You may have noticed that the last bulletin mentioned our new Trustees but failed to

explain why we needed more. The reason is that Dr Julia Schofield resigned from the

Trustees Committee because of pressure of work and her difficulty with attending

meetings. Those who know her will understand that she always gives 100% to all

her activities and she did not want to act in name only. One only has to note the

number and importance of the documents on which her name appears as lead author

(especially the Healthcare Needs Assessment for Skin Disease 2010) to be aware of

her commitment to everything she takes on.

We thank her for her support of the Society which is unwavering and we look

forward to seeing her in the not too distant future continuing to provide us with

education both dermatological and political.

Stephen Hayes has been very active in Committees recently, not least with the

Melanoma Task Force, producing information for hairdressers, beauticians and

therapists of all kinds about skin cancer, which was launched at a reception at

Portcullis House, an annex of the Houses of Parliament. The idea is to encourage

those who see patient’s skin to encourage clients to see their GPs regarding skin

lesions. I had the job of representing the Society because like most of the Executive

Committee Stephen H has to actually treat patients and could not get the time off!

Sian James is the MP involved, who steered through the change in the law re

banning the use of sunbeds for under 18s, for which she deserves much credit.

Primary Care Dermatology Society Autumn 2011

Bulletinpcds.org.uk

Chairman’s Report

The PCDS Trustee Committee

Mr Peter Lapsley Dr Tom PoynerDr Stephen Hayes Dr Jane RakowskiGladys Edwards Dr Andy Jordan

Adverse events should be reported. Reportingforms and information can be found atwww.yellowcard.gov.uk. Adverse eventsshould also be reported to Dermal.

Reference:1. Gallagher J. et al Routine infection control using a proprietaryrange of combined antiseptic emollients and soap substitutes –their effectiveness against MRSA and FRSA. Presented as aposter at the 18th Congress of the EADV in October 2009,Berlin.

Dermol® WashBenzalkonium chloride 0.1% w/w,chlorhexidine dihydrochloride 0.1% w/w,liquid paraffin 2.5% w/w, isopropyl myristate 2.5% w/w.Uses: Antimicrobial emollient for use as a soap substitute in dry and pruritic skin conditions, especially eczema anddermatitis. Directions: Adults, children and the elderly: Useinstead of ordinary soap or shower gel to wash with at the

sink, in the bath or shower. Pat the skin dry using a soft towel,avoid rubbing as this can irritate the skin. It can be used forfrequent hand washing and applied after washing as required.Contra-indications, warnings, side-effects etc: Please referto SPC for full details before prescribing. Do not use if sensitive to any of the ingredients. In the unlikely event of a reaction stop treatment. Keep away from the eyes. Package quantity,NHS price and MA number: 200ml pump dispenser £3.55,PL00173/0407. Legal category: P MA holder: DermalLaboratories, Tatmore Place, Gosmore, Hitchin, Herts, SG4 7QR.Date of preparation: June 2011. ‘Dermol’ is a registeredtrademark.

NEW

…and soothe itchy eczema

Introducing new Dermol Wash

When your patients with dry itchy eczema need an antimicrobial emollient wash

• Established and well proven formulation

• Two antiseptics provide significant antimicrobialactivity against MRSA and FRSA (methicillin andfusidic acid-resistant Staphylococcus aureus)1

• Two emollients which soothe and rehydrate dryskin, helping to restore the correct skin barrier

• 200ml pump dispenser, ideal for use at the sink Dermol Wash®

Knock out Staph…

As long as we have your email you will have received a new document, the Quality

Standards for Dermatology. This was instigated because of concerns and hopes that

the new commissioning organisations will need guidance and standards against

which their services can be measured. The group that formulated these

recommendations involved a wide range of involved organisations as you will see

from the document. Individuals took on responsibility for each section with support

and then each section was modified according to consensus view (Helen Frow our

Bulletin editor was responsible for standard one.) It was facilitated by the Department

of Health but not directly sponsored by them. We hope it will prove helpful and not

restrictive in establishing new and assessing existing services. If you have not

received this document let Carol have your email and we will send it to you, –

pcds@pcds.org.uk

A recent brief survey was emailed out to you all asking for your opinions regarding

the meeting timings and venues. The 230 results have indicated no real preference

either way for weekend meetings (53% for Fri/Sat vs 47% Sat/Sun) and a slight

preference for the summer meeting to rotate around the country rather than a fixed

area around the English midlands, (60 vs 40%). Friday was the preferred day for

one-day meetings (53 vs 22%).

We do, however, not know whether respondents were regular attendees since we

omitted to ask the question! Using up study leave or holiday is unpopular with some

and speakers are finding it increasingly difficult to get time off with local targets

putting pressure on Consultants to avoid absences from their clinics. Another

pressure is to avoid family weekend time. We will continue to experiment and offer

the widest choice to try to please most, if not everyone.

We may well use the brief survey monkey questionnaire (only 5 or 6 questions) to

find out your views on different matters and we would be grateful if you would take

part so that the PCDS view is not just the Committee view.

We are getting a few more contacts from members but would like to get more, so

please let us know your views.

Stephen Kownacki

Executive Chair

Sian James MP, and a beardless chairman

Editorial Autumn 2011

Skin Problems in PrimaryCare – More ResearchRequired

I hope everyone has had a great summer. I can’t quite

believe that it’s almost over again. In the last edition I

mentioned that I was going to Glastonbury to help in the

health protection tent, and of course also to enjoy the

festival. Having never been to Glastonbury, my eyes were

out on stalks for most of the weekend. That is, once I got

over the fact that after five minutes you couldn’t see the

colour of my cool new pair of Hunter wellies. Staying upright

was very difficult for the first 48 hours due to miles of

knee-deep mud. I was thus very grateful to my Pilates teacher,

for improving my core stability. There were people trying to run

through the mud, which proved to be a very high-risk strategy!

The sun spectacularly came out late on Saturday and we were

then busy supplying sunscreen and giving out sun protection

advice. We also provided a service to screen for skin

malignancies. The mood was relaxed and people were grateful

4 5

for help and advice. I’ve never had someone be so delighted to

be told that they had an accessory nipple!

On a more serious note about skin cancer services, the BAD are

organising a meeting on commissioning community skin cancer

services on September 29th at The Royal Collage of Physicians.

Stephen Hayes will be presenting. The timescale between

receiving your Bulletin and this will be tight but he is keen to

collect ANYTHING on good skin cancer community work,

anything at all. Please get it to him via pcds@pcds.org.uk as

this is our chance to accentuate the positive. I’m sure that he

will be pleased to collect this information to present at future

meetings also, if we are late to go to print. It’s good to know

what everyone is achieving out in the community.

