As we move into the summer months the PCDS Committee is ever more busy with

current and future meetings. The desire to provide a relevant and interesting variety

of topics and presenters is an ongoing task for which we rely on feedback from

members attending meetings. The evaluation forms we use are studied and where

possible acted upon. We do have difficulty sometimes reconciling those who want

weekdays and others wanting weekends but we try, even then, to provide both at

different times of year and at different venues.

You may have noticed the summer meeting takes place over Friday/Saturday this

year and this is mainly because hotels large enough for us now expect us to book the

same number of bedrooms on Friday if we want Saturday nights. Weddings (not

necessarily royal) being the problem competitor. We would very much like to hear

from those members not attending meetings to contact us and let us know what

might tempt you. Let us know what you want, where and what days you might

prefer.

The first few Essential Dermatology (ED) day courses have been very popular and we

are indebted to members all around the country who have passed on contact

addresses of VTS organisers and commissioners and who have sent out flyers for us.

Not only are we grateful for the help but also for the increased communication with

our membership which we all appreciate especially Carol, our administrator.

Primary Care Dermatology Society Summer 2011

Bulletinpcds.org.uk

Chairman’s Report

The PCDS Trustee Committee

Mr Peter Lapsley Dr Tom PoynerDr Stephen Hayes Dr Jane Rakowski

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Dermol® 600 Bath Emollient Benzalkoniumchloride 0.5%, liquid paraffin 25%, isopropylmyristate 25%.Uses: Antimicrobial bath emollient for the management of dry,scaly and/or pruritic skin conditions, especially eczema anddermatitis. Directions: Adults, children and the elderly: Add to a bath of warm water. Soak and pat dry.

Contra-indications, warnings, side-effects etc: Please refer toSPC for full details before prescribing. Do not use if sensitive toany of the ingredients. In the unlikely event of a reaction stoptreatment. Keep away from the eyes. Take care not to slip in thebath or shower. Package quantities, NHS prices and MAnumbers: Dermol 200 Shower Emollient: 200ml shower pack£3.55, PL00173/0156. Dermol 500 Lotion: 500ml pump dispenser£6.03, PL00173/0051. Dermol Cream: 100g tube £2.86, 500gpump dispenser £6.63, PL00173/0171. Dermol 600 Bath

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References:1. Gallagher J. Rosher P. Temple S. Dixon A. Routine infection

control using a proprietary range of combined antisepticemollients and soap substitutes – their effectiveness againstMRSA and FRSA. Presented as a poster at the 18th Congress ofthe EADV in October 2009, Berlin.

2. Dermol Range – Total Unit Sales since launch. DermalLaboratories Ltd. Data on file.

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

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2

Please continue to advertise our meetings to

your colleagues. The main aim of the Society is

to educate GPs in dermatology at all levels. A

special bonus of the ED meetings is the

excellent memory stick (I can say that because I

had only a very small part in its production) which

not only has all the presentations but a wealth of

educational matter including a dermoscopy

starter course which makes it worth the £75

course fee on its own!

Some time ago I asked by email for future QOF

suggestions, albeit at rather short notice. The

response was varied but of the 20 or so replies

the overwhelming response was not to submit

anything! The cynicism of QOF-weary GPs held

sway at this time! I did as suggested but the

BAD did submit quite a selection for

consideration. These included, people with

chronic skin disease should be reviewed annually

and offered a second opinion from an

appropriately trained practitioner in dermatology;

GPs to have a specified number of hours

teaching in skin cancer; reduce mortality due to

the co-morbidities of skin disease; ensure the

quality of GP training for people with skin

disease and people should be treated by the

right person, right place first time. I would not

argue with any of these aims and it is significant

that the wording has changed over the last year

or so to use terms such as “appropriately trained

practitioner” which could include GPs or nurses

rather than the previously ubiquitous

“Dermatologist.”

If you have not looked at the PCDS website

recently I recommend that you give it a look

since there have been many additions and it is

becoming an extremely useful reference site as

well as a low stress teaching aid for registrars

etc. I hear from trainers that it is a great resource

and free!

I look forward to meeting more of you at any, or

all, of our meetings in 2011 and beyond.

Stephen Kownacki

Executive Chair

Our annual meeting of the Primary Care Dermatology Society of Ireland goes

from strength to strength. This year’s meeting was held in Galway on March

4th/5th and was attended by over 200 delegates. A crowded programme,

spread over the 2 days, had something for everybody. Some sessions ran

concurrently to cater for varying levels of dermatology knowledge and

experience among the delegates. Areas covered in depth this year included

atopic eczema, psoriasis, dermatology problems in special groups and

paediatric dermatology.

PCDS members who made very well received presentations were Liz

Ogden, Stephen Hayes and Iain Henderson. We had a great turn out from

our sponsors from the pharmaceutical industry, without whose support the

meeting could not go ahead. Great thanks is due to them all. Leo Pharma

sponsored our gala dinner on Friday night.

Our next meeting is a full day of dermoscopy training with Dr Jonathan

Bowling and Dr Tony Downs on Friday 16th September 2011, at The Royal

College of Physicians, Dublin. With two such experienced and proven

teachers we expect a big turnout of delegates on the day.

Dermatology has done well in the HSE clinical care programme. The aim of

the programme is to deliver timely, effective and appropriate care of a range

of chronic conditions. In Munster we have only had 5 dermatologists in the

public hospital system. This is about to more than double with the

appointment of 2 extra consultants to each of Cork and Limerick, with a

further 2 eventually for Waterford. This should bring about a much delayed,

but badly needed improvement in patient access to specialist care. As the

primary care clinical lead for dermatology I hope to promote and highlight the

essential role general practitioners play in providing dermatology care in the

community. Unfortunately no new funds whatsoever have come the primary

care way though we have been promised we are next in line (but with that

awful provision “should funding allow”). The programme in dermatology has

set a target of reducing referrals from primary care by 10%. It is hoped to

achieve this by developing care pathways for the common chronic,

inflammatory rashes, such as acne, psoriasis and eczema. It is also hoped to

reduce the rate of lesions referred to secondary care. Without extra

resourcing it is difficult to see how this is to be advanced. We live in hope.

Our annual meeting next year will be on the 24th/25th February 2012. The

venue has yet to be finalised. Options being explored are Croke Park, Dublin

and Killarney. Why not put this date in your diary for next year.

Dr Johnny Loughnane

News From Ireland

Editorial Summer 2011

Wow – summer has arrived very early this year. I’m still

catching up after a tropical Easter in Sheffield and two

lovely long weekends. I’m very excited as I have the

opportunity to attend Glastonbury this year. I will be

helping some colleagues from Exeter and the South West in

the “mole watch” tent. Being very new to festivals and having

very little knowledge of trendy new bands I would like any

advice that you have to offer. This includes advice on who to

watch, camping gear, avoiding the mud and any appropriate

fashion tips.

