Dermatitis artefacta.

Dermatitis artefacta (factitious skin disorder) is a rare psychocutaneous disorder that poses a complex clinical challenge to clinicians. The hallmarks of diagnosis include self-inflicted lesions in accessible areas of the face and extremities that do not correlate with organic disease patterns. Importantly, patients are unable to take ownership of the cutaneous signs. It is essential to acknowledge and focus on the psychologic disorders and life stressors that have predisposed the condition rather than the mechanism of self-injury. The best outcomes are achieved via a holistic approach in the setting of a multidisciplinary psychocutaneous team addressing cutaneous, psychiatric, and psychologic aspects of the condition simultaneously. A nonconfrontational approach to patient care builds rapport and trust, facilitating sustained engagement with treatment. Emphasis on patient education, reassurance with ongoing support, and judgment-free consultations are key. Enhancing patient and clinician education is essential in raising awareness of this condition to promote appropriate and timely referral to the psychocutaneous multidisciplinary team.

Maintaining Clinical Freedom Whilst Achieving Value in Biologics Prescribing: An Integrated Cross-Specialty Consensus of UK Dermatologists, Rheumatologists and Gastroenterologists.

BACKGROUND: Biologics are now key drugs in the management of immune-mediated inflammatory diseases. However, the increasingly complex biologics environment and growing cost pressures in the UK have led to variability in drug commissioning and inequity of patient access across regions. OBJECTIVES: Our objectives were to provide consensus recommendations for enhancing the current situation in biologic prescribing in the UK by balancing clinical freedom with equitable distribution of biologics given the limited availability of resources. METHODS: A modified Delphi approach was used to reach integrated, cross-specialty consensus among dermatologists, rheumatologists and gastroenterologists practising within the English National Health Service (NHS). RESULTS: We describe the concepts of clinical freedom and clinical judgement and demonstrate how, together with patient choice, they can be exercised in the context of biologic prescribing in the NHS. We highlight that in England, local variations occur that are at odds with National Institute for Health and Care Excellence (NICE) guidance; these variably limit the degree to which clinicians can exercise clinical freedom and impact on equity of patient access to treatments. We define factors encompassing a drug's value and identify challenges to the measurement and interpretation of this concept, which can raise barriers to the freedom of clinical choice and appropriate prescribing decisions allowing practices of holistic and personalised medicine. Cross-specialty consensus recommendations on ensuring equitable access to biologics in the NHS while protecting appropriate and individualised drug selection for patients are provided. We have also provided strategies for improving physician-commissioner communication to harmonise equity of patient access to biologics across England and improve patient outcomes. Commentary from patient advisory groups indicates that they welcome our exploration that value does not equal cost and agree that there should be an emphasis on shared decision making, which requires the clinician to practice clinical freedom by aligning the patient's needs and preferences with available treatment choices. CONCLUSIONS: This consensus highlights the need to strike a balance between clinical freedom and short-term cost restrictions to support equitable resource distribution within the English NHS. Consideration of these recommendations may help to harmonise local, regional and national services and balance equity of patient access to biologic treatments with excellence in the NHS.

An evaluation of intensity of delusional belief in patients with delusional infestation pre- and post-treatment in a specialist psychodermatology center.

INTRODUCTION: The majority of patients with delusional infestation (DI) seek help from dermatologists as they consider their condition to be of cutaneous origin and deny referral to psychiatrists, with the prevalence of the condition arising. The objectives of our study were: (i) to assess whether there is a fixed delusional ideation in patients with DI, (ii) to assess the efficacy of managing such patients with combined dermatological and psychiatric treatment and (iii) to test any correlation between BABS scores and other variables. METHODS: All consecutive newly diagnosed patients with DI, from January 2014 to January 2015, seen in our specialist psychodermatology clinic were enrolled in our prospective observational study. Brown Assessment of Beliefs Scale (BABS) was used to assess the intensity of delusion. Correlation between BABS and other variables was also assessed. RESULTS: Forty-three patients were enrolled. There was a range of BABS scores pre- and post-treatment, indicative of the presence of a range of delusional ideation. A significant reduction in the BABS scores was noted post-treatment from 16.10 ± 5.53 to 11.66 ± 8.26 (p < .002). CONCLUSION: This is the first study to objectively demonstrate that delusional belief in patients with DI is not a binary phenomenon and to demonstrate an efficacious response to a combined multidisciplinary psychodermatological approach.

A Retrospective Analysis of Efficacy and Safety of Intralesional Triamcinolone Injections in the Treatment of Frontal Fibrosing Alopecia Either as Monotherapy or as a Concomitant Therapy.