Hopefully now you will have all received the Quality Standards

for Dermatology that Stephen Kownacki mentioned in his

report. It will be an important document to help those involved

in commissioning Dermatology services.

The mismatch between

the importance of

dermatology in clinical

practice and the

amount of primary

care-based research

devoted to skin problems needs to be

addressed through a partnership

between academics, practitioners and

patients.

Skin problems are a common reason for

people to see their general practitioner

and the majority of patients are managed

exclusively in primary care. However, the

amount of research actually done in

primary care to support the decisions

that doctors make regarding the

treatment of even common conditions

like eczema and acne is poor1. Primary

care research in general has gone from

strength to strength but as a recent

report by the National Schools

highlighted,2 while mental health and

musculoskeletal problems have

historically received a lot of attention,

dermatological conditions have remained

a “Cinderella” topic. There is a need to

address the mismatch between clinical

and academic activity and this is your call

to help make the change.

A “Primary Care Dermatology Research

Specialist Interest Group” has recently

been established under the auspices of

the Society for Academic Primary Care,

with the aim of promoting more research

into the diagnosis and management of

the skin problems commonly seen in

primary care. As well as identifying

people already working in primary care

research who are interested in moving

into this area, we also want to enlist the

help of doctors and nurses with an

interest in dermatology who would like to

support more primary care-based studies.

Good research demands a partnership

between academics, practitioners and

patients. Academics, like me, who work

in universities across the UK have the

expertise and resource to develop ideas

and obtain funding, but the delivery of

studies will only be possible with the

support of interested practitioners, such

as members of the PCDS.

To contribute ideas for research,

comment on proposals and support the

recruitment of patients into primary

care-based research studies, please

contact me at m.ridd@bristol.ac.uk. Join

the list of clinicians who want to improve

the evidence base for our patients with

the skin problems commonly seen and

treated in primary care.

References1. Ridd M, Thomas K, Wallace P, Sullivan F. Primarycare dermatology research: why, what and how?British Journal of General Practice 2011; 61:89-90

2. Sullivan F, Wallace P. UK primary care researchportfolio review. 2010. Dundee, Scottish School ofPrimary Care Research

Almirall have launched a new

product for the treatment of

actinic keratosis called Actikerall,

(5 mg/g fluorouracil and 100 mg/g

salicylic acid) it is a cutaneous

solution for the treatment of

palpable and/or moderately thick

hyperkeratotic actinic keratosis

(grade I/II) in adult patients. It will

be interesting to see how this

compares with its other

competitors.

I’ve also been made aware that

Dermal have launched a new

product, DERMOL WASH – an

antimicrobial emollient wash for

patients with dry, itchy skin

conditions such as eczema and

pruritus.

There’s a lot of work going on

behind the scenes, regarding

upgrading our website at the

moment, which Tim Cunliffe will

detail later.

Finally if anyone has any ideas for

the Bulletin, please let me know.

Helen Frow

Dr Matthew RiddGP and NIHR Clinical Lecturer, Academic Unit of Primary Health Care, School ofSocial and Community Medicine, University of Bristol

6 7

Teledermatology in the UK

Teledermatology is the delivery of dermatological services using

telecommunication technologies. It is a continually evolving

sub-speciality of dermatology, and an area of rapid growth as

communication technologies become increasingly

sophisticated. Primary Care Trusts and commissioners in the

UK are showing increasing interest in teledermatology services

as a potential way of improving dermatological care closer to

home, managing waiting lists, and achieving tariff savings

compared to standard face-to-face consultation in secondary

care. This article provides an update of the current state of

teledermatology in the UK, including an overview of NHS-based

systems and private providers of teledermatology systems.

Teledermatology using existing NHS systems

Choose and Book

Choose and Book (C&B) (http://www.chooseandbook.nhs.uk) is

the UK national electronic patient referral service that allows

secondary care providers to review referrals via a secure virtual

private network (VPN) connection. The C&B ‘Advice and

Guidance’ facility offers GPs the opportunity to discuss patients

with hospital consultants without referral to outpatients, with the

option to attach digital patient images to the advice request.

Clinical photographs can be taken in the GP practice using a

home or practice digital camera (> 6 mega pixel, with flash and

‘close up’ function), then uploaded to choose and book when

convenient, before deleting. A maximum of 5MB of attachments

can be uploaded, each attachment with a maximum file size of

1MB. A photograph of a locally agreed consent form should be

included as one of the attachments. The Consultant

Dermatologist can provide rapid feedback and management

advice, and add attachments such as proposed treatment plans

or links to external documents and websites.

The teledermatology functionality of C&B has always been

available, but has not been widely promoted within local health

communities or utilised to its maximum potential until recently.

As this system uses existing NHS technology there are no

set-up costs relating to software installation or maintenance.

C&B referrals are secure and encrypted, and the system stores

a permanent record of the teledermatology consultation, which

can be easily accessed by secondary care providers if the

patient is subsequently seen in outpatients, or for audit

purposes. To set up a successful C&B teledermatology service,

GPs and local dermatologists need to work closely together to

agree on a turnaround time for referrals according to local job

plan arrangements, and a tariff for non-face-to-face referral.

Teledermatology using C&B is being successfully used in

Exeter, with increasing interest around the country. Further

information on consent and photography can be viewed on the

Exeter dermatology website: www.rdehospital.nhs.uk/patients/

services/dermatology/info_GP.html

E-mail

A number of UK dermatology departments are providing local

teledermatology services using NHSnet/N3 for security and

encryption, either on an informal basis, or via a dedicated

hospital e-mail address with a negotiated local tariff per referral

(eg Cardiff and Oxford). E-mail based teledermatology avoids

the need to purchase expensive teledermatology software, but

archiving and storing referrals is more difficult. The Cardiff

dermatology department has been operating an e-mail-based

teledermatology advice service since 2006, with technical

support from the Trusts Media Resource department who

archive all images and provide photography training to

participating local GPs. The Oxford dermatology department

provide a similar service, organising quarterly reviews of cases

with referring GPs to provide educational feedback and

photography training. Information on other UK NHS

teledermatology centres is available on the British

Teledermatology Society website (www.teledermatology.co.uk).

Private Providers of Teledermatology Systems

Vantage diagnostics™

Vantage diagnostics Ltd™ is a UK-based company that is

marketing teledermatology and teledermoscopy services direct

to PCTs and NHS commissioners. The company provides a

web-based system that can be integrated with existing NHS IT

systems, along with imaging equipment (digital SLR cameras –

Canon G10) and training for clinicians and nurses. Vantage have

carried out pilot projects in Hampshire using geographically

remote UK dermatologists, and are currently piloting in Bristol

and Hillingdon with local dermatology teams. Practice set-up

costs are around £1000, with a tariff per referral of between

£25 and £45.

