Assessment of attitudes towards sun-protective behaviour in Australians: A cross-sectional study.

OBJECTIVE: To assess the knowledge, attitudes and behaviour towards sun protection measures in a sample of Australian adults. METHODS: A multicentre, cross-sectional study was undertaken during 2014 using a population-based survey of 416 individuals over the age of 18. The knowledge, behaviour and attitudes towards sun protection measures in this group of adults were assessed. The impact of educational level and employment status on responses was also evaluated. RESULTS: Sunscreen is the most common sun-protective measure. Daily sunscreen use is below 20%. Forgetfulness was the largest barrier to sunscreen use. A total of 85% of respondents did not apply a sufficient amount of sunscreen. Only 32% of individuals reapplied sunscreen every 2 hours and 20% never reapplied it. In the preceding year, one or more sun burns were suffered by 46% of the participants in the survey. In all, 36% of individuals rarely or never check their sunscreens expiry date and less than 50% of individuals replaced their sunscreen each year. Furthermore, 65% were unaware that sunscreens stored above 25°C were less effective than when stored correctly as per manufactures labelling. CONCLUSIONS: This study highlights a number of significant deficiencies that future sun-protection programmes could target in order to improve the general public's knowledge and attitudes towards sun protection. There is also a need for this to be translated into the public's sun-protection behaviour.

Interscalene brachial plexus block for shoulder arthroscopic surgery: Prospective randomised controlled study of effects of 0.5% ropivacaine and 0.5% ropivacaine with dexamethasone.

BACKGROUND AND AIMS: Various adjuvants have been used to prolong the duration of local anaesthetic action after peripheral and regional nerve blocks. We evaluated the effect of dexamethasone on the duration of pain relief in shoulder arthroscopic surgeries performed under interscalene brachial plexus using ropivacaine as local anaesthetic. METHODS: After Ethical Committee approval and informed consent from patients we performed a prospective, randomised, comparative study on patients scheduled for arthroscopic shoulder surgery under interscalene block (ISB). Patients in ropivacaine group (Group R) received 30 ml of 0.5% ropivacaine plus 2 ml normal saline (n = 50) and dexamethasone-ropivacaine (Group RD) received 0.5% ropivacaine 30 ml plus 8 mg dexamethasone (4 mg/ml) (n = 50). Duration of analgesia, onset of sensory and motor block, success and failure of block, and complications were recorded and compared. Computer software SPSS version-16 (SPSS Inc., Chicago, Illinois, USA) was used for statistical analysis. Chi-square test and Student's t-test were used and P < 0.05 was considered as significant. RESULTS: The mean duration of analgesia in Group RD was 1103.72 ± 296.027 min and in Group R it was 551.54 ± 166.92 min (P = 0.0001). Onset of sensory block in Group RD was 12.24 ± 1.88 min and in Group R was 13.48 ± 1.81 min (P = 0.5170). Onset of motor block in Group RD was 16.24 ± 2.04 min and in Group R was 17.76 ± 2.21 min (P = 0.2244). Onset of surgical anaesthesia in Group RD was19.46 ± 1.86 min and in Group R was 20.84 ± 1.71 min (P = 0.0859). CONCLUSION: Dexamethasone significantly prolonged duration of analgesia of ropivacaine during ISB used for arthroscopic surgeries of shoulder. Dexamethasone when mixed with ropivacaine had no effect on the onset of sensory and motor effects of ISB with ropivacaine.

The skin microbiome: Associations between altered microbial communities and disease.

A single square centimetre of the human skin can contain up to one billion microorganisms. These diverse communities of bacteria, fungi, mites and viruses can provide protection against disease, but can also exacerbate skin lesions, promote disease and delay wound healing. This review addresses the current knowledge surrounding the healthy skin microbiome and examines how different alterations to the skin microbial communities can contribute to disease. Current methodologies are considered, changes in microbial diversity and colonisation by specific microorganisms are discussed in the context of atopic dermatitis, psoriasis, acne vulgaris and chronic wounds. The recent impact of modern Westernised lifestyles on the human skin microbiome is also examined, as well as the potential benefits and pitfalls of novel therapeutic strategies. Further analysis of the human skin microbiome, and its interactions with the host immune system and other commensal microorganisms, will undoubtedly elucidate molecular mechanisms for disease and reveal gateways for novel therapeutic treatment strategies.

