Quantitative evaluation of dermatological antiseptics.

Topical antiseptics are frequently used in dermatological management, yet evidence for the efficacy of traditional generic formulations is often largely anecdotal. We tested the in vitro bactericidal activity of four commonly used topical antiseptics against Staphylococcus aureus, using a modified version of the European Standard EN 1276, a quantitative suspension test for evaluation of the bactericidal activity of chemical disinfectants and antiseptics. To meet the standard for antiseptic effectiveness of EN 1276, at least a 5 log10 reduction in bacterial count within 5 minutes of exposure is required. While 1% benzalkonium chloride and 6% hydrogen peroxide both achieved a 5 log10 reduction in S. aureus count, neither 2% aqueous eosin nor 1 : 10 000 potassium permanganate showed significant bactericidal activity compared with control at exposure periods of up to 1 h. Aqueous eosin and potassium permanganate may have desirable astringent properties, but these results suggest they lack effective antiseptic activity, at least against S. aureus.

Cutaneous Mycobacterium chelonae infection in Edinburgh and the Lothians, South-East Scotland, U.K.

BACKGROUND: We reviewed all cases of Mycobacterium chelonae infection seen in our department between 1 January 2008 and 31 December 2012. OBJECTIVES: To review the epidemiology, clinical features and management of cutaneous M. chelonae in South-East Scotland, and to compare prevalence data with the rest of Scotland. METHODS: The Scottish Mycobacteria Reference Laboratory database was searched for all cases of cutaneous mycobacterial infections. RESULTS: One hundred and thirty-four cases of cutaneous mycobacterial infection were recorded. Sixty-three were tuberculous; of the remaining 71, M. chelonae was the most common nontuberculous organism (27 cases). National Health Service (NHS) Lothian Health Board was the area with highest incidence in the Scotland (12 cases). Three main groups of patients in the NHS Lothian Health Board contracted M. chelonae: immunosuppressed patients (n = 6); those who had undergone tattooing (n = 4); and others (n = 2). One case is, we believe, the first report of M. chelonae cutaneous infection associated with topical corticosteroid immunosuppression. The majority of patients were treated with clarithromycin monotherapy. CONCLUSION: The most prevalent nontuberculous cutaneous mycobacterial organism in Scotland is M. chelonae. The prevalence of M. chelonae in Edinburgh and the Lothians compared with the rest of Scotland is disproportionately high, possibly owing to increased local awareness and established facilities for mycobacterial studies. Immunosuppression with prednisolone appears to be a major risk factor. The first outbreak of tattoo-related M. chelonae infection in the U.K. has been reported. Clinicians should be aware of mycobacterial cutaneous infection and ensure that diagnostic skin samples are cultured at the optimal temperatures.

Mycobacterium chelonae infection: a complication of tattooing.

We describe an outbreak of Mycobacterium chelonae infection in four young immunocompetent patients who were tattooed by the same artist. All had been previously tattooed without complication, but following the latest tattooing session, they all developed a very similar papular eruption confined to skin that had been newly coloured light grey. On histological examination of the eruption, granulomatous inflammation with microabscess formation was seen, in association with the tattoo pigment. Skin cultures grown under optimal conditions grew M. chelonae, sensitive to clarithromycin, from one patient. M. chelonae was also cultured from the contents and nozzle of an opened bottle of light-grey ink from the tattoo parlour frequented by the patients. Dermatologists should consider mycobacterial infection in patients who develop inflammatory changes within a new tattoo.

The profile of dermatological problems in primary care.

BACKGROUND: Cutaneous disease is thought to account for 10-15% of patient consultations with general practitioners, but relatively little is known about the demography of dermatological conditions in primary care. AIM: To assess the proportion and diagnostic profile of dermatological conditions seen in primary care in the southeast of Scotland, and to draw comparisons with secondary dermatological care. METHODS: General practitioners in 13 general practices were asked to note all skin-related consultations during a 2-week period. The case notes of these patients were reviewed, and diagnosis and treatment was recorded. Patients who had consulted for the same skin disorder on >or= 3 occasions during the previous year were invited for assessment by a consultant dermatologist. Where possible, the case notes from 10% of all consultations during the 2-week study period were examined to assess accuracy of recording. RESULTS: The percentage of consultations relating to cutaneous disorders varied between practices, ranging from 3% to 18.8%, with a mean of 8.4%. Eczema accounted for 22.5%, infections 20.3% and benign tumours for 11.4% of consultations with a dermatological basis. In contrast, in secondary care, benign tumours accounted for 23.8%, malignant tumours for 16.4% and eczema for 16.3% of dermatological consultations. CONCLUSIONS: Dermatological disorders make up a significant proportion of general practitioners' workload. The diagnostic profile of primary-care dermatology differs markedly from that of hospital practice. General practitioners may benefit from training specifically tailored to the common primary-care dermatological conditions.

The changing face of dermatological practice: 25 years' experience.