I recently found there were a few perks to being Editor of the

Bulletin. I have been sent a book to review for members of the

PCDS.

Acute Adult Dermatology,

Diagnosis and Management by

Daniel Creamer, Jonathan Barker

and Francisco Kerdel.

This book was published by

Manson Publishing £29.95.

I really liked this book. It’s good

value and pitched at a level that

would suit GPs with an interest

in dermatology and

dermatology trainees. The information

was presented in a clear and concise way. There were

excellent clinical photos illustrating each disease. The diseases

are broken down into clinical features, differential diagnoses,

4 5

complications and investigations. The

treatment is then broken down into

immediate and long term management.

It covers a wide variety of dermatology

and also covers some tropical

dermatoses. It would be an invaluable

resource to have in your top drawer to

use as a quick reference. The publishers

have offered 15% discount for members

of the PCDS. If you wish to take

advantage of this, please contact me via

pcds.org.uk.

Acne Academy

This is an excellent new online resource

developed by a group of dermatologists,

Stephen Kownacki as a GP with a

special interest, a pharmacist and nurse

specialist to provide information to both

patients and health care professionals.

It provides access to balanced practical

information about acne, advice on self

management and where to seek help. It

is a valuable resource for patients and

their families and well worth directing

them to the website.

For health care professionals there are

links to other useful resources and also

recent updates on treatment guidance and relevant up to date research.

http://www.acneacademy.org/

New Guidance on prescribing antibiotics with combinedhormonal contraception

The Faculty of Sexual and Reproductive Healthcare have recently updated their 2005

guidance on drug interactions with hormonal contraception1. This obviously affects the

advice given when prescribing oral antibiotics for a wide variety of dermatological

conditions.

There is no longer the need to advise that additional precautions are required when

using combined hormonal contraception (CHC) with antibiotics that are not enzyme

inducers. This includes both short and prolonged courses of oral antibiotics.

Rifampicin-like drugs (e.g. rifampicin, rifabutin) are the only antibiotics that are enzyme

inducers and that have consistently been shown to reduce serum levels of

ethinylestradiol. Rifampicin is used in conditions such as cutaneous TB infections,

hydradenitis suppuritiva and folliculitis decalvans. The advice given in such cases

would be to use a form of contraception that is not affected by enzyme inducing drugs

such as the mirena coil or depo provera. This advice is directly in line with guidance

from the World Health Organisation

(WHO2) and the US Medical Eligibility

Criteria for contraceptive use3.

The Faculty admits adopting a cautious

approach in the past despite the lack of

evidence supporting a causal relationship

between antibiotics that are not enzyme

inducers and reduced COC efficacy. The

revised guidance is based on direct

evidence from clinical trials and also

indirect supporting evidence.

This will obviously change the way that

we have traditionally practiced both in

dermatology and general practice over

(for some of us) many years. I thoroughly

recommend that you read the guidance

and for those interested review the

evidence.Helen Frow

References1. http://www.ffprhc.org.uk/Default2.asp?Section=Publications&SubSection=ClinicalGuidance2

2. World Health Organization. Medical Eligibility Criteria for Contraceptive Use (3rd edn). 2010

http://www.who.int/reproductivehealth/publications/family_planning/9789241563888/en/index.html

3. Centre for Disease Control and Prevention. U.S. Medical Eligibility Criteria for Contraceptive Use, 2010. 2010.

http://www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf

6 7

Understanding the Histology Report: Part Two – Inflammatory Dermatoses

Introduction

Most histopathologists find the diagnosis of inflammatory

dermatoses more challenging than that of skin tumours and

their difficulty may be reflected in the histology report. There are

reasons for this.

The skin has a relatively limited number of ways in which it can

react to injury, and this is reflected in histological similarities

between conditions that may, clinically, be completely unrelated.

In many cases the histological features of inflammatory skin

biopsies may just be non-specific.

Clinicopathological correlation is essential if the correct

diagnosis is to be achieved. The request form needs to show

the patient’s age, along with the distribution, gross appearance

and treatment history (topical steroids, for example, can modify

features). The duration of the lesion or rash is important, as the

histology of an inflammatory dermatosis can change as it

evolves. Most importantly, a clinical differential diagnosis should

be given on the request form. The return on any “hopeful”,

blind biopsy is low!

To help reach a diagnosis, pathologists have developed an

approach to inflammatory skin biopsies using pattern analysis -

recognizing a major pattern to the inflammatory process,

allowing classification of it into one of several groups, and then

refining the diagnosis using more subtle details. The late

Bernard Ackermann was one of the first to use this method,

which he documented in a textbook1 that includes a series of

very detailed algorithms. The most recent version of this

publication can be found online2. David Weedon has provided an

alternative approach3, and his is widely used in the UK.

Weedon describes several major tissue reaction patterns (Figure

1), and a few minor ones specific to just a small number of

conditions. Identifying the tissue reaction pattern, and combining

it with the distribution or pattern of inflammation in the dermis

and subcutis (Figure 2), provides a simple algorithmic approach

that can guide the pathologist towards the correct diagnosis.

Below, I describe Weedon’s major tissue reaction patterns, and

include some details about common diagnoses in those

categories. I have attempted to explain some of the histological

terms you might come across in the histology report.

The Major Tissue Reaction Patterns

1. The lichenoid reaction pattern (“interface dermatitis”)

The essential feature in lichenoid conditions is damage to the

cells at the base of the epidermis, where the epidermis

“interfaces” with the underlying dermis. Lichen planus (LP) and

discoid lupus erythematosus (DLE) are good examples from

the two main groups of lichenoid conditions.

In LP, cell damage and death is mostly via apoptosis, a type of

individual cell necrosis often called “programmed cell death”,

and a result of attack by T lymphocytes. Apoptosis gives rise to

the so-called Civatte or colloid bodies, which are necrotic

remnants of keratinocytes (epidermal cells). The repeated

damage and loss of the basal cells in LP nibbles away at the

normal rounded outline of the basal epidermis such that it

becomes more angular (“saw-toothing”). In DLE, vacuolar

(hydropic) change predominates. This appears as vacuoles or

spaces around the injured basal keratinocytes.

The dermal inflammatory infiltrate in LP consists mainly of

lymphocytes, is relatively heavy and superficial, and so is

described as “band-like”. DLE has a much lighter infiltrate and

also involves skin appendages.

2. The psoriasiform reaction pattern

This is a type of epidermal hyperplasia in which there is a regular

pattern of elongation of the epidermis (specifically of the rete

ridges).

Psoriasis is the archetypal example. Other clues to a diagnosis

of psoriasis include thinning of the suprapapillary plate, the strip

of epidermis lying over the top of the papillary dermis, and the

presence of prominent neutrophils (acute inflammatory cells).

Neutrophils can give rise to subcorneal abscesses (of Munro)

and the so-called “squirting papillae”, areas where they are

seen passing through the epidermis from the blood vessels in

the papillary dermis below.

