RESUMO
Diabetes is a common condition that is increasing in incidence worldwide. Although the skin manifestations of this condition are well described, there is scant literature on the associated nail changes. In this review, we describe the various clinical features of nail changes associated with diabetes, which can be broadly divided into infections, vascular changes, neuropathic manifestations and miscellaneous changes, although there is overlap between them. There is no pathognomonic nail alteration, but it is important for clinicians to be aware of the potential nail manifestations in diabetes as they can facilitate investigations and thereby early diagnosis of diabetes, resulting in holistic management of the patient.
Assuntos
Complicações do Diabetes/diagnóstico , Complicações do Diabetes/terapia , Doenças da Unha/diagnóstico , Doenças da Unha/terapia , Humanos , Doenças da Unha/etiologiaRESUMO
BACKGROUND: The first UK guidelines for the management of hidradenitis suppurativa (HS) were published by the British Association of Dermatologists (BAD) in 2018. The guidelines contained a set of audit criteria. AIM: To evaluate current HS management against the audit standards in the BAD guidelines. METHODS: BAD members were invited to complete audit questionnaires between January and May 2020 for five consecutive patients with HS per department. RESULTS: In total, 88 centres participated, providing data for 406 patients. Disease staging using the Hurley system and disease severity using a validated tool during follow-ups was documented in 75% and 56% of cases, respectively, while quality of life and pain were documented in 49% and 50% of cases, respectively. Screening for cardiovascular disease risk factors was as follows: smoking 75%, body mass index 27% and others such as lipids and diabetes 57%. Screening for depression and anxiety was performed in 40% and 25% of cases, respectively. Support for smokers or obese patients was documented in 35% and 23% of cases. In total, 182 patients were on adalimumab, of whom 68% had documentation of baseline disease severity, and 76% were reported as having inadequate response or contraindications to systemic treatments; 44% of patients continued on adalimumab despite having < 25% improvement in lesion count. CONCLUSION: UK dermatologists performed well against several audit standards, including documenting disease staging at baseline and smoking status. However, improvements are needed, particularly with regard to screening and management of comorbidities that could reduce the long-term complications associated with HS. A re-audit is required to evaluate changes in practice in the future.
Assuntos
Auditoria Clínica , Hidradenite Supurativa/diagnóstico , Hidradenite Supurativa/tratamento farmacológico , Adalimumab/uso terapêutico , Anti-Infecciosos Locais/uso terapêutico , Anti-Inflamatórios/uso terapêutico , Índice de Massa Corporal , Fármacos Dermatológicos/uso terapêutico , Fidelidade a Diretrizes , Hidradenite Supurativa/complicações , Humanos , Guias de Prática Clínica como Assunto , Qualidade de Vida , Fatores de Risco , Índice de Gravidade de Doença , Fumar/efeitos adversos , Tetraciclinas/uso terapêutico , Reino UnidoRESUMO
Nail changes are frequently seen in patients with cutaneous lichen planus and alopecia areata. This manuscript provides an updated overview on the clinical features, management and prognosis of both conditions. Searches of electronic databases PubMed and EMBASE were conducted and eligible articles were accessed. Practical management principles relevant to these two conditions are also included.
Assuntos
Alopecia em Áreas/complicações , Líquen Plano/complicações , Doenças da Unha/etiologia , Unhas/patologia , Administração Intravesical , Administração Tópica , Humanos , Doenças da Unha/tratamento farmacológico , Prognóstico , Esteroides/administração & dosagemRESUMO
Nail changes are visible in a variety of inflammatory dermatoses. The commonest dermatological condition with nail manifestations is chronic plaque psoriasis. This two-part article reviews the nail signs in psoriasis in Part 1, and the nail changes in cutaneous lichen planus and alopecia areata in Part 2. It provides a brief summary of the salient points in the clinical features, management and prognosis of these entities, with practical recommendations that may be beneficial to all dermatologists.
