004;208:365-372. 3. Queille-Roussel C, Paul C, Duteil L, et al. Br J Dermatol 2001;144:507-513.

Date of preparation: November 2008.ELI08000007

Information about adverse event reporting can be found atwww.yellowcard.gov.uk. To report an adverse event in a patient

taking a Novartis drug please call (01276) 698370.

Before Toctino

After Toctino

Continued from page 13