Scansol Ltd.

Scansol Ltd is a UK-based company that operates the MOLE

Clinic™, an independent skin cancer screening and diagnostic

centre in London. The company provides a direct

mole-screening service to the general public from its London

clinic and via selected Boots and Superdrug pharmacies

nationwide, including MOLECheck™, a nurse-led screening

service, and TELEDerm®, a specialist-led diagnostic service. The

company is currently marketing the TELEDerm® diagnostic

Dr Carolyn Charman BM.BCH, FRCP, MDConsultant Dermatologist, Royal Devon and Exeter HospitalBritish Teledermatology Society Secretary & Treasurer

carolyn.charman@rdeft.nhs.uk

Have you ever wanted rapid advice from a Consultant Dermatologist without your patient having to wait for an

out-patient review?

Do you run a dermatology GPSI clinic that would benefit from a streamlined photographic advice link to both primary

care and your local dermatology department?

Do you see patients who you feel don’t need a face-to-face dermatology opinion but in whom you would like

dermatological reassurance that treatment isn’t required?

Do you find local dermatology referral pathways complicated, and would your patients benefit from triage to the

appropriate clinic by a Consultant Dermatologist?

Have you ever e-mailed patient images to your local dermatologist for informal advice?

If so teledermatology could have a role in your practice?

Teledermatology can be used to triage patients with basal cell carcinoma onto appropriate skin surgery lists, if appropriate pre-operative information is provided

8 9

service to NHS GPs and commissioners, with referral of digital

dermoscopic images of suspect moles to a panel of European

Dermatologists with qualifications in dermoscopy, who are

registered with GMC & MDU for UK work. The company have

carried out pilot work with Hastings and Rotherham PCT, and

have a tariff per referral of around £35-£45.

Eceptionist™

Eceptionist™ is a US-based company providing a range of

telehealth and referral management software, which is

currently being used by dermatology departments in Medway,

Kent, and in Bangor, North Wales to provide local

teledermatology advice and triage.

KSYOS

KSYOS is a successful Telemedical Centre based in the

Netherlands, which has been carrying out pilot work with local

dermatologists in Medway, Kent since Feb 2010, with recent

expansion across West Kent, using a tariff per referral of £50.

Can teledermatology be used for skin cancerdiagnosis?

Exclusion of Skin Cancer

The use of teledermatology and teledermoscopy for the

exclusion of skin cancer, particularly melanoma remains

controversial, and is not currently recommended by the British

Association of Dermatologists until further long term UK

patient outcome studies are available.1 Although

teledermatology has the ability to triage out clearly benign

lesions, it can never provide the same quality of dermatological

care as a face-to-face consultation in which the whole body

can be carefully examined by a trained dermatologist, with

dermoscopic comparison and evaluation of the patient’s

individual pattern of mole pigmentation. Published safety data

worldwide shows conflicting data on accuracy of diagnosis,

reflecting variations in photographic technique and

telecommunication systems as well as reporting. A US study

of 542 patients with pigmented lesions showed that 7 out of

36 potentially fatal melanomas would have been mismanaged

by teledermatology,2 although studies from Spain and New

Zealand have been more supportive of a role in pigmented

lesion diagnosis.3,4 Studies supporting the use of

teledermatology/teledermoscopy for skin cancer diagnosis

have usually used melanographers experienced in digital and

dermoscopic imaging, requiring training, cost and time, which

may not be practical for busy GPs.4

Skin Cancer Triage

Teldermatology can be used effectively to direct patients with

suspected skin cancer to the most appropriate dermatological

service at the first appointment by upgrading or downgrading

referrals, or booking patients directly onto skin surgery lists,

avoiding unnecessary clinic appointments. In the UK skin

cancer triage is being successfully used by dermatology units

in Scotland and Kent.5 In Exeter the dermatology department

has found that considerable resource, time and travel savings

can be made by using teledermatology to triage patients with

basal cell carcinoma directly onto appropriate skin surgery

lists.6 Teledermatology can be used more confidently for basal

cell carcinoma management than pigmented lesions,7 and with

basal cell carcinomas accounting for the bulk of dermatology

skin cancer referrals, this is an important area for future

expansion of UK C&B teledermatology.

Does teledermatology reduce hospital referral?

Data from published studies,4,8 experience from UK NHS

teledermatology centres including Cardiff, Oxford and Exeter,

and recent audits by private teledermatology providers have all

shown that around 50-75% of patients referred via

teledermatology can be managed without face-to-face

consultation in the short term, although long term data on the

number of patients subsequently requiring outpatient referral

within 6-12 months of the teledermatology consultation is

lacking.

Future challenges

Although an increasing number of profit-making private

teledermatology providers are advertising directly to NHS

commissioners as a quick fix to dermatology service provision,

there is huge scope for the expansion of teledermatology in

the UK using existing NHS technologies such as Choose and

Book. Teledermatology services will always be most effective

when closely integrated with existing local dermatology

services, to allow smooth triage and accurate long term audit

of patient pathways and service costs. The development of

successful and cost effective NHS teledermatology requires

collaboration between local primary care teams,

dermatologists, medical photography, and secondary care IT

services, with more research focussing on clinical outcomes

and patient/GP satisfaction to prove that teledermatology can

offer a cost-saving and safe service.8, 9

References1. The Role of Teledermatology inthe Delivery of DermatologicalServices. BAD PositionStatement, April 2010. www.bad.org.uk (ClinicalServices; Service ProvisionGuidelines)

2. Warshaw EM et al. Accuracy ofteledermatology for pigmentedneoplasms. J Am Acad Dermatol2009;61:753-65.+

3. Halpern SM. Doesteledermoscopy validateteledermatology for triage of skinlesions? Br J Dermatol2010;162:709-10.

4. Tan E, Yung A, Jameson M et al.Successful triage of patientsreferred to a skin lesion clinic usingteledermoscopy (IMAGE IT trial). Br J Dermatol 2010; 162:803-811.

5. May C, Giles L, Gupta G.Prospective observationalcomparative study assessing therole of store and forwardteledermatology triage in skincancer. Clinical and ExperimentalDermatol 2008;33:736-739.

6. Charman CR et al. Simpleexcision of basal cell carcinomas;patients prefer to be booked in forsurgery via teledermatology referralrather than via the out-patient clinic.British Journal of Dermatology2008; 159 (S1):59.