Assuntos
Fármacos Dermatológicos/administração & dosagem , Glucocorticoides/administração & dosagem , Doenças da Unha/etiologia , Unhas/patologia , Psoríase/complicações , Administração Tópica , Dermoscopia , Humanos , Injeções Intralesionais , Metotrexato/uso terapêutico , Doenças da Unha/diagnóstico , Doenças da Unha/tratamento farmacológico , Psoríase/patologia , Esteroides/administração & dosagem , Triancinolona/administração & dosagemAssuntos
Alopecia , Líquen Plano , Alopecia/epidemiologia , Estudos Transversais , Feminino , Fibrose , Humanos , Reino Unido/epidemiologiaRESUMO
Psoriasis remains one of the commonest conditions seen in dermatological practice, and its treatment is one of the greatest cost burdens for the UK National Health Service. Treatment of psoriasis is complex, with numerous overlapping lines and therapies used in combination. This complexity reflects the underlying pathophysiology of the disease as well as the heterogeneous population that it affects. National Institute for Health and Care Excellence (NICE) guidance for the treatment of psoriasis has been available since 2013, and has been the subject of three national audits conducted by the British Association of Dermatologists. This report synthesizes the results of the most recent of those exercises and places it in the context of the NICE guidance and previous audits. It clearly shows the significant burden of disease, issues with provision of services and long waiting times and the marked shift in therapies towards targeted biologic therapies.
Assuntos
Terapia Biológica/métodos , Psoríase/diagnóstico , Psoríase/terapia , Medicina Estatal/economia , Administração Tópica , Terapia Biológica/estatística & dados numéricos , Terapia Combinada/métodos , Efeitos Psicossociais da Doença , Dermatologistas/organização & administração , Humanos , Auditoria Médica/estatística & dados numéricos , Fototerapia/métodos , Fototerapia/estatística & dados numéricos , Psoríase/fisiopatologia , Psoríase/psicologia , Sistemas de Apoio Psicossocial , Medicina Estatal/organização & administração , Reino Unido/epidemiologia , Listas de EsperaRESUMO
BACKGROUND: Bullous pemphigoid (BP) is an autoimmune, subepidermal, blistering condition that typically affects elderly people. AIM: To undertake a national clinical audit based on standards derived from the British Association of Dermatologists (BAD) clinical guidelines on the management of BP. METHODS: In 2018, BAD members were invited to submit data for five consecutive adults with BP per centre, who had been under hospital supervision for at least 12 months, in a national audit over an 11-week period. RESULTS: In total, 123 responders from 120 hospitals provided data for 524 cases. Diagnosis was made either clinically (10.7%; 56 of 524) or through histology with direct immunofluorescence (41.6%; 218 of 524), indirect immunofluorescence (10.3%; 54 of 524) or both (37.4%; 196 of 524). Most patients had very mild baseline disease (63.9%; 225 of 352) with 21.9% (77 of 352) considered mild, 9.8% (31 of 352) moderate and 5.4% (19 of 352) severe. Documentation of diabetes, glycated haemoglobin (HbA1c), blood pressure and hypertension was available for 54.1% (283 of 523), 51% (267 of 524), 44.2% (231 of 522) and 61.5% (321 of 522) of cases, respectively. Oral corticosteroids were commenced in 85.5% (448 of 524) of patients, with 38.4% (172 of 448) of these having documented risk of osteoporosis; data regarding prescription of bone-protection therapies were available for 99.7% (447 of 448) of cases, with 75.6% (338 of 447) of these having a bone-protection prescription. Patient satisfaction was documented in 59.3% (310 of 523) of cases. Systemic treatment was commenced in 95.9% (502 of 524) of cases during the 12-month assessment period, with baseline blood test and follow-up data available for 96.6% (485 of 502) and 95.6% (480 of 502), respectively. Documentation of baseline blood tests was available for 87.4% (424 of 485) of cases, with follow-up tests recorded in 69.8% (335 of 480). CONCLUSION: Overall, compliance with elements of documentation was moderate or low, whereas standards pertaining to direct care were high.