Lichen Simplex chronicus is another psoriasiform dermatosis.

Here the hyperplasia is less regular, lymphocytes rather than

neutrophils predominate and the suprapapillary plate is thicker.

Bowen’s disease can be psoriasiform but marked keratinocyte

atypia is present.

3. The spongiotic reaction pattern

Spongiosis is the presence of fluid between keratinocytes, and

when florid can cause microvesicle formation. It is seen in a

variety of conditions including atopic or allergic dermatitis -

eczema means "to bubble up".

A feature often seen with spongiosis is exocytosis, the

presence of leucocytes (white blood cells) in the epidermis,

usually lymphocytes. Other features help narrow the diagnosis,

such as the presence of numerous eosinophils in an allergic

dermatitis. In long-standing cases of eczema, the prolonged

scratching can cause superimposed lichen simplex chronicus

(see above).

4. The vesiculobullous reaction pattern

Vesicles and bullae can occur in a variety of conditions such as

eczema and lichen planus, but this reaction pattern includes

those where they are a primary feature. Classification is by a

Fig 1: Lichen planus with band-like inflammation and“saw-toothing”. Inset shows Civatte bodies (onearrowed)

Fig 2: The regular epidermal hyperplasia of psoriasis Fig 3: Epidermal vesicle formation (between arrows)in a case pemphigus

Dr Jason DaviesConsultant Histopathologist, North Devon District Hospital, Barnstaple

Lichenoid (‘interface dermatitis’)

Psoriasiform

Spongiotic

Vesiculobullous

Granulomatous

Vasculopathic

Combined

Superficial perivascular inflammation

Superficial and deep dermal inflammation

Folliculitis and perifolliculitis

Panniculitis

Table 1: Major tissue reaction patterns

Table 2: Patterns of inflammation

8

combination of light microscopy (LM) and immunofluorescence

(IMF).

The LM feature of most value is the level where the

vesicle/bulla forms, either intra-epidermal, or sub-epidermal,

the latter in the vicinity of the basement membrane on which

the epidermis sits. The type of associated inflammatory cell

helps to refine the diagnosis. Intra-epidermal blistering

dermatoses include the various types of pemphigus and

Grover’s and Darier’s diseases. The commonest sub-epidermal

dermatosis is bullous pemphigoid and prominent eosinophils

are a distinguishing feature.

IMF is important in diagnosis but needs to be performed on

fresh tissue – hence the need for special transport media. For

example, the LM features of dermatitis herpetiformis and

linear IgA disease can be identical. However, IMF allows their

separation, showing a linear band of IgA staining along the

lower epidermis in the latter, whilst DH has patchy, granular

IgA deposits in the papillary dermis.

5. The granulomatous reaction pattern

Granulomata are aggregates of histiocytes (macrophages) and

these cells can fuse to form giant cells. There are several types

of Granulomata. They can be “naked”, meaning they lack a

significant lymphocyte rim, as in sarcoidosis, they can be

“caseating” (showing central necrosis) as in tuberculosis,

whilst some infective processes, including fungal infections,

can give rise to suppurative granulomata, rich in neutrophils.

Prominent giant cells are a clue to foreign body granulomas,

and the causative foreign material may be detected using a

polarising attachment on the microscope. Finally, in palisaded

granulomata the histiocytes line up in orderly fashion around

the periphery. This is characteristic of granuloma annulare and

rheumatoid nodules.

6. The vasculopathic reaction pattern

The classification of vasculitis is beyond the scope of this

article, but involves vessels of varying sizes and locations.

Ancillary tests such as serology are required in many, but some

are biopsied. Any biopsy for suspected vasculitis should

include subcutaneous tissue, to ensure sampling of

medium-sized vessels as would be involved in polyarteritis

nodosa.

A diagnosis of vasculitis necessitates identifying primary injury

to vascular spaces. Damage can cause swelling of endothelial

cells (which line the interior of vessels), vessel wall necrosis,

and leakage of red cells into the surrounding dermis

(erythrocyte extravasation).

The histological appearances can be very difficult to separate

from the secondary vessel damage that occurs at the edges of

non-specific ulcers. In such cases the histopathologist will

examine vessels away from the ulcer’s vicinity.

Leucocytoclastic (hypersensitivity) vasculitis is probably the

most frequently biopsied. This involves small venules in the

superficial dermis. Histologically there is bright red fibrinoid

necrosis in the vessel wall and a florid surrounding infiltrate of

neutrophils and fragmented nuclear debris from degenerate

neutrophils, termed leukocytoclasis.

7. Combined reaction patterns

Mixed patterns can occur. For example, some drug reactions

can be both spongiotic and lichenoid, and there are

granulomatous forms of vasculitis (eg Wegener’s).

Conclusion

Inflammatory skin biopsy diagnosis can be difficult, but with a

combined clinical and histopathological approach, most cases

can be resolved. The MDT meeting can be an effective forum

to discuss problematic biopsies.

I hope that in these two short articles I have helped increase

your understanding of some aspects of histopathology reports.

However, dermatopathology is an extensive subject and I have

only been able to cover a small area. If you have a report that

you just don’t understand then contact your histopathologist –

most are approachable!

References1. Ackerman AB. Histological diagnosis of inflammatory skin diseases. Lea andFebiger. 1978

2. http://www.derm101.com

3. Weedon D. Skin pathology. 3rd edn. Churchill Livingstone. 2009.

Fig 4: Tuberculous granuloma of skin with central, caseous necrosis (arrow)

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10 11

Being a relative newcomer to the PCDS and not knowing

any of my fellow delegates, I walked into the Grand Hyatt

Hotel with some trepidation on Friday 13th. When we first

met in the library over a glass of wine and delicious canapés, my

trepidation totally melted away and the warm friendship of the

PCDS shone through and I soon felt that this was going to be a

good weekend and the educational part had not yet started.

Bright and early on the Saturday morning Childhood Eczema

was on the menu, with a lecture by Dr Sue Lewis-Jones with an

overview of the treatment of some of those difficult to treat

eczematous rashes. The use of patch testing for allergens, Oral

Allergy Syndrome, emollient usage and the use of calcineurin

inhibitors in children was discussed. This was followed up by a

lecture on the Eczema Education Programme in Germany by Dr

Sylke Gellrich, a Community Dermatologist with the Charité

Medical Facility in Berlin. It certainly impressed on me that the

key to treating eczema at all ages is ’education, education,

education’ and how well patients respond to an education

scheme. It also impressed us that Dr Gellrich, whose native

language is obviously not English; was able to deliver an

excellent lecture in English despite this.

Changing the tact somewhat, Dr Stephen Jones, Consultant

Dermatologist in the Wirrall and President of BAD helped iron

Friday 13th May – Sunday 15th May 2011

out a lot of the indecisions regarding the diagnosis of

Connective Tissue Disorders. Some of the tips given included

the fact that the rash on the hands related to Dermatomyositis

occurs mainly over the dorsal interphalangeal joints whereas

the similar rash in SLE occurs between the joints leaving the

joints somewhat spared. The continuum between DLE and

SLE was explained as well as many other gems of information.