7. Warshaw EM et al. Accuracy ofteledermatology for non-pigmentedneoplasms. J Am Acad Dermatol2009; 60:579-88.

8. Eedy DJ, Wootton R.Teledermatology: A Review. Br JDermatol 2001; 144;696-707.

9. Eminović N, de Keizer NF,Bindels PJE, Hasman A. Maturity ofteledermatology evaluationresearch: a systematic literaturereview. Br J Dermatol 2007;156;412-419.

PCDS Quiz

Q1. A 35 year old African woman presented with these lesions on her hands. They had

been present for many years and were asymptomatic. However she did not like the look

of them and wondered if anything could be done to clear them.

a. What is the diagnosis?

b. What is the cause?

c. Is there an effective treatment that you can offer?

Q3. A 70 year old man was advised to have these pigmented lesions on the plantar

surface of his foot checked out. They were asymptomatic and he had never noticed

them himself, although arthritis prevented him from inspecting the soles of his feet. He

lived alone. There was no history of trauma.

a. What is the diagnosis?

b. Is histology essential for diagnosis?

c. What non invasive test can confirm the diagnosis without recourse to referral?

Q2. This 16 year old boy is on roaccutane and his acne is responding well to it. He is a

keen rugby player and roaccutane is causing 2 sport related problems for him, one of

which is visible in this slide.

What are the 2 problems?

Dr Johnny Loughnane, GP Limerick

10 11

Fungal infections of the skin are amongst the commonest

of diseases worldwide. More than 12% of the population

are estimated to have tinea pedis, while over 20% of those

older than 65 are believed to have fungal nail disease. The

main fungi that affect the skin or mucous membranes belong to

three main groups – the dermatophytes, the Candida and

Malassezia species. While the dermatophytes, or ringworm

fungi, almost always originate from some external source, both

Candida and Malassezia are normal human commensals, some

internal or external event triggering them to cause disease.

Over the past twenty years, due to the widening range of drugs

available, our ability to treat these infections has improved

dramatically. So what can improve our management and what

can go wrong ?

1. Foot Infections

Athlete’s foot or tinea pedis is a common condition usually

caused by dermatophytes. However, scaling in the toe webs is

not always caused by these organisms and treatment may have

to be modified. Candida species and the filamentous bacterium

Corynebacterium minutissimum (erythrasma) can both cause

similar clinical changes. However, both these respond well to

topically applied azole antifungals but erythrasma does not

respond to terbinafine. Patients who describe their web space

symptoms as painful rather than itchy are more likely to have

superimposed gram negative bacterial infection (fig 1) which

will respond to antiseptics such as povidone iodine. However

you need to use an antifungal as well, as once the bacteria

have been destroyed the fungi often return.

2. Tinea Corporis

Ringworm of the body is uncommon in the UK (fig 2). Scaly ring

like lesions occur with many other conditions such as eczema

(particularly discoid eczema), annular erythemas and

seborrhoeic dermatitis. It is worth taking samples for laboratory

examination if you are considering this diagnosis.

3. Scalp Ringworm

This is difficult to diagnose clinically. The problem is that while

the classic presentation is with areas of hair loss in the scalp

associated with scaling, sometimes hair loss is minimal or

scaling hard to see, and the lesions asymptomatic. There is no

effective substitute for oral therapy and so before committing

to treatment it is best to take scalp samples. Standard scalp

scraping is useful but an alternative is brushing with disposable

tooth brushes (fig 3).

4. Treatment of Scalp Ringworm

The choice of treatment depends on the organism. In many

areas of the UK the main cause is Microsporum canis which

responds to griseofulvin. However, the paediatric liquid

formulation is difficult to obtain and it may be necessary to

crush the tablets with milk or juice. The conventional dose is

15-20 mg kg daily for a minimum of 4 weeks. If your practice

is in an inner city area and particularly, where there are many

children of African Caribbean origin the most common

organism is Trichophyton tonsurans. This can be spread

between children and treating asymptomatic siblings

prophylactically with topical ketoconazole shampoo is useful.

The best treatment for this organism, which responds poorly

to griseofulvin, is oral terbinafine.

5. Fungal Nail Disease

Onychomycosis or fungal nail infection is a common problem

and patients often present for treatment. There is no really

effective topical treatment at present and there is no

alternative to oral therapy. Given the length of time that the

treatment can take and the cost it is important to be sure that

this is a fungus before starting treatment. Taking a clipping

consisting of as much nail material as possible is important. A

clinical clue to the presence of fungus is the appearance of

scaling on the soles of the feet or between the toe webs.

Scaling on the sole can be subtle and often presents as small

circles or a line of scaling along the lateral border of the foot

(fig 4).

6. What do I do if the laboratory reportsCandida?

Candida yeasts commonly live under a dystrophic nail. It is a

congenial environment and therefore the presence of Candida

does not often signify that it is causing the nail dystrophy unless

there is obvious paronychia. Often it is therefore best to ignore.

Patients with the unusual primary Candida infections of the nail

plate are usually immunosuppressed – solid organ transplant or

chronic recipients of oral corticosteroids or have severe

Raynauds phenomenon.

7. Treating Patients with Vaginal Candidosis withFluconazole – no treatment response

Patients often treat themselves with oral fluconazole as a single

dose for vaginal thrush as it is inexpensive and simple. So it is

not surprising that they may fail to respond and present in the

surgery. The two commonest reasons are that the infection is

something else. Bacterial vaginosis or trichomonas are other

possibilities. An alternative possibility is that the organism is

resistant to fluconazole; Candida glabrata is often fluconazole

resistant, but can cause an identical pattern of disease.

Unresponsive patients may need to be referred but a ten day

course of itraconazole is sometimes effective.

8. Patients with Paronychia often do notRespond to Antifungal Drugs or Creams

Paronychia is an inflammation affecting some of the nail folds of

the fingers. Sometimes there is a light discharge of pus and the

Top 10 Fungal Tips

Professor R. J. HayInfection Clinic, Dermatology Department,Kings College Hospital, Denmark Hill. London

Fig 3. Sampling scalp ringworm with a disposabletoothbrush

Fig 4. Lateral scaling on the foot – a clue to tineapedis

Fig 5. Malassezia folliculitis

Fig 1. Gram negativesuperinfection of

tinea pedis

Fig 2. Tinea corporis – very extensive but difficult tomake out

12

Abbreviated Prescribing Information. Aquamol®Presentation: A soft white cream. Each pack contains purifiedwater, white soft paraffin, liquid paraffin, cetearyl alcohol,PPG-5-ceteth 20, disodium cocoamphodiacetate, polysorbate60, chlorocresol, sodium chloride, citric acid monohydrate.Indications: For the management of mild to moderate eczema,psoriasis and other dry skin conditions. Directions: Adults and

children over 1 year: Apply liberally to the affected area andsmooth gently into the skin following the direction of the hairgrowth until the cream turns from white to colourless. Use asoften as required, but at least twice daily at regular intervals.Aquamol can also be used as a soap substitute. For external useonly. Precautions: Hypersensitivity to any of the ingredients, orif the skin is broken, badly cracked or bleeding. Avoid contact

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penetration enhancers and as a beneficial soap substitute.