Assuntos
Corticosteroides/uso terapêutico , Fidelidade a Diretrizes/estatística & dados numéricos , Penfigoide Bolhoso/diagnóstico , Penfigoide Bolhoso/tratamento farmacológico , Auditoria Clínica , Comorbidade , Documentação/estatística & dados numéricos , Imunofluorescência , Humanos , Satisfação do Paciente , Guias de Prática Clínica como Assunto , Reino UnidoRESUMO
BACKGROUND: We conducted a re-audit of the surgical practice of UK dermatologists for the treatment of nonmelanoma skin cancer and examined changes with reference to our previous audit in 2014. The audit was supplemented by a detailed assessment of completeness of the histopathology reports for each tumour. METHODS: UK dermatologists collected data on 10 consecutive nonmicrographic excisions for basal cell carcinoma (BCC) and 5 for squamous cell carcinoma (SCC). Data were collected on site, preoperative diagnosis, histological diagnosis, proximity to previous scars, and histological deep and peripheral margins. RESULTS: In total, 222 responses were received from 135 centres, reporting on 3290 excisions. Excisions from the head and neck accounted for 56.7% of cases. Tumour diameter (mean ± SD) was 11.4 ± SD 7.1 mm (maximum size 100 mm) and 97% of cases were primary excisions. BCCs and SCCs respectively accounted for 65.7% and 26.8% of total cases. Of the suspected BCCs and SCCs, 95.8% and 80.4%, respectively, were confirmed histologically. All margins for any tumour were clear in 97.0% of cases, and complication rate in the audit was < 1%. Of the 2864 histology reports evaluated, only 706 (24.6%) contained all core data items; 95% of these were structure (synoptic) reports. Commonly omitted items were level of invasion, risk and T stage, which were absent from 35.7%, 64.2% and 44.1% of reports, respectively. CONCLUSIONS: Diagnostic accuracy and complete excision rates remain high. Complication rates may be under-reported owing to lack of follow-up. Histopathology reporting has a greater chance of being complete if reports are generated on a field-based platform (synoptic reporting).
Assuntos
Dermatologistas , Patologistas , Padrões de Prática Médica/estatística & dados numéricos , Neoplasias Cutâneas/cirurgia , Carcinoma Basocelular/cirurgia , Carcinoma de Células Escamosas/cirurgia , Auditoria Clínica , Procedimentos Cirúrgicos Dermatológicos/estatística & dados numéricos , Margens de Excisão , Neoplasias Cutâneas/diagnóstico , Neoplasias Cutâneas/patologia , Sociedades Médicas , Reino UnidoAssuntos
Dermatologia/estatística & dados numéricos , Encaminhamento e Consulta/estatística & dados numéricos , Consulta Remota/instrumentação , Neoplasias Cutâneas/patologia , Adulto , Biópsia/estatística & dados numéricos , Dermatologia/tendências , Clínicos Gerais/normas , Hospitais de Ensino/normas , Humanos , Fotografação/métodos , Padrões de Referência , Neoplasias Cutâneas/diagnóstico , Neoplasias Cutâneas/epidemiologia , Inquéritos e Questionários , Fatores de TempoRESUMO
BACKGROUND: In 2010, the British Association of Dermatologists (BAD) published clinical guidelines for the safe introduction and continued use of isotretinoin in patients with acne in the UK. The BAD provides UK dermatologists with a facility for national audit, and it undertook an audit on compliance with these guidelines in 2012. AIM: To determine current clinical practices relating to use of isotretinoin among dermatologists in the UK (including geographical variations) as measured against BAD standards, and to ascertain any improvement since the 2012 audit. METHODS: The 2012 isotretinoin audit proforma was used, with additional questions on clinical setting, complaints and litigation. A web-based survey tool was used for data entry and submission, with email invitation to working, UK-based BAD members (n = 1226) in December 2013 and weekly reminders during the 8.5-week data collection period. Responders were requested to enter data for the three most recent consecutive patients (including one male and one female patient) who had completed treatment within the previous 6 months. RESULTS: In total, 338 (27.6%) respondents provided data on 1013 patients. Serum lipids were checked in 93.4% of patients and documentation of mental health and/or mood state was recorded in 82.1%. Regarding the Pregnancy Prevention Programme (PPP), 91.6% of female patients of childbearing potential had signed the PPP information form, while 93.3% who had followed the PPP had taken pregnancy tests both before and during treatment, and 54.7% had taken a pregnancy test 5 weeks post-treatment. CONCLUSION: Overall, there is currently good compliance with standards. Certain aspects of care that are less frequently preformed, such as pregnancy testing post-treatment, are highlighted.