Role of nanocrystalline silver dressings in the management of toxic epidermal necrolysis (TEN) and TEN/Stevens-Johnson syndrome overlap.

Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are severe mucocutaneous eruptions. There is currently no defined optimal approach to wound care. The objective of this study was to evaluate silver dressings in the wound-care management of TEN and SJS/TEN syndrome overlap with a retrospective case review of nine patients with TEN and SJS/TEN overlap presenting to our institution. Nanocrystalline silver dressings appear to be useful in the rapid commencement of healing in these patients. TEN and SJS/TEN overlap are rare conditions. This contributed to a relatively small number of cases included in the study. The ease of application, antimicrobial properties and low frequency of change make nanocrystalline silver dressings ideal in TEN/SJS.

The influence of age and gender in knowledge, behaviors and attitudes towards sun protection: a cross-sectional survey of Australian outpatient clinic attendees.

OBJECTIVE: The aim of this study was to evaluate the differences in knowledge, attitudes, and behaviors regarding sun protection in different age groups and between men and women. METHOD: A multicenter cross-sectional study using a population-based survey of 416 individuals over the age of 18 years was undertaken during 2014. RESULTS: Of individuals aged 18-30 years, 94% had experienced at least one episode of sunburn in the previous year. The likelihood of self-examining increased as age increased (p < 0.001). Only 15% of participants used the recommended amount (40 ml) of sunscreen. Women were twice as likely to put on sunscreen as men. Women had better knowledge about sun protection and sunscreen use, and were twice as likely to know that sunscreen was denatured by heat and had an expiry date (p = 0.01). Women were more than twice as likely to put on sunscreen every day compared with men (p = 0.002). Reported barriers to sunscreen use included greasiness and forgetfulness and this was more commonly reported as age decreased (p = 0.002; p = 0.004). The younger population was less likely to use more than one modality of sun protection (p = 0.05). CONCLUSION: This study highlights a number of gender- and age-specific findings with regards to sun protection. There are knowledge, attitude, and behavior deficiencies within each demographic group that need to be specifically targeted through educational and public health efforts in order to improve general sun protection measures and decrease the incidence of skin cancers.

Vulval papules: a case for diagnosis.

You are asked to examine a 68-year-old woman with a 3-year history of multiple bilateral and largely asymptomatic white papules on her labia majora. Based on the history and photographs, what is your diagnosis?

Vulvovaginal pyoderma gangrenosum secondary to rituximab therapy.

Rituximab is being used increasingly for the treatment of B-cell malignancies and nonmalignant conditions. Pyoderma gangrenosum is a rare neutrophilic dermatosis, which can be either idiopathic or associated with underlying systemic inflammatory conditions. We present a series of 4 patients who presented with ulcerative pyoderma gangrenosum in the vulvovaginal area after treatment with rituximab.

Vulvovaginal candidiasis as a chronic disease: diagnostic criteria and definition.

OBJECTIVE: Although recurrent vulvovaginal candidiasis is defined as 4 or more discrete attacks of vulvovaginal candidiasis per year, there is no diagnostic nomenclature or definition for the many women who are chronically symptomatic. This study aims to establish and propose a definition and a set of diagnostic criteria, which would enable clinicians to promptly identify and treat women with chronic vulvovaginal candidiasis (CVVC). DESIGN: Prospective cohort study. SETTING: Public and private vulvar dermatology outpatient clinics in Sydney, Australia. PARTICIPANTS: Data were obtained prospectively from 50 women with presumptive CVVC and 42 controls. Historical and clinical features of CVVC identified by expert consensus were compared between the 2 groups. Diagnostic criteria were then prospectively applied to a further 163 patients to verify their accuracy. OUTCOME MEASURES: Signs and symptoms diagnostic of CVVC. RESULTS: The following characteristics were found to be significantly more common in women with CVVC compared to controls (p ≤ .001): a history of positive vaginal Candida swab, discharge, dyspareunia, soreness, swelling, cyclicity, and exacerbation of symptoms with antibiotics. CONCLUSIONS: We propose that CVVC can be confidently diagnosed using the major criteria of a chronic nonspecific and nonerosive vulvovaginitis that includes at least 5 or more properties from the following criteria: soreness, dyspareunia, positive vaginal swab either at presentation or in the past, previous response to antifungal medication, exacerbation with antibiotics, cyclicity, swelling, and discharge. This condition responds reliably to oral antifungal medication.

