The British Association of Dermatologists' Undergraduate Curriculum Update 2021.

The General Medical Council (GMC) plans to introduce a national Medical Licensing Assessment (MLA) in 2024 for all UK medical students as part of their primary medical qualification, with dermatology specified in its assessment blueprint. We present an Update to the British Association of Dermatologists' Undergraduate Curriculum, aligned both to the MLA Content Map and the GMC Outcomes for Graduates 2018.

Next steps in dermatology training: choosing to enter higher speciality training and the transition from trainee to consultant dermatologist.

BACKGROUND: Junior doctors are required to make career decisions at an early stage in their postgraduate training. Trainees also feel inadequately prepared for the transition to consultant roles. AIM: To explore the key factors influencing the choice of dermatology as a postgraduate medical career and to identify the training needs required for transition from trainee to consultant. METHODS: An online questionnaire was designed to identify (i) why trainees chose a postgraduate medical career in dermatology, and (ii) the training required for transition from trainee to consultant. RESULTS: In total, 46 responses were received from trainees in their first to final years (ST3-6), of whom 89% had undertaken an undergraduate dermatology placement, with a median duration of 2 weeks. Dermatology was considered as a career during medical school by 61% of trainees, and 41% confirmed their decision to pursue a career in dermatology during foundation training. The most influential factors involved in speciality selection were first, enjoyment of the work, second, postgraduate experience and equal third, the variety of the speciality and the regularity of working hours (P < 0.05). Mentoring was pivotal to career decision-making. Significant numbers of trainees expressed a need for training in medical leadership, such as running an outpatient clinic and supervising clinical multidisciplinary teams. Although larger numbers of trainees had training in management of dermatology services, such as service improvement (52%) and local governance/National Health Service structures (43%), significant numbers of trainees had no training in writing job plans (89%) or business plans (85%). Training was significantly deficient for personal management and self-awareness. CONCLUSION: Our study highlights important considerations in career decision-making for trainees. Training in medical leadership, management and self-awareness could be enhanced to ensure that trainees feel adequately equipped for consultant roles.

Distinctive clinical and histological characteristics of atrophic and hypertrophic facial photoageing.

BACKGROUND: Photoageing describes complex cutaneous changes which occur following chronic exposure to solar ultraviolet radiation (UVR). Amongst White Northern Europeans, facial photoageing appears as distinct clinical phenotypes: 'hypertrophic' photoageing (HP) and 'atrophic' photoageing (AP). Deep, coarse wrinkles predominate in individuals with HP, whereas those with AP have relatively smooth, unwrinkled skin with pronounced telangiectasia. AP individuals have an increased propensity for developing keratinocyte cancers. OBJECTIVES: To investigate whether histological differences underlie these distinct phenotypes of facial photoageing. METHODS: Facial skin biopsies were obtained from participants with AP (10 M, 10 F; mean age: 78.7 years) or HP (10 M, 10 F; mean age: 74.5 years) and were assessed histologically and by immunohistochemistry. RESULTS: Demographic characterization revealed 95% of AP subjects, as compared to 35% with HP, were Fitzpatrick skin type I/II; of these, 50% had a history of one or more keratinocyte cancers. There was no history of keratinocyte cancers in the HP cohort. Analysis of UVR-induced mitochondrial DNA damage confirmed that all volunteers had received similar lifetime cumulative doses of sun exposure. Histologically, male AP had a significantly thicker epidermis than did AP females or those of either sex with HP. HP facial skin exhibited severe solar elastosis, whereas in AP facial skin, solar elastosis was apparent only in females. Loss of papillary dermal fibrillin-rich microfibrils occurred in all HP and AP female subjects, but not in AP males. Furthermore, male AP had a significant reduction in collagen VII at the dermal-epidermal junction than did AP females or those of either sex with HP. CONCLUSIONS: This study provides further evidence that AP and HP represent distinct clinical and histological entities. Knowledge of these two phenotypes is clinically relevant due to the increased prevalence of keratinocyte cancers in those - particularly males - with the AP phenotype.

A photonumeric scale for the assessment of atrophic facial photodamage.