This unique formulation and mode of action of AQUAMOL®

can make all the difference for those living with eczema.

For further information, call 01484 842217 or visit www.aquamazing.co.uk

Now

on

Drug Tariffnail plate may show lateral onycholysis. The nail plate infection

will respond to oral antifungals such as itraconazole or

fluconazole and a standard duration of treatment is necessary

e.g. at least two pulses of itraconazole 400mg daily for one

week per month. In addition, the infection under the nail fold is

only part of the problem as there is often an associated irritant

dermatitis due to exposure to food and other material. It is

worth using a topically applied azole lotion, not cream, as this

seeps under the nail fold better. Also try applying a medium to

high strength topical corticosteroid to the nail fold swelling as

this will alleviate the dermatitis.

9. Pityriasis Versicolor

Pityriasis versicolor is a common infection, particularly in the

summer or autumn and the upper trunk is covered with hypo

or hyper pigmented patches with mild scaling and itching. The

presence of scales is a diagnostic clue so it is worth using a

blunt instrument to scratch the skin to demonstrate. The

scrapings can also be examined by a mycology laboratory if

you are in doubt. Although there are no randomised trials,

using 3 – 7 applications of ketoconazole shampoo to a large

affected area is a convenient treatment. It is applied in the

shower and then washed off after 5 minutes.

10. Malassezia folliculitis

Patients returning from summer holidays may present with a

scattered itchy folliculitis (fig 5) without comedones. Although

superficially resembling acne the itching is typical and there are

no blackheads. This responds to a 5 day course of itraconazole

(200mg daily) as Malassezia often causes this rash.

Fungal infections still cause us both therapeutic and diagnostic

problems. However there is often a way of improving on this

when the occasion arises.

Providing Private Cosmetic Treatmentread on...

You may not be aware that new guidelines being developed for anyone who can provide cosmetic treatment.

While standing on the southbound platform at Durham waiting for my train to take me to the PCDS Committee meeting

in London, I had the good fortune to come across Dr Dutta, who is one of our PCDS members.

Dr Dutta informed me of a potential radical shake up of how the cosmetic, soon to be called aesthetic, industry runs. The

third draft of these guidelines is in progress and is focusing in on who should be able to provide such treatments and the

necessary training requirements. These new guidelines may become an EU Directive.

The PCDS as such has not been invited to partake in this piece of work and so it is difficult to comment as the outcomes

are not yet known. There is, however, a possibility that the guidelines could impact on those providing cosmetic work in

the community.

Dr Dutta is part of the group reviewing these guidelines. He currently works from Aesthetic Beauty Centre in Sunderland,

SR2 7DE.

Dr Tim Cunliffe

GPwSI in Dermatology & Skin Surgery, Middlesbrough Specialist Skin Service

14 15

A Ten Year Journey from Clinical Assistant to Consultant Dermatologist

I have recently been appointed

Consultant Dermatologist at a

district general hospital, where 10

years ago I took on a post as clinical

assistant. I was awarded the

Certificate of Eligibility for Specialist

Registration (CESR), equivalent to

CCT, in 2010. This article sets out to

explain how I completed my training.

After qualifying, I initially trained in general medicine and

completed MRCP, then went on to do General Practice. I

became a Clinical Assistant in dermatology in January 2000. I

increased my sessional commitment quite quickly up to 3

sessions per week. In 2002, after the Consultant left, I became

a Hospital Practitioner and did extra work to cover the workload,

and I gave up doing General Practice. In 2004 we set up a

formal arrangement with the Consultants from our neighbouring

larger trust, which meant them coming up regularly for

combined clinics. In 2005 I became an Associate Specialist.

Subsequently I undertook the further training required for

Article 14 or CESR.

There are three key documents you need to consult in order to

complete the application: the GMC Guidance on applying for

CESR, the GMC specialty specific guidance for dermatology,

and the specialty training curriculum for dermatology (from the

JRCPTB).

The first requirement for CESR is completion of core medical

training. I have MRCP and completed core medical training

some years ago. If you do not have MRCP, then you would

firstly have to fulfil the core medical training requirement by

having done a job as junior hospital doctor in general medicine

(involving general medical on-call), and secondly, you would

have to do a 6 month recognised training job in dermatology.

Once these essential criteria are met, you then have to ensure

you have adequate training in all the different parts of the

Dermatology Specialty Specific Curriculum – which is the

training curriculum used by dermatology specialist registrars.

This is broken down into 15 separate areas and includes

headings such as contact dermatitis/patch testing,

phototherapy, paediatric dermatology, dermatopathology and

skin surgery. Some of these subjects require experience in the

relevant subspecialist clinics working alongside a Consultant,

while others may require attendance at a course. Certain

courses seem to be more important, such as phototherapy and

patch testing. But you may be able to demonstrate adequate

training in these areas without doing a specific course. It is

helpful to talk to registrars and trainers about how they fulfil the

various training requirements.

You will also need to keep a log book of activity over 5 years.

I think different people have tackled this in slightly different

ways. I kept quarterly records of numbers of clinics and

average numbers of patients seen, and numbers of surgical

procedures. I then included anonymised copies of a large

number of my clinic letters – both letters back to GPs, and

letters to other Specialists. These are in order to demonstrate

range of experience. I also kept a list of interesting cases that I

had seen, as well as records of inpatients I had seen as ward

referrals.

After all of this, you then start to work through the different

parts of the CESR application form, which correspond to the

components of Good Medical Practice. The first important area

is to supply evidence of appraisals and assessments. I

collected DOPs and mini CEX assessments from my

Consultant colleagues, multisource feedback, and patient

satisfaction surveys.

The other headings include audit, CPD, teaching, participation

in meetings, research, publications and presentations. For all

these areas you need to provide written proof of what you have

done, and these have to be validated by your Consultant

colleagues.

Once all this evidence has been gathered, you need to send it

all off to the GMC. They then take some time to consider the

application, and at some point pass it onto the BAD for their

assessment. They need structured reports from 6 referees –

and at least 2 of these should be Consultant Dermatologists.

It’s obviously very important you make sure that your

Consultant referees are supportive of your application.