A case series of 11 patients with hormone-responsive sebaceous adenitis of the labia minora.

Sebaceous adenitis, an idiopathic inflammation of the sebaceous gland, is a condition that is well described in animals but has been reported only thrice previously in humans. We present a series of 11 cases of sebaceous adenitis that presented as tender nodular lesions clinically similar to hidradenitis suppurativa, but was confined to the labia minora. All cases responded to tetracyclines and anti-androgen therapy.

Comparative evaluation of femoral nerve block and intravenous fentanyl for positioning during spinal anaesthesia in surgery of femur fracture.

BACKGROUND: Spinal anaesthesia is the preferred technique to fix fracture of the femur. Extreme pain does not allow ideal positioning for this procedure. Intravenous fentanyl and femoral nerve block are commonly used techniques to reduce the pain during position for spinal anaesthesia however; results are conflicting regarding superiority of femoral nerve block over intravenous fentanyl. AIMS: We conducted this study to compare the analgesic effect provided by femoral nerve block (FNB) and intra- venous (IV) fentanyl prior to positioning for central neuraxial block in patients undergoing surgery for femur fracture. PATIENTS AND METHODS: In this randomized prospective study 60 patients scheduled for fracture femur operation under spinal were included. Patients were distributed in two groups through computer generated random numbers table; Femoral nerve block group (FNB) and Intravenous fentanyl group (FENT). In FNB group patients received FNB guided by a peripheral nerve stimulator (Stimuplex; B Braun, Melsungen, AG) 5 minutes prior to positioning. 20mL, 1.5% lidocaine with adrenaline (1:200,000) was injected incrementally after a negative aspiration test. Patients in the fentanyl group received injection fentanyl 1 µg/kg IV 5 mins prior to positioning. Spinal block was performed and pain scores before and during positioning were recorded. Statistical analysis was done with Sigmaplot version-10 computer software. Student t-test was applied to compare the means and P < 0.05 was taken as significant. RESULTS: VAS during positioning in group FNB: 0.57 ± 0.31 versus FENT 2.53 ± 1.61 (P = 0.0020). Time to perform spinal anesthesia in group FNB: 15.33 ± 1.64 min versus FENT 19.56 ± 3.09 min (P = 0.000049). Quality of patient positioning for spinal anesthesia in group FNB 2.67± 0.606 versus FENT 1.967 ± 0.85 (P = 0.000027). Patient acceptance was less in group FENT (P = 0.000031). CONCLUSION: Femoral nerve block provides better analgesia, patient satisfaction and satisfactory positioning than IV fentanyl for position during spinal anaesthesia in patients of fracture femur.

A case of subacute cutaneous lupus erythematosus as a result of ranibizumab (Lucentis) treatment.

Cutaneous lupus erythematosus is a previously undiagnosed side-effect of ranibizumab. Here, we present a case of an 82-year-old female Caucasian patient with wet age-related macular degeneration. Following a single intraocular injection of Lucentis (ranibizumab), she developed a subacute cutaneous lupus erythematosus which, with treatment, took nearly 12 months to resolve. This shows that cutaneous lupus erythematosus is a potential side-effect of many medications, including ranibizumab, as in our case and, in an aging population where polypharmacy is a growing reality, clinicians should be aware of how to diagnose and best manage such cases.

Haemorrhagic purpura in an elderly man. BHD.

You are asked to review an 85 year old man with bullous lesions on the torso and limbs (as shown), which developed after treatment with low-molecular weight heparin (LMWH), unfractionated heparin (UFH), and furosemide. Based on the given history and the clinical and histological images, what is your diagnosis?