RESUMO
BACKGROUND: The incidence of skin cancer is increasing. The two-week wait conversion rate (TWWCR) is the percentage of urgent suspected skin cancer referrals that are confirmed as cancer. AIMS: To examine the relationships between different epidemiological factors and TWWCR for malignant melanoma (MM) and cutaneous squamous cell carcinoma (SCC). METHODS: We extracted data from the National Cancer Data Repository (NCDR) and National Cancer Waiting Times Monitoring Dataset between 2009 and 2010 for MM and SCC in England. We conducted partial correlation and stepwise multiple regression analysis on TWWCR, age, incidence, detection rate, tumour thickness (MM only), percentage MM/SCC and social deprivation. We also looked at the two-week wait referral rate (TWWRR) and incidence rate with respect to age. RESULTS: TWWCR was significantly correlated with age when partial correlation was used to control for the factors described above for MM (P < 0.05) and SCC (P < 0.001). Stepwise regression of these factors returned only age as significant in the final model for MM (P < 0.001) and SCC (P < 0.01). Incidence of MM and SCC increased with age. TWWRR also increase with age, but with higher rate in younger people relative to their incidence. CONCLUSIONS: Age is a predictor of TWWCR independent of the other factors measured, including thickness and incidence. This may be explained by the higher number of referrals for younger patients despite the lower incidence of skin cancer in this group. This may reflect a more appropriate rate of referral in order to achieve earlier diagnosis and better outcomes.
Assuntos
Carcinoma de Células Escamosas/epidemiologia , Melanoma/epidemiologia , Encaminhamento e Consulta , Neoplasias Cutâneas/epidemiologia , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Escamosas/patologia , Criança , Pré-Escolar , Detecção Precoce de Câncer , Inglaterra/epidemiologia , Humanos , Incidência , Lactente , Melanoma/patologia , Pessoa de Meia-Idade , Análise Multivariada , Estadiamento de Neoplasias , Neoplasias Cutâneas/patologia , Adulto JovemAssuntos
Ceratose Actínica/terapia , Assistência ao Convalescente/métodos , Terapia Combinada , Custos e Análise de Custo , Criocirurgia/métodos , Fármacos Dermatológicos/uso terapêutico , Emolientes/uso terapêutico , Previsões , Humanos , Hospedeiro Imunocomprometido , Ceratose Actínica/diagnóstico , Ceratose Actínica/prevenção & controle , Terapia a Laser/métodos , Fotoquimioterapia/métodos , Atenção Primária à Saúde/métodos , Encaminhamento e Consulta , Fatores de Risco , Atenção Secundária à Saúde/métodos , Autocuidado/métodos , Protetores Solares/uso terapêutico , Falha de TratamentoAssuntos
Dermatoses do Pé/diagnóstico , Dermatoses da Mão/diagnóstico , Onicomicose/diagnóstico , Adolescente , Adulto , Criança , Pré-Escolar , Técnicas de Laboratório Clínico/tendências , Inglaterra/epidemiologia , Feminino , Dermatoses do Pé/epidemiologia , Dermatoses do Pé/microbiologia , Dermatoses da Mão/epidemiologia , Dermatoses da Mão/microbiologia , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Onicomicose/epidemiologia , Onicomicose/microbiologia , Estudos Retrospectivos , Estações do Ano , Adulto JovemRESUMO
BACKGROUND: Diagnosis and management of nonmelanoma skin cancer (NMSC) represents a large part of the dermatology workload, and complete excision is a required surgical standard for treatment. AIM: To conduct an audit of the surgical practice for the treatment of NMSC by dermatologists in the UK. METHODS: Data on 10 consecutive nonmicrographic excisions of nonmelanoma skin cancer by UK dermatologists. Data collected included site, preoperative diagnosis, histological diagnosis, proximity to previous scars, and histological deep and peripheral margins. RESULTS: A total of 227 responses from 135 centres reported 2739 excisions. Excisions on the head and neck accounted for 58.3% of cases. Tumour diameter (mean ± SD) was 10.61 ± 6.9 mm (maximum 130 mm), and 96.7% of cases were primary excisions, with 3.3% being re-excisions. Basal cell carcinomas (BCCs) accounted for 79.1% (n = 2167) of the total cases and squamous cell carcinomas (SCCs) for 17.9% n = 491). Of the suspected BCCs and SCCS, 94.4% (n = 2045) and 66.8% (328), respectively, were confirmed histologically to be the respective carcinomas. Similar proportions of BCC and SCC cases were within 10 mm of a previous excision. Lateral and deep margins were clear in 98.3% and 99.2% of BCC cases, respectively, and in 98.4% and 97.1% of SCC cases, respectively. Reported surgical complication rate in the audit was 3.4%. CONCLUSIONS: The majority of excisions for NMSC are for BCC and SCC. Our figures for diagnostic accuracy are at the upper range of previously published figures. Most patients were not followed up in secondary care, hence complication rates may be under-reported.
