Effectiveness and Safety of Azathioprine versus PUVA-SOL as Steroid-Sparing Agents in the Treatment of Unstable Vitiligo.

Vitiligo is an acquired chronic loss of skin pigmentation characterized by white and frequent symmetric patches, for which corticosteroids are the mainstay of treatment. Regular intake of steroids for prolonged periods is frequently associated with severe and sometimes irreversible adverse events. This study was designed to compare the effectiveness and safety profiles of azathioprine versus psoralen+ultraviolet light A (PUVA)-solar light (SOL; sunlight) to determine which agent reduces the length and adverse effects of vitiligo therapy in a better manner. This single-center, randomized, open-label, prospective case-control study recruited 100 patients. Oral mini-pulse (OMP) corticosteroid therapy was administered to all patients during the first month of the study. The first group of patients (group A) continued with azathioprine 50-mg tablet twice a day (BID), and the second group (group B) was given PUVA-SOL for 2 months with concurrent OMP. Disease activity was monitored. At the end of the study period, 58% (group A) and 50% (group B) of patients had their improved vitiligo area severity index (VASI) scores by 25%-50%. Similarly, 36% (group A) and 50% (group B) of patients improved their VASI score by more than 50%. On the global physician assessment scale, 42% (group A) and 54% (group B) patients had a good to excellent response. Based on these findings, both azathioprine and PUVA-SOL were considered as good steroid-sparing agents, primarily if used with an initial phase of concomitant oral corticosteroids.

The dermatologist identity crisis: a phenomenological analysis of dermatology trainee professional identity during generalist redeployment.

BACKGROUND: Dermatology faces a workforce crisis against a backdrop of wider medical education shifts towards generalism. A pivot towards generalism may have an impact on dermatology trainee professional identity, which, to our knowledge, has not been investigated and is known to have an impact on competence and conceptualization of ethics among physicians. Disruption because of the COVID-19 pandemic led to dermatology trainee redeployment and therefore presents a unique opportunity to examine dermatology trainee professional identity during times of pressure. AIM: To identify the impact of COVID-19 redeployment on dermatology trainee professional identity, the factors influencing identity and whether such factors affect trainees' perceptions about their future careers. METHODS: Ten trainees were purposively recruited to the study. Data were collected through semistructured interviews and were analysed phenomenologically using the template analysis method. Central and integrative themes were identified. RESULTS: Three central themes were identified: trainee identity and values; redeployment transitions; and future clarity. Three integrative themes were found: tribes; sense of purpose; and uncertainty. Trainees see competence and community as central to the dermatologist identity. Most trainees experienced a reaffirmation of their prior values, psychologically retreating to close-knit communities. However, some underwent disorienting dilemmas, later reflecting on their futures as dermatologists. CONCLUSION: Healthcare crises may have a significant impact on dermatology trainee professional identity and may lead to reaffirmation of prior tribal values or disorienting reflection upon future career trajectories. Improved support among diverse communities, minimization of uncertainty and fostering a sense of purpose among trainees may aid identity enrichment and safeguard the future dermatology consultant workforce.

Medical abortion can be provided safely and effectively by pharmacy workers trained within a harm reduction framework: Nepal.

OBJECTIVES: To examine the treatment efficacy, safety and satisfaction of women using medical abortion (MA) pills provided by pharmacists following an education intervention based on a harm reduction approach. STUDY DESIGN: This was an operations research study over a six-month period in 2015, using a non-inferiority design. We provided training to dispense MA pills, based on a harm reduction approach, to a group of pharmacy workers in Makwanpur district (GROUP 2). We compared selected outcomes with women who bought the pills from pharmacy workers in Chitwan district (GROUP 1), who had received similar training in 2010. The primary endpoint measured in 992 women in both districts was complete abortion within 30 days of using the pills. We assessed the efficacy of MA (self-reported complete abortion) and safety (no reported adverse event). To determine complete abortion, we asked women about passage of the products of conception, cessation of abdominal cramps, vaginal bleeding, need for manual vacuum aspiration or repeated doses of misoprostol. We used a four-point Lickert Scale to determine level of satisfaction with MA use. Pearson Chi-Square test was used to examine any differences in proportion of complete abortions between women who were served by the two groups of pharmacy workers. RESULTS: The difference in the rate of complete abortions between the two groups of women, 96.9% and 98.8%, was not statistically significant. The women reported no serious complications, and there was little difference in their satisfaction levels. CONCLUSIONS: Trained pharmacy workers dispensed MA safely and effectively to the satisfaction of almost all women clients, and the positive results of training had continued several years later. IMPLICATIONS: The role of pharmacy workers as providers of correct and complete information on safe and effective use of MA needs to be recognized and policies formulated to allow them to provide MA drugs for first trimester use.