The final act of the Saturday morning was a very energetic

lecture by Professor Eggert Stockfleth, Consultant

Dermatologist at Charité Medical Faculty. His lecture on Skin

Cancers and Actinic Keratoses was very interesting from the

point of view of the differences in the aggression of treatment

of AK’s in Germany compared to this country. Some of this

may be as a result of the fact that the city of Berlin has almost

as many dermatologists as the whole of the United Kingdom.

The burden of skin cancers is increasing throughout the world

not only because of the depletion of the ozone layers but also

because of the amount of immunosuppression, both natural

and iatrogenic. Are we building a new as yet unknown

population suffering from cancers from the use of the biologic

medications? – Probably!!

That’s enough of the academic stuff for the first day. It was

now time for a lesson in the exceptionally interesting history of

Berlin. The bus tour around the city filled the afternoon and

covered all the well-known sites such as the Reichstag, the

Brandenburg Gate, the Holocaust Memorial, the remains of the

Berlin Wall and Checkpoint Charlie. Some of us apparently saw

Yusuf Islam aka Cat Stevens from the coach. Some even tried

to climb the remnants of the wall. Someone should have told

them they could have walked around it in this day and age!

Later in the evening we were taken for a meal at the Altes

Zollhaus where we had the conference dinner and another

chance to meet and talk to our colleagues from all over the

country. One of the things about putting a group of GP’s

together is that you always find someone in the group who

knows something that you don’t know anything about but

would like to. I suppose that’s one of the advantages about

being a generalist.

The next morning Dr Sue Lewis-Jones lectured about her

experiences in advising the Ethiopian dermatologists on setting

up their dermatology service. There was an awful lot of

pathology on show including leprosy, leishmaniasis and even

boring old eczema! Dr Lewis-Jones gave a very good

explanation of the various types of leprosy and their treatment

as well as enlightening us about the vast numbers of patients

seen in a day in the local hospital.

It was then time for some more Berliner expertise in the form

of Dr Sandra Phillip of the Charité University Medical Centre.

Her subject was Psoriasis and its Comorbidities. She produced

compelling evidence to suggest that those patients with

moderate to severe psoriasis should be screened for metabolic

syndrome and given the appropriate advice regarding weight,

smoking and exercise. This is in addition to psoriasis’ well

known rheumatological and gastroenterological co-morbidities.

This is something that will more than likely change my view on

these patients in the future. Talking of the future, we next

went into the past with a very entertaining lecture by Dr Ralf

Hartmann of the Bundeswehr Krankenhaus, Berlin entitled

‘Dermatology – What has changed in the Past 20 years?‘ The

lecture was extremely amusing in parts with a lot of references

to the fact that in the US dermatologists are ‘Beauty Surgeons’

and do not to deal with the important pathological dermatology.

The final lecture was presented by Dr Stephen Jones who

showed us a number of interesting cases, including a case of

Dermatitis Artefacta where the patient self-harmed the skin to

such an extent that he frequently required hospital admission.

This was finally resolved by telling the patient that he could

come into hospital when he had no more lesions. This led to a

marked reduction in his self-harming pattern. What an amazing

effect the mind has over pathological processes and how

problems can be solved with a little lateral thinking.

After our lunch we all gradually departed to the various corners

of the United Kingdom having been well fed, watered and

rested and definitely better educated in Dermatology, the

German Dermatology Service and the History of Berlin.

Personally, I would strongly recommend the PCDS to arrange

further similar conferences in other parts of Europe on a

regular basis.

Richard Lonsdale

PCDS 2nd European Meeting:Grand Hyatt Hotel, Berlin

12 13

Sewing with Christy

My last article covered all the basics of local anaesthesia

including administration, equipment and a few personal

tips. In this article I will describe two of the most common

methods of administration, ‘field block’ and ‘nerve block’.

Firstly, the most conventional method is the “field block“, this

is used because in most cases of removal of skin lesions, there

is no clear cut single nerve supply to the target area involved.

Mark out the contour of the lesion to be excised with a surgical

marker (conventional ball point pen can tattoo the skin

permanently!) then plan your excision skin margin and draw this

as well. Wherever possible this should be a 4 mm margin for

BCCs, 6mm margin for SCCs and 2mm margin for lesions of

uncertain diagnosis. If the lesion is not marked prior to injecting

the local, the definition of the lesion could easily be lost to the

eye once the area is swollen and blanched by the local

anaesthetic. The field block should cover at least 5mm beyond

the area marked out for excision as your sutures will be placed

about 2–4mm from the edges of the wound. When using the

vertical mattress suturing technique to close the cavity (surgical

dead space), a wider area needs to be anaesthetised as the

furthest entry and exit point of the suture will be placed at the

outer borders of the cavity left behind.

For the field block technique, insert the needle into the skin

and advance forward to the furthest point which needs to be

anaesthetised. A 27 gauge ophthalmic needle is very useful

here as it is flexible with a long barrel and narrow gauge

(Sterican 27G x40mm length needle made by Braun. Bottom

right needle on diagram 1). Since this needle has a small

gauge, it is much easier and quicker to draw the anaesthetic

with a standard green needle from the bottle, then use the

Sterican needle to inject. Always inject slowly and withdrawing

at the same time. The continuous movement of the needle

ensures that even if the anaesthetic is inadvertently injected

into a blood vessel, only a small amount of local will be placed

into the circulation.

When rapid anaesthesia is required, inject intra-dermally,

however, be aware that this can be very painful. When a shave

excision is planned, the injection is placed superficially at a 15

degree angle with the bevel facing upwards ,the skin becomes

raised and blanched. This will lift the target lesion off the skin

surface and make it lot easier to shave with either a size 10

blade or curette.

When injecting into the subcutaneous layer of the skin at a 45

degree angle the technique is a lot less painful but, be patient,

the anaesthetic will take a lot longer to work. It is very difficult

to gauge how much local anaesthetic is needed when injecting

into deeper plane i.e. subcutaneously, as there is no certainty

where the anaesthetic has ended up.

If the operating site is extensive, it may be necessary to insert

the needle more than once. In this situation always re-insert

the needle into the skin which is already numb. The anaesthetic

is injected in a ring fashion, around the planned surgery area,

ensuring all the sensory nerves to the site are blocked.

The second technique is the “Nerve block” where the

anaesthetic is targeted to an area next to the root of one or two

specific nerves which supply the planned surgery area. For this

method to be effective a sound understanding of the

anatomical distribution of the nerve supply at the procedure

site and its surface marking is essential to achieve a successful

block. It is always useful to visualise the nerve pathway to

know where to inject the anaesthetic. Once the exact position

of the nerve has been identified insert small amount (1-2 ml) of

local anaesthesia and sit back and wait. All nerve blocks takes

time to work, allow 10-20 minutes and will fail if it is wrongly

placed or not enough time been allowed for it to take effect . A

small amount of local anaesthesia is enough to numb a large

area of skin and does not produce distortion of the local

anatomy surrounding the target lesion. On the other hand this

method does not produce local vaso-constriction which may

make the procedure more difficult to perform.