BACKGROUND: In order to plan appropriate delivery of dermatology services we need periodically to assess the type of work we undertake and to examine changing trends in the numbers and type of referrals and the workload these referrals generate. OBJECTIVES: To quantify outpatient workload in hospital-based and private practice; to assess reasons for referral to secondary care and to examine the changes over 25 years in the diagnostic spectrum of conditions referred. METHODS: During November 2005, all outpatient dermatological consultations in the south-east of Scotland were recorded. Demographic data, source of and reason for referral, diagnoses, investigations performed, treatment administered and disposal were recorded, and comparisons made with four previous studies. RESULTS: During the 1-month study, attendances were recorded for 2118 new and 2796 review patients (new/review 1 : 1.3, female/male 1.3 : 1, age range 0-106 years). Eighty-nine per cent of new referrals came from primary care and 11% from secondary care. Fifty-seven per cent of referrals were for diagnosis and 38% for management advice. Benign tumours accounted for 33.4%, malignant tumours 11.6%, eczema 16% and psoriasis 7.4% of new cases. For return patients, 20% had skin cancer, 16.5% eczema, 13.4% psoriasis and 9% acne. The referral rate has risen over 25 years from 12.6 per 1000 population in 1980 to 21 per 1000 in 2005, with secondary care referrals increasing from 61 in November 1980 to 230 in November 2005. CONCLUSIONS: Attendances for benign and malignant skin tumours have increased sixfold since 1980. Patients with eczema and psoriasis account for one third of clinic visits. New referrals have risen by 67%, with those from other hospital specialties almost quadrupling since 1980 to 11% of the total in 2005. These results confirm the demand from both primary and secondary care for a specialist dermatology service.

Factitious panniculitis masquerading as pyoderma gangrenosum.

We report a case of factitious panniculitis masquerading as florid pyoderma gangrenosum in a 35-year-old woman. At presentation, she had tender, ecchymotic plaques over the lower trunk and limbs, and several biopsies showed active lobular panniculitis. However, the extensive ulceration that ensued was clinically persuasive for pyoderma gangrenosum. We elected to treat the inflammatory element symptomatically with a range of topical and systemic medications including clobetasol propionate, tacrolimus 0.1% ointment, prednisolone, dapsone, cyclosporin A and mycophenolate mofetil, none of which effected an improvement. The possibility of a factitious aetiology had been suspected from the outset, and when signs of clinical depression emerged, antidepressant therapy was initiated and the ulcers were encased in fibreglass casts. Within a short period, healing commenced and slowly progressed with scar formation. In retrospect, we consider the diagnosis to have been factitious panniculitis on the basis of strong circumstantial evidence and the disparity between the histological and clinical features.

Quality of life in epidermolysis bullosa.

The quality of life of people with epidermolysis bullosa (EB) living in Scotland was assessed by postal questionnaire using the Dermatology Life Quality Index (DLQI) and the Children's Dermatology Life Quality Index (CDLQI). There were 143 people with EB simplex (EBS) and 99 individuals with non-Hallopeau--Siemens subtypes of dystrophic EB (DEB). A further six individuals had the severe Hallopeau--Siemens subtype of DEB (RDEB-HS). The overall response was 48% (EBS 52%, DEB 40% and RDEB-HS 83%). Impairment of quality of life (QOL) was greatest in those with RDEB-HS, mean scores (adults, 18; children, 22) exceeding those of any skin disorder previously assessed. The effect on QOL of EBS and other subtypes of DEB was similar to that of moderately severe psoriasis and eczema. EBS had a greater impact on QOL than the non-Hallopeau--Siemens subtypes of DEB (EBS adults mean score, 10.7; EBS children mean score, 15; DEB adults mean score, 7.5; DEB children mean score, 11.5).

The clinical spectrum of dystrophic epidermolysis bullosa.

BACKGROUND: Dystrophic epidermolysis bullosa (DEB) is a genodermatosis resulting from mutations in COL7A1, the gene encoding type VII collagen. The site and specific nature of the underlying mutation determine the clinical phenotype, which ranges widely from a severe mutilating condition to a relatively mild disorder. OBJECTIVES: To document the clinical spectrum of DEB within a defined complete population. METHODS: Since 1992, when compilation of the U.K. epidermolysis bullosa register began, an exhaustive search for DEB sufferers within the Scottish population has been undertaken and their clinical features comprehensively recorded. RESULTS: One hundred and twenty-eight DEB sufferers have been identified within the Scottish population. In descending order, the frequencies of the different forms of DEB were dominant DEB (DDEB) in 88 individuals (68%), DEB of uncertain inheritance in 24 (19%) and recessive DEB (RDEB) in 16 patients (13%). Within this latter group, nine (7%) had the mutilating Hallopeau-Siemens subtype (RDEB-HS), five (4%) had localized (RDEB-loc) and two (2%) had a predominantly flexural (inverse) form of RDEB. During the study, two patients with RDEB died from squamous cell carcinomas (SCCs), one originating in the skin and the second arising in the oesophagus. Gastrointestinal problems such as dysphagia, constipation and anal fissures, and restriction of mouth opening were experienced by the majority of patients with RDEB and by a significant minority of DDEB sufferers. Pseudosyndactyly was most severe in RDEB-HS, all those over 9 years of age having mitten deformities of the hands. Milder pseudosyndactyly or flexion contractures of the fingers were present in younger patients with this subtype, in most adults suffering from other subtypes of RDEB and in 6% of those with DDEB. External ear involvement, a feature not often reported in DEB, was common in RDEB and also occurred in a minority of those with DDEB. Pruriginous lesions and albopapuloid lesions were each present in both DDEB and RDEB. CONCLUSIONS: Most patients with DEB have relatively mild dominantly inherited disease, only a minority suffering from severe recessive subtypes. Scarring, gastrointestinal involvement, albopapuloid lesions and a pruriginosa-like pattern each occur in both DDEB and RDEB. With increasing age, SCC is a major cause of morbidity and mortality.

Localized papular cutaneous schistosomiasis: two cases in travellers.

Schistosomiasis is endemic in many parts of the tropics and subtropics with an estimated 200 million people, at least, infected worldwide. The symptoms and signs of vesical and gastrointestinal forms are readily recognized but ectopic forms are rare even in endemic areas and present a greater diagnostic challenge, particularly when they are encountered in nontropical climes. We now report two cases of cutaneous schistosomiasis presenting in Edinburgh with subtle, but remarkably similar, skin lesions.