Preparedness of Foundation Year 1 doctors in dermatology.

BACKGROUND: UK medical graduates are required to reach standards defined by the General Medical Council (in Tomorrows Doctors) in all specialties, including dermatology. AIMS: We assessed the self-reported competence of Foundation Year 1 (FY1) doctors in the diagnosis and management of skin disease correlated against their undergraduate dermatology experience. METHODS: The FY1 doctors attending a teaching programme were surveyed at six hospital sites throughout the North Western Deanery. Questionnaires were completed on self-reported competence in learning outcomes defined by the British Association of Dermatologists (BAD). Information recorded previous undergraduate teaching (duration and delivery), and whether they felt sufficiently prepared to diagnose and manage patients with skin disease in their clinical practice. RESULTS: Of 174 FY1 doctors, 118 attended the teaching sessions. All of the attendees completed a questionnaire. Trainees who undertook longitudinal placements in dermatology (defined as 10 or more half days of clinical experience) regarded themselves significantly more prepared to practise for their stage of training: 61 per cent compared with 8.9 per cent (χ(2) = 32.8, df = 1, p < 0.05). Furthermore, these trainees rated their abilities in basic history taking, clinical examination, management of dermatological emergencies and diagnosis of skin malignancy as being greater than those who had not experienced longitudinal placements in the specialty. CONCLUSIONS: Longitudinal placements in dermatology offer undergraduates experience in the diagnosis and management of skin disease that develops confidence for foundation practice.

Nonhealing vegetating plaque on the finger: tuberculosis verrucosa cutis.

Tuberculosis verrucosa cutis is an uncommon form of tuberculosis that typically presents as a chronic warty plaque. It develops in individuals with moderate to high immunity to Mycobacterium tuberculosis due to inoculation of an open wound. We present the case of a Somali man born in the United Kingdom who presented with a nonhealing ulcer on the right hand of 10 years' duration. The patient was diagnosed with tuberculosis verrucosa cutis based on clinical suspicion, which was confirmed by several investigations including strongly positive results of a Mantoux test, IFN-gamma release assay, typical histology on skin biopsy, and polymerase chain reaction (PCR) analysis positive for mycobacterial DNA. Treatment with quadruple antituberculous therapy produced rapid resolution of the ulcer. This unusual condition often is overlooked in the differential diagnosis of nonhealing ulcers, yet it has an excellent prognosis with treatment. A high index of suspicion is required.

The use of retinoids in the treatment of photoaging.

Photoaging describes the clinical and histologic consequences of chronic sun exposure, the key features of which--wrinkles and mottled hyperpigmentation--are frequently and erroneously attributed to the aging process. Although a number of surgical procedures can improve the clinical appearance of photoaged skin, the only medical therapy with proved benefit derived from randomized clinical trial evidence is the use of topical retinoids, particularly tretinoin, isotretinoin, and tazarotene. Retinoids are capable not only of repairing photoaged skin at both the clinical and biochemical levels but their use may prevent photoaging. There is in addition emerging evidence that topical retinoids could be beneficial in the treatment of intrinsically aged skin.

Impaired Langerhans cell migration in psoriasis.

We have examined whether psoriasis is associated with systemic effects on epidermal Langerhans cell (LC) function and, specifically, the migration of LCs from the skin. Compared with normal skin, the frequency and morphology of epidermal LCs in uninvolved skin from patients with psoriasis was normal. However, mobilization of these cells in response to stimuli that normally induce migration (chemical allergen, tumor necrosis factor alpha [TNF-alpha], and interleukin-1beta [IL-1beta]) was largely absent, despite the fact that treatment with TNF-alpha and IL-1beta was associated with comparable inflammatory reactions in patients and controls. The failure of LC migration from uninvolved skin was not attributable to altered expression of receptors for IL-1beta or TNF-alpha that are required for mobilization, nor was there an association with induced cutaneous cytokine expression. Although a role for altered dynamics of LC migration/turnover has not been formally excluded, these data reveal a very consistent decrement of LC function in psoriasis that may play a decisive role in disease pathogenesis.