CONTEXT: Frontal fibrosing alopecia (FFA) is a primary cicatricial alopecia characterized by progressive recession of frontal, and often temporoparietal, hairline mainly in postmenopausal women. Currently, there are no guidelines or proposed evidence-based treatment for FFA. AIMS: The aim of this study was to retrospectively evaluate the effect and safety of intralesional triamcinolone acetonide injections (ITAIs) either as monotherapy or as concomitant treatment in the management of hairline recession in FFA. SUBJECTS AND METHODS: All patients with FFA, who visited our specialist hair clinic from July 2012 to October 2016 and were treated with ITAI either as monotherapy or as concomitant treatment, were enrolled in our study. Measurements were performed from five different points on the scalp. The analysis of data included demographics, associated symptoms, clinical and dermoscopic findings, comorbidities, family history of FFA, concomitant medication, treatment outcome, and recording of adverse events. STATISTICAL ANALYSIS: Statistical analysis was performed using the Statistical Package for the Social Sciences, version 22.0. RESULTS: A total of 40 patients, all females were enrolled in our study. The mean age of the patients was 65.88 ± 8.18 whereas the mean age of the diagnosis was 61.24 ± 7.4. A total of 39 patients were treated with a combination of treatments, including ITAI, and only one with ITAI as monotherapy. There was a halting of the progress of the disease, and no significant adverse events were noted, apart from mild pain. CONCLUSIONS: A halting in the progression of FFA was achieved, with unremarkable adverse events. ITAI could serve as an effective and safe option for the treatment of FFA, although difficult to assess it as monotherapy. Further randomized controlled trials are needed to evaluate its efficacy and safety as the sole treatment in the management of FFA.

A patient with delusional infestation by proxy: Issues for vulnerable adults.

A 57-year-old Caucasian female presented to our clinic with her 23-year-old son, who was profoundly autistic. Our patient was convinced that her son had an infestation with fibers and believed that he had developed the condition as a young child. She described the symptoms of the infestation in her son's skin on his behalf, as he was not able to communicate. She identified dietary factors as a causative factor and wanted them removed from his diet. Her son had seborrhoeic dermatitis on examination, with no evidence of an infestation. Our patient later identified that fibers were coming out of her skin also. Her medical history included a road traffic accident resulting in back pain. Blood, urine, and microbiological investigations were normal. She was diagnosed with delusional infestation (DI) by proxy, and was started on risperidone. We present an interesting case of a patient with DI by proxy, in which the delusional beliefs of the mother have been projected onto her son. Issues of safeguarding vulnerable adults are raised in such cases, suggesting the crucial role of the physician in ensuring patient safety. DI by proxy has been reported in patients with children and animals, but we believe this is the first report of DI by proxy involving a vulnerable adult.

Study of platelet-rich plasma injections in the treatment of androgenetic alopecia through an one-year period.

BACKGROUND: Platelet-rich plasma (PRP) is defined as an autologous concentration of plasma with a greater count of platelets than that of whole blood. Its action depends on the released growth factors from platelets. It has been investigated and used in numerous fields of medicine. Recently, PRP has received growing attention as a potential therapeutic tool for hair loss. AIMS: To evaluate the efficacy and safety of PRP injections in the scalp of patients with androgenetic alopecia. SETTINGS AND DESIGN: Prospective cohort study. MATERIALS AND METHODS: 20 patients, 18 males and 2 females, with androgenetic alopecia were enrolled in the study. PRP was prepared using a single spin method (Regenlab SA). Upon activation, it was injected in the androgen-related areas of scalp. Three treatment sessions were performed with an interval of 21 days and a booster session at 6 months following the onset of therapy. STATISTICAL ANALYSIS: Statistical analysis of the data was performed using the Statistical Package for the Social Sciences (SPSS), version 19.0 (IBM, NY, USA). RESULTS: Hair loss reduced and at 3 months it reached normal levels. Hair density reached a peak at 3 months (170.70 ± 37.81, P < 0.001). At 6 months and at 1 year, it was significantly increased, 156.25 ± 37.75 (P < 0.001) and 153.70 ± 39.92 (P < 0.001) respectively, comparing to baseline. Patients were satisfied with a mean result rating of 7.1 on a scale of 1-10. No remarkable adverse effects were noted. CONCLUSIONS: Our data suggest that PRP injections may have a positive therapeutic effect on male and female pattern hair loss without remarkable major side effects. Further studies are needed to confirm its efficacy.