Nerve blocks are most commonly used on fingers and toes

blocking the digital nerves supply. Fingers and toes are both

supplied by 2 dorsal and palmar or plantar nerves. The four

point injection (approximately 1ml of plain Xylocaine at each

site) technique is commonly used (Diagram 2). This method is

very useful in ingrowing toe nail or any procedure in the fingers

or toes.

When injecting into fingers or toes one should always use plain

Xylocaine to avoid the theoretical risk of Adrenaline

vaso-constriction causing vascular necrosis).

Another common nerve block is Supratrochlear and

Supraorbital nerve block. Place about 1ml of Xylocaine on the

medial end of eyebrow and same amount on the eyebrow in

line with mid pupillary point .This will numb half of the forehead

and scalp up to vertex region. (Diagram 3) However it may

cause temporary weakness of the Orbitcularis muscle and lead

to temporary drooping eyelid for a few hours. Always warn

patients about this possibility. It is a useful method as basal

cell carcinoma are commonly located on the forehead.

Mental nerve blocks will numb the lower half of lip area and

chin. The Mental nerve exits the lower jaw via the mental

foramen which is situated at the lower jaw root of the 2nd

pre-molar tooth. Retract the lower lip to view the lower gum,

identify the 2nd premolar tooth and inject below the tooth.

(below tooth number 20 and 29 on Diagram 4)

Finally, a useful general tip is to use an anaesthetic cocktail!

Combine a short acting and long acting anaesthetic agent to

prolong the effect and give the patient a better post op

experience (6-8 hours of pain free duration). Simply add the

same amount of short acting Xylocaine with or without

adrenaline to the same amount of Levo bupivacaine (0.25% of

Chirocaine).

A relaxed and pain free patient is a pleasure to work on. All

these local anaesthetic techniques take time and practice to

perfect so don’t get discouraged when it doesn’t work the first

time, just keep trying.

Practice safely and I will cover orientation of incision, cutting

and dissecting technique, control of bleeding in the next article.

Christy Chou

Diagram 1 Diagram 2 Diagram 3

Diagram 4

14 15

Recruiting patients with rare skindisease into two national trials

The Stop Gap TrialChief Investigator: Professor Hywel Williams, University of

Nottingham

Lead Clinician: Dr Tony Ormerod, University of Aberdeen

Trial Manager: Eleanor Mitchell, University of Nottingham

Pyoderma Gangrenosum (PG) is a painful ulcerating skin

condition that often affects people with an underlying systemic

disease (such as IBD, RA). It starts as a reddish purple papule

or blister in the skin that develops into a large, deep spreading

ulcer in a matter of days. People with PG are often

misdiagnosed, which can lead to inappropriate surgical

procedures which can worsen the condition. Many ulcers do

not heal and those that do may take many months, resulting in

lengthy hospital admissions. Patients often have recurrent

episodes of PG and may have multiple lesions.

The study is comparing prednisolone and ciclosporin which our

pilot study revealed are the two most commonly used

systemic treatments for PG (results awaiting publication).

However, currently there is no ‘gold-standard’ treatment as

there has been no large scale RCTs in this area. The purpose of

this trial is to evaluate the efficacy and safety for prednisolone

and cyclosporin; the hypothesis behind this being that

ciclosporin gains control of the disease more rapidly and reduces

time to healing for patients with PG compared to treatment with

oral prednisolone. For patients who warrant topical therapy,

there is also a parallel observational study. STOP GAP is a

pragmatic trial which has been designed to reflect normal care

as far as possible. Each patient has to attend 4 visits as part of

the study for a maximum period of 6 months or until the wound

has healed (whichever is first). Investigators can see patients as

part of their routine care in between the trial visits if necessary.

To be eligible to participate in the trial, patients must have a

clinical diagnosis of PG and not have taken one of the study

drugs for the previous month. They must be over the age of 18

years and able to give written, informed consent. A full list of

eligibility criteria can be found on the STOP GAP website.

We need your help!

The UK Dermatology Clinical Trials Network (www.ukdctn.org) is currently running two large

randomised controlled trials of rare skin conditions in 50 hospitals across the UK.

The STOP GAP Trial (Study of Treatments for Pyoderma Gangrenosum Patients) is recruiting

patients with the rare, ulcerative skin condition ‘Pyoderma Gangrenosum’. The BLISTER Trial (The

Bullous Pemphigoid Steroids and Tetracylines Study) is recruiting patients with bullous pemphigoid.

The UK DCTN are keen to promote these trials to all healthcare professionals involved in the

management of these disorders and more information about the studies is detailed below

Recruitment of patients for this trial is taking place in

secondary care dermatology departments around the UK but

many patients are seen in the community by GPs and nursing

teams involved in wound care. In order for us to reach the

target of 140 patients by April 2012, it is important that as

many patients as possible with PG are considered for entry

into the trial. Therefore, if you see a patient with PG in your

surgery, the STOP GAP study team would be grateful if you

would consider referring them to a Dermatologist involved in

the trial. A full list of hospitals involved in the study can be

found on the website, or by contacting the trial manager

directly.

The STOP GAP Trial is now the largest ever trial in PG and the

results will significantly contribute to the world literature of

Pyoderma Gangrenosum and how to manage this disease

more effectively.

The trial is being funded by the National Institute for Health

Research (NIHR) as part of a Programme Grant awarded to the

Centre of Evidence Based Dermatology at the University of

Nottingham.

For more information about the trial, please visit the website:

www.stopgaptrial.co.uk or contact Eleanor Mitchell, Trial

Manager: 0115 8230489 or stopgap@nottingham.ac.uk

The Blister Trial

Chief Investigator: Professor Hywel Williams, University of

Nottingham

Lead Clinician: Professor Fenella Wojnarowska

Trial Manager: Anna Sandell, University of Nottingham

Bullous pemphigoid (BP) is the most common of the

autoimmune blistering skin diseases in Western Europe.

BP is a serious condition with a significant associated morbidity

and mortality rate. Widespread tense and haemorrhagic

blisters, skin erosions and severe itching cause patients a great

deal of distress and pain. Patients are often admitted to

hospital for initial treatment; estimates of admission rates vary,

but they are generally high (up to 100%) thus representing a

significant cost to the NHS.

A Cochrane systematic review addressing the treatment of

bullous pemphigoid highlighted the lack of the evidence

informing our current treatment and UK guidelines. However,

the severity of symptoms and lesions in bullous pemphigoid

make treatment mandatory (usually with oral corticosteroids).

It is thought that in this susceptible elderly population that this

corticosteroid treatment contributes to the high mortality rate.