BACKGROUND: Photonumeric scales have consistently shown superiority over descriptive equivalents. They have the advantage of providing a consistent visual frame of reference by minimizing variability in perception and subjectivity. A photonumeric scale to assess hypertrophic facial photodamage already exists. However, there is currently no objective measure for atrophic facial photodamage. To address this, we have devised a nine-point photonumeric standardized scale. OBJECTIVES: To design, test and validate a photonumeric scale for the assessment of atrophic facial photodamage against a descriptive scale for the same indication. METHODS: A pool of 393 facial photographs (en face and 45° oblique) from 131 individuals with atrophic facial photodamage was created. Five photographic standards were selected and assigned grades zero through to eight, where zero is no photodamage and eight is severe atrophic photodamage, thus making a nine-point scale. Twenty photographs spanning the entire range of values were selected to test the scale. Testing was performed alongside a descriptive equivalent. A panel of 10 dermatologists, 10 nondermatology clinicians and 14 dermatology scientists marked the two scales; marking was repeated 1 week later. RESULTS: There was a significantly greater agreement between the graders using the photonumeric scale than the descriptive scale (kappa values 0·71 and 0·37 with standardized errors of 0·57 and 0·17, respectively) with no significant difference in repeatability between the two methods (P < 0·05). CONCLUSIONS: The study describes a new photonumeric scale for atrophic photodamage. This would be a useful adjunct in both the clinical and research settings.

Lifestyle and youthful looks.

BACKGROUND: Lifestyle has been proven to have a dramatic effect on the risk of age-related diseases. The association of lifestyle and facial ageing has been less well studied. OBJECTIVES: To identify lifestyle factors that associate with perceived facial age in white north European men and women. METHODS: Lifestyle, facial wrinkling and perceived facial age were studied in two cross-sectional studies consisting of 318 Dutch men and 329 women aged 45-75 years who were part of the Leiden Longevity Study, and 162 English women aged 45-75 years who were nonsmokers. RESULTS: In Dutch men, smoking, having skin that went red in the sun, being outside in the sun most of the summer, sunbed use, wearing false teeth and not flossing teeth were all significantly associated (P < 0·05) with a total 9·3-year higher perceived facial age in a multivariate model adjusting for chronological age. In Dutch women, smoking, sunbathing, sunbed use, few remaining teeth and a low body mass index (BMI) were associated with a total 10·9-year higher perceived facial age. In English women, cleaning teeth only once a day, wearing false teeth, irregular skin moisturization and having skin that went red in the sun were associated with a total 9·1-year higher perceived facial age. Smoking and sunbed use were associated more strongly with wrinkling in women than in men. BMI, sun exposure and skincare were associated predominantly with perceived facial age via wrinkling, whereas oral care was associated via other facial features. CONCLUSIONS: Although associative in nature, these results support the notion that lifestyle factors can have long-term beneficial effects on youthful looks.

A review of minimally invasive cosmetic procedures.

In today's society the desire to maintain a youthful appearance has driven the development of minimally invasive dermatological procedures that are designed to rejuvenate the ageing face. The aim of this review is to present evidence for the use of techniques which can easily be incorporated into outpatient dermatology practice with low overhead expenditure. For this reason, laser and light-based treatments have been omitted. This review will instead focus on chemical peels, intradermal fillers and botulinum toxin. These techniques address the main aspects of facial ageing, namely photodamage, volume loss and dynamic lines, which correlate anatomically to skin, subcutaneous fat and muscle. A combination of such techniques will provide the practitioner with a reasonable portfolio of treatments for a balanced, holistic result.

Acute erythroderma as an exclusion criterion for idiopathic CD4+ T lymphocytopenia.