Assuntos
Auditoria Clínica/métodos , Procedimentos Cirúrgicos Dermatológicos , Dermatologia , Inoculação de Neoplasia , Encaminhamento e Consulta , Neoplasias Cutâneas/cirurgia , Sociedades Médicas , Diagnóstico Diferencial , Humanos , Melanoma , Prevalência , Neoplasias Cutâneas/diagnóstico , Neoplasias Cutâneas/epidemiologia , Reino Unido/epidemiologiaRESUMO
BACKGROUND: Nail unit squamous cell carcinoma (NUSCC) is uncommon and diagnosis is often initially incorrect or delayed. Immunosuppression appears important in the clinical behaviour of NUSCCs. OBJECTIVES: To highlight the frequency and nature of immunosuppression in a case series of patients with NUSCC, and identify the distinguishing characteristics in this subgroup. MATERIALS AND METHODS: Clinical, photographic and histological details were reviewed for all patients with NUSCC, over a 16-year period in a university dermatology department. RESULTS: Forty-three patients were identified and seven (16%) were immunosuppressed. Patients with immunosuppression presented at a younger age (mean 52 vs. 63 years, P = 0.08) and sooner (mean 9 vs. 65 months, P < 0.001) than immunocompetent patients, and had a higher frequency of polydactylous disease [four of seven (57%) vs. two of 36 (6%), P < 0.001], relapse at the same site [two of seven (29%) vs. 0], and recurrent disease at other sites [four of seven (57%) vs. 0]. CONCLUSIONS: Immunosuppression plays a role in the development and clinical behaviour of NUSCCs. Clinicians should have a low threshold for early biopsy of nail dystrophies, particularly in those with immunosuppression. These patients are at higher risk of relapse and recurrent disease and therefore require prolonged follow-up.
Assuntos
Carcinoma de Células Escamosas/imunologia , Tolerância Imunológica/fisiologia , Terapia de Imunossupressão/efeitos adversos , Doenças da Unha/imunologia , Neoplasias Cutâneas/imunologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Imunocompetência/imunologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: Provisional clinical diagnosis is the first step in planning skin surgery. Different clinical priorities are given to basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and malignant melanoma (MM). Discriminating between SCC and BCC can be difficult. The rate of misdiagnosis of SCC as BCC is reported as 5.7-87.6%, and can cause treatment delay. We have developed a web-based surgery booking system that requires clinical commitment to a putative differential diagnosis category, rather than a single diagnosis, at the time of consultation. This includes a crucial overlap category of 'SCC or SCC/BCC'. AIM: To assess whether our system helped avoid treatment delay to patients with SCC, and to measure the number needed to treat (NNT). METHODS: This was a retrospective analysis from April 2012 to August 2013, comprising all patients undergoing booked excisional surgery in our unit. The clinical triaging category was compared with the histological diagnosis. Sensitivity, specificity, positive predictive value, negative predictive value (NPV), NNT and mean Breslow thickness were calculated. RESULTS: In total, 1455 lesions were excised, identifying 789 (54.2%) invasive malignancies (86 MM, 115 SCC, 583 BCC, 5 other), 100 in situ lesions and 150 dysplastic lesions. The majority (83.2%) of malignancies were designated into the correct malignant category. Misdiagnosis of SCC as BCC was 5.2%. Sensitivity and NPV for SCC were 94.8% and 99.4%, respectively. NNT was 1.26, 4.12 and 3.19 for BCC, SCC and MM respectively, and 1.73 for all malignancies. Mean invasive Breslow thickness was 1.29 mm [0.78 mm including melanoma in situ (MMIS)], and the MM to MMIS was 1.6. CONCLUSION: An overlap triage category of 'SCC or SCC/BCC' helps to prevent delay in the treatment for patients with SCC.