For me, the PMETB/GMC process lasted 12 months!! When

they eventually wrote back with their decision, they said they

were happy with all my training except that I needed to go and

do an Advanced Life Support (ALS) course. This is essential for

dermatology specialist registrars, which is why you have to do

it! This meant doing a course alongside mostly very junior

hospital doctors who had very little experience of acute

medical situations.

It seems to me that the essential requirements for achieving

the CESR are hard work and enthusiasm, and the support of

Dermatology Consultant colleagues. You also need to make

sure you work through all the sections of application form

thoroughly and provide evidence for every section.

After having been awarded the CESR, there is then the issue

of applying for a Consultant job. Currently there is a national

shortage of Dermatology Consultants, which means it is a

good time to be applying. My trust needed a Consultant, and

so they advertised the job. I applied and was interviewed.

This process has been positive and useful for me personally. It

has meant that I have completed certain aspects of training

that I would not otherwise have got around to. I am also now

much better at making sure I collect evidence of CPD,

appraisals, and feedback. I am more involved in audit and

research. I believe the process has prepared me very well for

whatever may be expected of me for revalidation. There has

been a positive outcome for my department and my trust,

which were in need of a Dermatology Consultant.

Whether or not this process would be good for you personally

to consider, will depend on your own situation, as well as that

of the department in which you work. I had a conversation

with one of my Consultant colleagues who is very involved in

registrar training, and enlisted his support before embarking on

the programme. I think you need the support and advice of

someone like this, who knows what is required by the BAD for

specialist training.

Good luck if you decide to give it a go !

Karen Davies

Consultant Dermatologist , Barnstaple

May 2011 – July 2011

Apparently, so my editor tells me, I

wittered on so much in the last edition

that I ran out of space. I will try, and

no doubt fail, to be more concise in

future. If only there were fewer shiny

papers to catch my magpie eye.

We begin with palmoplantar pustulosis

(PPP). Always a difficult condition to treat,

we find a couple of suggestions1 that

may help to guide our treatment

strategies in future. There is also the

suggestion that PPP, as a result of recent

genetic studies, should be considered not

to be a variant of psoriasis but a distinct

entity in its own right. Sufferers from PPP

should be encouraged to cease smoking

of tobacco as this is the biggest single

thing that can be done to ease the

condition. There are also links to

abnormalities in tonsillar tissue, so

consideration should be given to

tonsillectomy and to both thyroid disease

and coeliac disease – both of which

should be screened for. Perhaps we need

to look further than traditional treatments

too, after all, if PPP is not necessarily

related to psoriasis, then why should it

respond to the same treatment?

The vitamin D story keeps evolving. As

my regular readers will know, I keep

coming back to this time and again. We

now have a link between vitamin D

deficiency and the severity of atopic

dermatitis2. Although a small study, only 37 children, such a close correlation was

found that vitamin D itself may be worth evaluating as a treatment option in

patients with this disease.

A timely reminder from York. Nicorandil has long been recognised as a cause of

mucosal ulceration. It can also, it would seem, be a cause of leg ulceration3.

These ulcers are typically resistant to treatment and painful. A single case report

is presented, but the temporal association between the resolution of the ulcer on

cessation of nicorandil therapy was good. Worth bearing in mind.

The last few editions of this bulletin have seen several papers condemning the

continuing use of aqueous cream as a leave on emollient. Two more here4,5 do the

same. It is 20 years since the National Eczema Society first highlighted adverse

cutaneous reactions to aqueous cream. Hopefully, the final nails in its coffin are

now being forged.

Last year, in the BMJ, there was a paper looking critically at the potential link

between acne, isotretinoin and suicide attempts6. It concluded that there may be

an increased risk, but as suicide risk was already increasing prior to treatment, the

additional risk could not be attributed to isotretinoin. Now we have a critical

reappraisal of the study7. There was a fair degree of confusion following the

publication of the original paper, the critics looked at it as further evidence to

condemn isotretinoin; the supporters looked upon it as good evidence for

safety.The critical reappraisal is that...further research is needed. Don’t you just

love a satisfactory conclusion?

It’s always nice to inject the occasional note of controversy. Here we have a paper

suggesting that cellulitis is best diagnosed by dermatologists8. Whilst this study,

in Norfolk, did reduce the number of patients admitted to hospital with cellulitis,

the paucity of dermatological services in large parts of this fair country precludes

this study being generalised. Would it not make more sense to say that there is

an educational need within General Practice and, should primary care be better

equipped to confidently diagnose cellulitis and to recognise the underlying causes

of it, then admissions could similarly be reduced? Does anyone know of an

organisation whose raison d’etre is to educate primary care in matters

dermatological...

Journal Watch

As we will see in a moment, itch is a complex topic. The mere mention of

scabies, however, is enough to create an epidemic of scratching in susceptible

individuals. It is, however, oddly fascinating that scabies actually has cycles9. Not

tiny little bicycles ridden maniacally by epidermal parasites but epidemic cycles –

lasting around 17 years. Our friends in the North East should not be too

paranoid, however, that these epidemic cycles seem to originate there before

disseminating south across the country. If, however, you are female, aged

between 10 and 19 AND live in the North East, worry – you have a greater

relative risk of being infested.

So, onto the hard science bit. You will be pleased to hear that in the last few

years, there has been a lot of research looking at itching10. There have been

many advances elucidating mediators and neuronal pathways responsible for

itch transmission. This is obviously good news and may well lead to better,

more targeted treatments for this troublesome problem. There is a catch

however. The number of receptors, and their associated transmitters, sounds

like a roll call of all those things that you never quite got round to learning about

at medical school – I don’t think I’ve ever even heard of Mas-related G

protein-coupled receptors, and that’s just one of 25 or so similar targets! This is

hugely complicated neuroscience and it makes our current approach of lobbing a

few antihistamines at it seem like blood letting, or cupping. Once again, watch

this space...

It’s also nice to include a bit of applicable therapeutics. Seborrhoeic dermatitis,

in particular that which affects the scalp, can be a real pig to treat. Here we have

a study suggesting a new combination of two previously disparate therapies11.

Whilst we use corticosteroids and antifungals on a regular basis, this study

suggests using short contact clobetasol propionate shampoo twice weekly,

alternating with twice weekly ketoconazole shampoo for moderate to severe

scalp seborrhoea. The regime seems effective and, over the study period, safe.

The disclaimer, as always, this is out off license use and is thus the

responsibility of the prescriber.