Therefore, the avoidance of systemic corticosteroids in this

vulnerable group of patients is highly desirable and a safer,

effective, low cost alternative is needed.

There is some evidence that tetracyclines may be effective in

treating bullous pemphigoid. Tetracyclines are cheap and

readily available broad-spectrum antibiotics which have other

non-antibiotic properties. In bullous pemphigoid, they are

thought to work by decreasing the complement-mediated

inflammatory response at the basement membrane zone by

suppressing neutrophil chemotaxis and mediators of the

inflammatory response. Doxycycline is the tetracycline used in

this study as it has fewer gastrointestinal side effects than

oxytetracycline, has a better bioavailability and is easier to

swallow as the tablets are smaller, all of which should improve

adherence to the study.

BLISTER is comparing the efficacy and safety of prednisolone

versus doxycycline is a pragmatic trial which is designed to

reflect normal care as much as possible. Patients are involved

for 52 weeks and this involves 7 visits as part of the study.

Patients who are eligible need to have been naïve of treatment

with prednisolone or doxycycline for BP or any other condition

for 1 year and need to have 3 or more significant blisters on 2

or more body sites.

There are 57 hospitals taking part in this study across the UK

and 12 months left to recruit, so please get in contact with me

if you believe you could boost recruitment with patients from

your site. The most important thing to remember when

referring these patients to secondary care is that the patient

should not have started any systemic treatment for this

disease but they can be receiving topical steroids.

The trial is being funded by the National Institute for Health

Research (NIHR) Health Technology Assessment Programme,

Department of Health, United Kingdom,

For more information about the trial, please visit the website:

www.blistertrial.co.uk or contact Anna Sandell, Trial Manager:

0115 8230510 or blister@nottingham.ac.uk

February 2011 – April 2011

In the search for new knowledge,

sometimes studies have to be performed

to reiterate the blatantly obvious. We

have become so obsessed with evidence

based medicine, that occasionally,

backtracking is necessary to provide the

evidence base which we have assumed

all along. As an example, we have a

paper from Germany that shows1 that if

you are exposed to more ultraviolet light

as a consequence of your occupation,

you are more likely to develop a

squamous cell carcinoma. There you go.

Point proved, now move on.

In a similar vein, but of possibly greater

significance, is a multinational study2 that

looks at the changes within the skin and

peripheral blood in patients with psoriasis.

This shows that, if psoriasis improves

following sun exposure, there is a rapid

reduction in both local and systemic

inflammatory markers. Now there are

confounding factors, such as stress

reduction, but the effect does seem to

follow ‘natural irradiation’. It is interesting to

note, however, that this was a study

performed on twenty experimental subjects

who were taken to the Canary Islands and

exposed to ‘controlled sun exposure’. A few

skin biopsies and a blood test or two seems

a small price to pay for 16 days ‘exposure’.

It is rare that a paper looks at the specific

constraints in which the vast majority of us

work on a daily basis. Tacrolimus ointment can be used to both treat and prevent

flares in atopic eczema. Over a twelve month period, despite the study3 being

sponsored by the makers of tacrolimus ointment, a twice weekly maintenance

regime significantly delayed and reduced the number of exacerbations compared

with standard, reactive regimes. We often spend so long treating diseases, we

forget that it is often better and, in these trying times, cheaper, to prevent them in

the first place.

More psoriasis and ultraviolet light. Clarification now exists as to the best treatment

regime for the application of topical treatments during a course of phototherapy4. It

seems almost counterintuitive, but also seems to make some form of sense that the

application of emollients immediately prior to treatment with narrowband ultraviolet

light therapy can block the beneficial effects of the irradiation. If, however, they are

applied thirty minutes prior to treatment, they have no effect. Whether this is a

physical barrier or a local effect isn’t clarified, but it seems wise to advise the

application of treatments after phototherapy.

Back to tacrolimus5. More evidence to support the proactive paradigm of the

treatment of atopic eczema. Just to confuse the picture slightly, it would appear that

the use of topical steroids on a twice weekly basis may be more efficacious than

topical tacrolimus when used in the same manner. There are occasions when the

production of evidence actually serves to confuse, rather than clarify. It does,

however, create the need for more trials. Does research create research? I can see

the need for a trial to decide...

Comparative studies seem to be this bulletin’s theme. So here’s another one6.

Photodynamic therapy and topical Imiquimod have become standard treatments for

the treatment of actinic keratoses (although it is interesting to note that topical

5-fluorouracil seems to have been completely ignored...). Both studied treatments

are well tolerated, but photodynamic therapy seems to create a higher level of

patient satisfaction. This is not really surprising. In these days of instant this and

instant that, anything that provides a ‘single shot treatment’ would seem to have an

advantage over a treatment that needs application – both of the treatment vehicle on

a regular basis, but also by the sufferer from the disease.

Adult onset atopic dermatitis has recently been recognised as a disease entity in its

own right. Although it shares some features of the more commonplace atopic

Journal Watch

dermatitis (AD), the aetiology and risk factors require defining. Cigarette smoking,

both active and passive, has been shown to be an independent risk factor for the

development of adult onset AD7. As a tool to discourage people from smoking – and

parents from smoking in front of their children – however, the threat that they

develop eczema in later life seems not to carry as much weight as it perhaps should.

When an article is entitled ‘What’s new in acne?’8, it’s always worth a look at, after

all, acne must be one of the commonest primary care presentations of skin disease.

As it turns out, there’s quite a lot. Benzoyl peroxide is enjoying a bit of a resurgence

at the moment, and it appears that stronger preparations demonstrate no benefit

over weaker ones. Topical retinoids are due for a resurgence and it is reassuring to

note that they do not cause an initial worsening of acne and the irritation that they

cause usually settles by 8-12 weeks of use. The evidence for continuing to use

cyproterone acetate containing oral contraceptives becomes weaker and weaker –

particularly in light of recent problems reported in the press – just about any ‘pill’

seems to demonstrate a reduction in lesion count. Light treatments, particularly

photodynamic therapy, show little benefit over topical treatments. Spironolactone

doesn’t appear to be effective (do you know anyone who has actually used this?)

and, finally, diet may or may not have an influence on severity of acne. Helpful

results like that are always accompanied by a call for more robust research...

Slightly more compact is a study looking at alitretinoin for hand eczema9. This study

was sponsored by the makers of Toctino and, without prejudice, shows that

alitretinoin is well tolerated and effective, with ‘distinct therapeutic benefits’ in the

treatment of chronic hand eczema. Fancy that! On a more considered note, it does

seem that this is a useful new treatment for when other strategies have failed.

Whether it will make the leap to primary care remains doubtful.

Hopefully, by the time you read this, it will be topical and necessary to discuss

sunscreen use10. Sunscreens are traditionally organochemical and physical-mineral

preparations. This study looks at adding antioxidants to sunscreens to improve the

protection offered. It appears that there is a benefit in combining such products that

offers protection over and above that which is offered by the constituents alone.