BACKGROUND: Idiopathic CD4+ T lymphocytopenia is defined as a CD4+ T lymphocytopenia of less than 0.3 x 10(9)/L that is not associated with human immunodeficiency virus, other immunodeficiency, or immunosuppressive therapy. The associated clinical course and laboratory findings are variable. We describe a subset of patients whose peripheral CD4+ T-lymphocytopenia was transient, and suggest a pathomechanism for this phenomenon. OBSERVATIONS: We describe three patients with cutaneous T-cell lymphoma, atopic dermatitis, or psoriasis in whom acute erythroderma was concomitant with a peripheral CD4+ T lymphocytopenia that normalized after resolution of the erythroderma. Immunoperoxidase staining of skin biopsy specimens and quantitative estimation of CD4+ T lymphocytes in the cutaneous and peripheral blood compartments demonstrated that the peripheral CD4+ T lymphocytopenia in these cases most probably resulted from sequestration of CD4+ T lymphocytes in the skin. The skin of an erythrodermic patient appears capable of sequestering 10(10) to 10(11) CD4+ T lymphocytes, whereas the peripheral blood compartment contains in the range of 10(9) CD4+ T lymphocytes. CONCLUSIONS: We propose that CD4+ T lymphocytopenia can occur as a result of acute erythroderma of multiple causes and that acute erythroderma associated with transient CD4+ T lymphocytopenia be considered as an exclusion criterion for idiopathic peripheral blood CD4+ T lymphocytopenia.

Immunopathogenesis and immunotherapy of psoriasis.

Overwhelming evidence exists supporting the importance of T-lymphocytes and other immunologically competent cells in the pathogenesis of psoriasis. What is still uncertain, however, is whether the keratinocyte plays an initiating role in its own hyperproliferation. Studies at the basic science level have allowed us to identify various cellular and molecular events that the immunopharmacologist can target with a variety of approaches. At present, the most selective immunosuppressant available is cyclosporine. As rapid strides are made toward further elucidation of the immunopathogenesis of psoriasis, more highly selective approaches are fast becoming a reality.

Studies on the protein requirements of growing cattle. Effects of differing intakes of protein and energy on growth and nitrogen metabolism in young entire males.

Forty-eight Friesian entire male cattle, with an initial live weight (LW) of 135 kg, were used in two experiments to measure the response to increasing levels of dietary protein (9-11 and 7.5-10.5 g nitrogen X 6.25/kg LW0.75) at differing energy levels (800-900 kJ metabolizable energy (ME) kg LW0.75) over 120-d periods. Digestibility and N balance measurements were also made during the experiments. The diets, which were based on barley and soya-bean meal, were individually fed twice daily. In a third experiment, similar diets were given to four similar animals fitted with intestinal cannulas, at constant energy intake but with variations in dietary protein of 7.5-13.5 g N X 6.25/kg LW0.75. Chromic oxide paper was used as a digesta marker. Positive responses in LW gain and N balance to additional protein were found in both experiments but these were significant (P less than 0.05) only in the second experiment and were associated with significant (P less than 0.01) increases in the digestibility of modified acid-detergent fibre and ME intake. Mean values, which were not significantly different between treatments, for the degradability of dietary protein in the rumen and the efficiency of microbial protein synthesis were 0.57 and 31.3 g/kg organic matter apparently digested in the rumen respectively. Corresponding values obtained by regression analysis were 0.56 and 28.2. The results in general support the Agricultural Research Council (1980) proposals and suggest that undegraded dietary protein was not limiting in these experiments but that rumen-degradable protein levels were limiting on some treatments. Regression analysis indicated that the mean response to additional protein (g LW gain/g N X 6.25) per kg LW was 0.52 in Expt 1 and 0.51 in Expt 2. These responses could be largely explained by increases in ME intakes. Measurements of duodenal amino acid flow showed marked increases in essential amino acids (EAA) across the rumen. However, EAA flows, were not significantly increased at higher N intakes suggesting that protein per se was not limiting in these experiments.

Multiple warty dyskeratomas of the scalp.

Two patients presented with the unusual condition of multiple warty dyskeratomas on the scalp. Biopsies of affected skin stained positive with human keratin monoclonal antibodies HKN-6 and -7, specific for cortex and inner root sheath of normal human hair, respectively. Multiple warty dyskeratomas are a rare occurrence and their aetiopathogenesis remains elusive. Positive immunohistochemical staining of a lesion with antikeratin antibodies HKN-6 and -7, specific for human hair keratin, suggests a follicular origin for warty dyskeratoma.