Finally, a paper left over from last time... Dermoscopy, we forget, is still a young

science and the algorithms for the diagnosis of melanoma haven’t really been

updated since they were first proposed more than ten years ago. They were

tested on clear cut melanomas or on excised melanocytic naevi. When

Giuseppe Argenziano suggests that now might be time to reappraise this12, then

it is wise to sit up and take notice. The current clinical setting, in which we are

seeing more and more patients with early-stage melanomas and multiple

atypical naevi suggests a revision of the original seven point checklist – with a

lower threshold for excision – is long overdue. The original algorithm placed a

greater emphasis on the presence of an atypical pigment network, a blue white

veil and an atypical vascular pattern. The suggested revised algorithm places

these with equal importance with irregular dots/globules, irregular streaks,

irregular blotches and regression structures. The threshold for excision has

similarly been reduced from three points or above to a single point or above. As

with all things dermoscopical, this needs to be in a clinical setting, by a trained

dermoscopist.

References1. Mrowrietz and van de Kerkhof - Management ofpalmoplantar pustulosis: do we need to change?BJD2011:164;942-946

2. Peroni et al – Correlation between serum25-hydroxyvitamin D levels and severity of atopicdermatitis in children.BJD2011:164;1078-1082.

3. Mikeljevic and Highet - Nicorandil-induced legulceration without mucosal involvement.CED2011:36;372-373.

4. Cork and Danby – Aqueous cream damages theskin barrierBJD2011:117901180

5. Mohammed et al – Influence of Aqueous creamBP on corneocyte size, maturity, skin proteaseactivity, protein content and transepidermal waterloss.BJD2011:164;1304-1310

6. Sundstrom et al – Association of suicide attemptswith acne and treatment with isotretinoin:retrospectiveSwedish cohort study.BMJ2010:341;

7. Langan and Batchelor – Acne, Isotretinoin andsuicide attempts: a critical appraisal.BJD2011:164;1183-1187

8. Levell et al – Sever lower limb cellulitis is bestdiagnosed by dermatologists and managed withshared care between primary and secondary careBJD2011:164;1326-1328.

9. Lassa et al – Epidemiology of scabies prevalencein the UK from general practice recordsBJD2011:164;1329-1334.

10. Tey and Yosipovitch – Targeted treatment ofPruritus: a look into the future.BJD2011;165:5-17

11. Ortonne et al – Efficacious and safe managementof moderate to severe scalp seborrhoeic dermatitisusing clobetasol proprionate shampoo 0.05%combined with ketoconazole shampoo 2%: arandomised, controlled study.BJD2011;165:171-176.

12. Argenziano et al – Seven point checklist ofdermoscopy revisitedBJD2011:164;785-790

16 17

18

It’s been a quiet summer up here, no major sporting tournaments and no riots.

Probably too dreich and no Old Firm matches to act as a catalyst. We have however

things to look forward to in the autumn such as the rugby World Cup. An English

rugby player complained about the crunchiness of his noodles in a Chinese

restaurant then it was pointed out to him that these were his chopsticks.

More importantly the Scottish meeting is this autumn. You all should have received

your programme and booking form by now so don’t delay and book up for the early

bird rate before Sept 30th. If you haven’t received it yet, contact HQ tout de suite.

The Melanoma Action and Support Scotland (MASScot) are holding a discussion on

improving patient outcomes in melanoma in Scotland at the Scottish Parliament on

14th Sept. I shall bring up the possibility of public awareness events at sporting and

music events such as the Open Golf Championship and T in the Park in the future.

Red tape and bureaucracy make progress towards this very sluggish so having the

ears of a few MSPs may help. I’m sure the Sun Awareness Campaign (mentioned in

the last bulletin) that was supposed to be run in schools but has so far not been

implemented will be another subject brought up. The summer has been so bad up

here I’m more worried about Vit. D deficiency than melanomas!

I’m still trying to set up some sort of database for Scottish dermatology meetings

where anyone can log in and see what is happening in their area so if you hear of

anything which looks interesting let me know at iain.henderson@ntlworld.com.

Astellas are having a dermatology masterclass at the Camponile Hotel at Glasgow

Airport on 11th October. Anybody interested email

Gareth.Mackenzie@gb.astellas.com.

I’ve checked the NES Scotland website and there are no dermatology meetings run

by them anywhere in Scotland. The RCGP has a dermatology symposium at the

Royal College of Physicians in Edinburgh on 21st Sept. Details on the RCGP website

or email c.berwick@rcpe.ac.uk.

To finish, another rugby joke to get you in the mood. An English rugby player goes

to the doctor and says “Every morning I wake up, look in the mirror and feel like

throwing up. What’s wrong with me?” The doctor replies, “I don’t know but your

eyesight is perfect.”

Alright here’s one to follow on from the last bulletin’s joke theme.

What do you call a woman with 2 toilets on her head……LULU.

Hope to see you all at Westerwood in November.

Bye the noo.

Iain Henderson

News From Northof the Border

Abbreviated Prescribing Information for Dovobet® 50 microgram/g + 0.5 mg/g gel. Indications: Topical treatment of scalp psoriasis in adults. Topical treatment of mild to moderate ‘non-scalp’ plaque psoriasis vulgaris in adults. Active ingredients: 50 µg/g calcipotriol (as monohydrate) and 0.5 mg/g betamethasone (as dipropionate). Dosage and Administration: Apply to affected areas once daily. Recommended treatment period is 4 weeks for scalp and 8 weeks for ‘non-scalp’ areas. If it is necessary to continue or restart treatment after this period, treatment should be continued after medical review and under regular medical supervision. When using calcipotriol containing medicinal products the maximum dose should not exceed 15g/day. Treated area should not exceed 30% of body surface. Safety and efficacy in children under 18 years have not been established. Safety and efficacy in severe renal insufficiency or severe hepatic disorders have not been evaluated. Shake bottle before use. Do not apply directly to the face or eyes. Wash hands after use. It is not recommended to take a shower or bath, or to wash the hair in case of scalp application, immediately after application as the gel should remain on the skin during the night or day. If used on the scalp usually between 1g and 4g/day is sufficient for treatment. Contra-indications: Hypersensitivity to any constituents. Erythrodermic, exfoliative or pustular psoriasis. Patients with known calcium metabolism disorders. Viral skin lesions, fungal or bacterial skin infections, parasitic infections, skin manifestations in relation to tuberculosis or syphilis, perioral dermatitis, atrophic skin, striae atrophicae, fragility of skin veins, ichthyosis, acne vulgaris, acne rosacea, rosacea, ulcers, wounds, perianal and genital pruritus. Precautions and Warnings: Avoid concurrent treatment with other steroids. Adrenocortical suppression or impact on the metabolic control of diabetes mellitus may occur. Avoid application on large areas of damaged skin, under occlusive dressings or on mucous membranes or skin folds. Do not use on the skin of the face or genitals. Avoid inadvertent transfer to face, mouth and eyes. Wash hands after applying. There may be a risk of generalised pustular psoriasis. With long-term use there is an increased risk of local and systemic corticosteroid adverse reactions in which case treatment should be discontinued. There may be a risk of rebound when discontinuing treatment. No experience of use in guttate psoriasis. No experience of concurrent use with other antipsoriatic products administered topically (to the