This combination was particularly effective in preventing photoaging. Expect a

proliferation of new products to hit the shelves...sometime.

The use of photography as an aid to referral management has long been a

contentious topic. In the wilds of Scotland, a study was set up using a novel

approach11. Instead of relying upon the referring practitioner to send a blurry image

captured on a mobile phone, professional medical photographers were engaged to

photograph suspect lesions before the images were reviewed by a dermatologist

and triaged into treatment clinics. Despite the increased cost of the image capture,

this model actually worked out both more cost effective and improved the delivery

of definitive care on the first hospital visit. This could well be a model worth pursuing

elsewhere.

There couldn’t be a bulletin without an advance in immunology. Recently, a model

for autoimmune diseases has been developed where the immune response is

skewed away from regulatory T cells and towards specific T-helper cells (Th1 and

Th17). In this study12, this hypothesis was applied to the pathogenesis of vitiligo. We

have always lumped vitiligo in with other autoimmune diseases, now we appear to

be getting to the root cause of it. This study demonstrated increased levels of

Interleukin-17 in both lesional skin and in circulating serum suggesting an important

role for this particular cytokine in the pathogenesis of vitiligo. As we know from

psoriasis, once an interleukin has been identified, it is only a matter of time before

someone develops a monoclonal antibody

against it. Interesting stuff.

Despite basal cell carcinoma being the

most common cutaneous malignancy, the

anatomical cell of origin is still uncertain.

There is gathering evidence that it may be

a tumour of the hair follicle13, although

there are still some contrary voices being

heard. If you combine all these

hypotheses, then the genesis of BCCs

from mutated stem cells, of either

follicular or inter-follicular origin becomes

increasingly likely. What, I can hear you cry

over your hazelnut latte, is the relevance

of all this? If the stem cell can be

identified, then it can be targeted

specifically – perhaps using receptor

proteins in a more precise fashion than the

current, more shotgun blast like

treatments.

Halo naevi are an interesting phenomenon.

They can present on their own, be a

marker for the presence of a melanoma or,

it seems14, in a subset of patients, can be

the trigger for vitiligo. There does seem to

be some overlap between these two,

otherwise distinct, entities. This may,

along with the interleukin story above, lead

to a greater understanding of the

pathogenesis of vitiligo.

Finally, we have a paper from Brian

Diffey15 looking at the time we spend

outdoors. Whilst this seems, well, less

high powered than some papers we have

looked at, it is nonetheless extremely

important considering the rather delicate

state that the majority of the population

finds itself in with regard to vitamin D

synthesis. Sun exposure, during the

summer months, of 5-30 minutes , three

times a week, is probably adequate to give

an adequate vitamin D status. It would

seem that we easily do this, with, during

the summer months, an average of 1-2

hours being spent outdoors per day. This,

however, may not be comprehensive as

the time of day is almost as important as

the duration of exposure. This may explain

why the majority of the British population

is vitamin D insufficient during the winter

months. I would suggest reading the rest

16 17

18

I’m writing this having just returned from Berlin. Another excellent meeting in what is

a fascinating city. The Russians may have got the idea of a wall from the Romans and

who knows after the recent election another Hadrian or Antonine equivalent may be

appearing if Alex gets his way! Good to see that 25% of the delegates in Berlin were

from Scotland. What do you call a Scots woman with one leg?…..EILEEN.

The more I hear of the fiasco of the NHS “reforms” south of the border the more I’m

glad I’m in the barbaric north. I wondered about having a debate with the motion of

“NHS Scotland should be fully independent” but I have already filled the programme

for the Scottish meeting on 12th/13th November at Westerwood with such

interesting speakers and topics I had no space left. Topics include bullous disorders,

connective tissue disorders, psychodermatology, feet and sex amongst others. I

washed my kilt after last year’s ceilidh…. I couldn’t do a fling with it!

Before Berlin I attended a meeting for GPwSIs which included Clinical Assistants and

Hospital Practitioners at Crieff Hydro. This will hopefully be an annual event so if you

feel you fall into the category of the above have a word with your local LEO rep.

We have the Essential Dermatology Course in Glasgow on May 26th and have been

told there are 70 delegates for this. This shows there is a real hunger for

dermatological knowledge in these parts.

For patients with psoriasis and psoriatic arthritis, PSALV are running a

self-management course in June in Glasgow – further information on the PSALV

website.

The Skin Care Campaign Scotland and the Dermatology Council both met on the 3rd

of March. I was unable to attend but some points of note from the minutes include

the Sun Awareness Campaign to be run in schools had not been implemented by the

Holyrood government. Nicola Sturgeon was in favour of it, however, it was uncertain

which department was in charge of moving it forward. Nicola Sturgeon did say that

some indicator for measuring psoriasis treatment was on the Health Secretary’s

agenda. There was, however, nothing agreed either by the government or the RCGP

about compulsory dermatology education for GP registrars despite Dr Sue

Lewis-Jones highlighting this need 2 years ago! The wheels of bureaucracy etc!

The new SIGN guideline on the Management of Atopic Eczema in Primary Care has

now been published for your perusal on the website (No. 125). If you wish to hear

about the recommendations from this guideline, Dr Doug Smith who was on the

Guideline Development Committee will be doing a workshop on these at the Scottish

meeting in November.

I think that’s all for now. Have a great summer.

One last joke…

What do you call a Scotsman without his 4-legged friend?...Douglas

Iain Henderson

News From Northof the Border

of this bulletin outdoors, in the sun,

with adequate protection and a small

refereshing cup of antioxidants – tea,

perhaps. Julian Peace

References1. Schmitt et al - Occupational ultravioletexposure increases the risk for thedevelopment of cutaneous squamous cellcarcinoma: a systematic review andmeta-analysis. BJD2011:164;291-307

2. Soyland et al – Sun exposure induces rapidimmunological changes in skin and peripheralblood in patients with psoriasis.BJD2011:164;344-355

3. Healy et al - Cost-effectiveness of tacrolimusointment in adults and children with moderateand severe atopic dermatitis: twice weeklymaintenance treatment vs. Standard twice dailyreactive treatment of exacerbations from a thirdparty payer (UK National Health Service)perspective. BJD2011:164;387-395

4. Skellet et al - A randomised, double-blind,negatively controlled pilot study to determinewhether the use of emollients or calcipotriolalters the sensitivity of the skin to ultravioletradiation during phototherapy with narrowbandultraviolet B. BJD2011:164;402-406

5. Schmitt et al – Efficacy and tolerability ofproactive treatment with topical corticosteroidsand calcineurin inhibitors for atopic eczema:systematic review and meta-analysis ofrandomised controlled trials.BJD2011:164;415-428

6. Serra-Guillen et al – A randomisedcomparative study of tolerance and satisfactionin the treatment of actinic Keratosis of the faceand scalp between 5% Imiquimod cream andphotodynamic therapy with methylaminolaevulinate BJD2011:164;429-433