same treatment area) or systemically; or with phototherapy. Physicians are recommended to advise patients to limit or avoid excessive exposure to natural or artif icial sunlight. Use with UV radiation only if the physician and patient consider that the potential benefits outweigh the potential risks. Contains butylated hydroxytoluene which may cause local skin reactions or irritation to the eyes and mucous membranes. Use in Pregnancy and Lactation: Only use in pregnancy when potential benefit justifies potential risks. Caution when prescribed for women who breast-feed. Instruct patient not to use on breast when breast-feeding. Side Effects: Pruritus. Additional undesirable effects observed for calcipotriol and betamethasone: Calcipotriol: application site reactions, skin irritation, burning and stinging sensation, dry skin, erythema, rash, dermatitis, eczema, psoriasis aggravated, photosensitivity and hypersensitivity reactions including very rare cases of angioedema and facial oedema. Hypercalcaemia or hypercalciuria may appear very rarely. Betamethasone: local reactions, especially during prolonged application including skin atrophy, telangiectasia, striae, folliculitis, hypertrichosis, perioral dermatitis, allergic contact dermatitis, depigmentation, increase of intra-ocular pressure, cataract, colloid milia, generalised pustular psoriasis, infections. Systemic reactions occur more frequently when applied under occlusion, on skin folds, to large areas and long- term treatment. Legal Category: POM. Product Licence Number and Holder: 05293/0005 LEO Pharmaceutical Products Ltd. A/S, Ballerup, Denmark. Basic NHS Price: £36.50/60g, £67.79/2 x 60g. Last revised: November 2010. Further information can be found in the Summary of Product Characteristics or from: LEO Pharma, Longwick Road, Princes Risborough, Buckinghamshire, HP27 9RR. ® Registered Trademark. e-mail: Dovobet.UKenquiries@leo-pharma.com

Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk. Adverse events should also be reported to Drug Safety at LEO Pharma by calling 01844 347333.

* Mild to moderate plaque psoriasis

See the Dovobet® Gel di� erence

The bene� ts are clear. Dovobet® Gel is a treatment for both body* and scalp psoriasis.

Simple to apply, it’s designed with patients in mind. Giving them the con� dence they

need to reveal more of themselves.

For further information visit: morethanpsoriasis.co.uk

LEO® ©LEO Pharma, UK, All LEO trademarks mentioned belong to the LEO Group. Code: 1008/10888 February 2011

Q1. a. The diagnosis is Keratosis Punctata(also called Palmar Pits)

b. It is thought that they may be caused bymanual work

c. Unfortunately there seems to be no reallyeffective treatment, although moisturiseruse is recommended

More common in atopic patients

Note: Keratosis Punctata is thought to be anormal variant in darkly pigmented skin.They occur in palmar and sometimesplantar creases, presenting as small (1 to5mm) hyperkeratotic plugs. If plugs areremoved, or fall out spontaneously,permanent pits result. They are oftenhyperpigmented. Occurrence may besporadic or familial

Q2.One of the lesser recognised sideeffects of roaccutane is skin fragility. Thiscaused him to suffer recurrent, easilyinduced, skin abrasions while playing rugby

Roaccutane may more commonly causemuscle and joint stiffness after exercise.This does not lead to permanent joint orsoft tissue damage

Neither problem prevented him fromcontinuing to play

Q3. a. These are resolving, haemorrhagic,friction blisters. He is a farmer and hadrecently been wearing a new pair ofwellingtons. These were the probablecause, although he was adamant that hehad no pain or discomfort

b. Histology is not essential as dermoscopygives a distinctive picture, with manyhaemorrhagic globules easily recognisable

c. The appearance of the foot followingde-roofing of the hard, overlying skin furtherconfirms the diagnosis

He also had a lesion on his right cheek,which on dermoscopy was suspicious. Hewas referred for excision and subsequenthistology confirmed the diagnosis of lentigomaligna

Quiz Answers

2nd Floor, Titan Court, 3 Bishop Square, Hatfield AL10 9NA T: 01707 226024 F: 01707 226001 E: pcds@pcds.org.uk W: pcds.org.uk

Forthcoming Meetings 2011 Members of the corporate membership scheme

Autumn MeetingLady Margaret Hall, OxfordThursday 22nd September 2011

Essential DermatologySt John's Hotel, SolihullFriday 23rd September 2011

Dermoscopy for BeginnersCrowne Plaza LiverpoolWednesday 28th September 2011

Essential DermatologyNewcastle Marriott Metro CentreFriday 14th October 2011

Basic Skin SurgeryGuys & St Thomas' Education Centre, LondonThursday 20th & Friday 21st October 2011

Advanced Skin SurgeryGuys & St Thomas' Education Centre, LondonFriday 21st & Saturday 22nd October 2011

Advanced Dermoscopy CourseBMA House, LondonThursday 27th October 2011

Essential DermatologyWoodbury Park Hotel, ExeterThursday 3rd November 2011

Scottish MeetingWesterwood Hotel, CumbernauldSaturday 12th & Sunday 13th November 2011

Dermoscopy for BeginnersLeicester MarriottThursday 17th November 2011

Spring MeetingCavendish Conference Centre, LondonFriday 9th March 2012 Keynote Speakers:Dr Giuseppe Argenziano, ItalyDr Iris Zalaudek, AustriaBook early!

Website Update... don’t be deceived

www.pcds.org.uk...www.pcds.org.uk...www.pcds.org.uk...www.pcds.org.uk...

The news on the website is good – we are now getting 6,000 visits per month and thefigures continue to increase.

For those who visit the website frequently it may appear that little has been done of late,but don’t be deceived. Behind the scenes we are working hard to expand the website andmove it over to new software. This work will take several months but once completed theadvantages will be obvious:

• A new homepage with a big emphasis on clinical guidance and education • Easier navigation • A search facility• All clinical chapters will appear in the same format, and images will be able to be viewed

in a larger format when needed • Existing clinical chapters will be updated• Up to 30 new clinical chapters• An updated section on investigations

And on top of this there is much more in the pipeline as we plan to re-visit the dermoscopicand surgical aspects of the website.

If there is anything else that you would like to see on the website then please feel free tocontact the society with your ideas

Tim CunliffeGPwSI in Dermatology & Skin Surgery, Middlesbrough Specialist Skin Service