7. Lee et al – Lifetime exposure to cigarettesmoking and the development of adult onsetatopic dermatitis BJD2011:164;483-489

8. Smith et al – What’s new in acne? Ananalysis of systematic reviews published in2009-2010.CED:36;119-123

9. DIrschka et al – An open-label studyassessing the safety and efficacy of allitretinoinin patients with severe chronic hand eczemaunresponsive to topical corticosteroidsCED:36;149-154

10. Wu et al – Anti-oxidants add protection to abroad-spectrum sunscreen. CED:36;178-187

11. Morton et al – Community photo-triage forskin cancer referrals: an aid to service deliveryCED:36;248-254

12. Bassiouny et al – Role of interleukin-17 inthe pathogenesis of vitiligo CED36:292-297

13. Sellheyer – Basal cell carcinoma: cell oforigin, cancer stem cell hypothesis and stemcell markers BJD2011:164;696-711

14. Van Geel et al – Prognostic value and clinicalsignificance of halo naevi regarding vitiligoBJD2011:164;743-749

15. Diffey – An overview of the time peoplespend outdoors. BJD2011:164;848-854

and

to

Children with atopic eczema?

Oilatum®

(light liquid paraffin)

Prescribing Information (Please refer to full Summary of Product Characteristics before prescribing)

Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk. Adverse events should also be reported to Stiefel, a GSK company on 0800 221 441.

NICE guidelines recommend complete emollient therapy for children with atopic eczema. This isthe use of emollients for washing, bathing and moisturising, even when the atopic eczema is clear.1

Patient adherence to an emollient regime has the potential to reduce the need for GP consultations.1

When prescribing Oilatum, ‘Soak and Smooth to Soothe’2–4 is a simple way of explainingcomplete emollient therapy to your patients.

Oilatum® Junior (Light liquid paraffin 63.4% w/w)Uses Liquid bath additive for the treatment of contact dermatitis, atopic dermatitis, senilepruritus, ichthyosis and related dry skin conditions. Dosage and administration Topicaluse only. Use as frequently as necessary. Oilatum Junior should always be used with water,either added to the water or applied to wet skin. Adult bath: Add 1-3 capfuls to an 8-inchbath of water, soak for 10-20 minutes and pat dry. Infant bath: Add ½-2 capfuls to a basinof water, apply gently over entire body with a sponge and pat dry. Contra-indicationsNone. Precautions Patients should be advised to take care to avoid slipping in the bath.If rash or skin irritation develops treatment should be stopped. Drug Interactions Noneknown. Pregnancy and lactation Safety in human pregnancy or lactation has not beenestablished. Side effects None Legal category: GSL. Presentation and Basic NHScost 150ml £2.82, 250ml £3.25, 300ml £5.10 and 600ml £5.89 Product Licence (PL)no. PL 19494/0064. PL holder GlaxoSmithKline UK Limited, 980 Great West Road,Brentford, Middlesex, TW8 9GS. Trading as Stiefel, Stockley Park West, Uxbridge,Middlesex, UB11 1BT. Last date of revision January 2011. Oilatum Junior is a registeredtrademark of Stiefel, a GSK company.

Oilatum® Shower Gel Fragrance-Free (Light liquid paraffin 70% w/w) Uses Treatment of contact dermatitis, atopic dermatitis, senile pruritus, ichthyosis andrelated dry skin conditions. Dosage and administration Topical use only. Adults, childrenand the elderly: always apply to wet skin, normally as a shower gel. Use as frequently asnecessary. Shower as usual. Apply liberally to wet skin and massage gently. Rinse briefly

and lightly pat the skin dry. Contra-indications None. Precautions Patients should beadvised to take care to avoid slipping in the shower. Should not be used on greasy skin.Drug Interactions None. Pregnancy and lactation Inadequate evidence regarding thesafety of Oilatum Shower Gel Fragrance-Free in human pregnancy and lactation. Sideeffects None. Legal category: GSL. Presentation and Basic NHS cost: 150g £5.15Product Licence (PL) no. PL 19494/0065. PL holder GlaxoSmithKline UK Limited, 980Great West Road, Brentford, Middlesex, TW8 9GS. Trading as Stiefel, Stockley Park West,Uxbridge, Middlesex, UB11 1BT. Last date of revision January 2011. Oilatum ShowerGel Fragrance-Free is a registered trademark of Stiefel, a GSK company.

Oilatum® Junior Cream (Light liquid paraffin 6% w/w and white soft paraffin 15% w/w)Uses Treatment of contact dermatitis, atopic eczema, senile pruritus, ichthyosis and relateddry skin conditions. Dosage and administration Topical use only. Use as often asrequired. Apply to the affected area and rub in well especially after washing. Oilatum JuniorCream is suitable for adults, children and the elderly. Contra-indications Hypersensitivityto any of the ingredients. Precautions Cetostearyl alcohol and potassium sorbate maycause local skin reactions (e.g. contact dermatitis). Hospital users are advised to followlocal procedures and policies for using topical products on in-patients. Drug InteractionsNone. Pregnancy and lactation There are no restrictions on the use of Oilatum JuniorCream during pregnancy or lactation. Side effects May cause irritation in patientshypersensitive to any of the ingredients. Legal category: GSL. Presentation and Basic

NHS cost Tube: 150g £3.38, Pump pack: 350ml £4.65, 500ml £4.99, 1050ml £9.98.Product Licence (PL) no. PL 19494/0076 and PL 19494/0072 PL holderGlaxoSmithKline UK Limited, 980 Great West Road, Brentford, Middlesex, TW8 9GS.Trading as Stiefel, Stockley Park West, Uxbridge, Middlesex, UB11 1BT. Last date ofrevision February 2011. Oilatum Junior Cream is a registered trademark of Stiefel, a GSK company.

References:1. NICE Guideline 57. Atopic eczema in children. December 2007. Available at:

http://www.nice.org.uk. Last accessed March 2011. 2. Oilatum Junior Summary of Product Characteristics, 2010. 3. Oilatum Shower Gel Fragrance-Free Summary of Product Characteristics, 2010. 4. Oilatum Junior Cream Summary of Product Characteristics, 2011.

Date of preparation: March 2011 UK/MARK/0287j/11

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

Essential DermatologyRCP, LondonFriday 9th September 2011

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

There is currently much work going on behind the scenes as we get ready to launch the

website with the new software.

Once up and running the new software will have the following benefits:

• The chapters on clinical guidance will run in a standard format, which will not only make

for better reading but it will make updating a lot easier

• Clicking on images will enable them to be opened up into a bigger window

• On-line payments

Once the new software is up and running there are a variety of new chapters including

vitiligo, dermatitis herpetiformis and Neurofibromatosis 1.

As ever any thoughts or suggestions about the websites are welcome.

Best wishes

Tim Cunliffe

Website Update...

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