Ice anaesthesia in procedural dermatology.

This article presents findings from a survey of Australian dermatologists who were questioned about their preferred pain control methods when carrying out injectable procedures. We also present, what is to the best of our knowledge, the first proof-of-concept experiment exploring the relationship between ice-to-skin contact time and skin surface temperature, using both ice wrapped in latex and ice wrapped in aluminium foil. Of 79 dermatologists 32 responded to the survey (41% response rate): 31 (97%) injected botulinum toxin type A (BTA) for dynamic lines, 26 (81%) injected BTA for hyperhidrosis, and 24 (75%) injected skin fillers. Ice anaesthesia was the most common method of pain control (75%) followed by use of topical anaesthesia (50%) such as EMLA, compound agents and lignocaine 4%. Ice wrapped in latex or latex-like material was the most common ice packaging used by those surveyed and the median ice-to-skin contact time was 10 s. The ice experiment results indicated that ice wrapped with aluminium foil was equivalent to ice wrapped in latex for short contact times (< 20 s), but more effective at reducing skin temperature with longer contact times (> 20 s). These findings will be of relevance to cosmetic and paediatric dermatologists or any area of procedural medicine where effective non-injectable pain control is required.

Recurrent menstrual toxic shock syndrome despite discontinuation of tampon use: is menstrual toxic shock syndrome really caused by tampons?

Menstrual toxic shock syndrome (MTSS) is a rare and potentially life-threatening illness. We present a case of recurrent MTSS initially associated with tampon use that continued to recur when tampons were discontinued, which was successfully treated with rifampicin and clindamycin.

Management of nonsexually acquired genital ulceration using oral and topical corticosteroids followed by doxycycline prophylaxis.

BACKGROUND: Data regarding the treatment of nonsexually acquired genital ulceration (NSAGU) are limited. OBJECTIVE: We sought to provide evidence for the safety and efficacy of topical and systemic corticosteroids followed by doxycycline prophylaxis for acute and recurrent NSAGU. METHODS: A retrospective chart review was conducted of patients with NSAGU treated in a private dermogynecology practice. RESULTS: A total of 26 girls and women with NSAGU were identified and divided into 2 groups: group A = 17 patients with moderate to severe ulceration treated in the acute stage with oral corticosteroid; and group B = 9 patients with mild ulceration treated in the acute stage with topical corticosteroid. Patients in group A, with a mean age of 27.9 years (range, 11-62 years), were treated with oral prednisolone commencing with 15 to 50 mg per day depending on severity. Sixteen (94%) achieved rapid pain relief and complete healing of ulcers within 16 days. Eight (47%) commenced doxycycline prophylaxis. Women in group B, with a mean age of 42.5 years (range, 26-67 years) were treated with topical corticosteroids. Eight (89%) had a history of recurrent ulcers and 6 (66%) commenced doxycycline prophylaxis. Of all 14 patients on doxycycline prophylaxis, none reported any recurrences during a mean follow-up of 18.3 months. There were no adverse effects caused by prednisolone. One patient experienced mild photosensitivity from doxycycline but continued to take it. LIMITATIONS: This was a retrospective case series from a single private practice-based population. CONCLUSION: Topical or oral corticosteroids followed by prophylactic doxycycline can be effective in rapidly resolving acute flareups and preventing recurrences of NSAGU. All patients responded to therapy without treatment-limiting side effects.

A vesicular variant of pseudoverrucous papules and nodules in the genital area of an incontinent 4-year-old.

Irritant contact dermatitis is a common cause of chronic vulvitis in patients wearing diapers and incontinence garments. In most cases the diagnosis is obvious; however, atypical presentations may mimic more serious dermatoses. We present a 4-year-old girl who presented at birth with cloacal atresia corrected surgically and resulting in chronic incontinence requiring full-time diapers. She presented with crops of herpetiform vesicles and bullae on a base that ranged from normal skin to severe erythema and oedema. A histological examination revealed a well-demarcated lesion showing a thickened epidermis with hyperkeratosis and parakeratosis, acanthosis and an abrupt transition to pallor of the upper half. Focal full thickness epidermis necrosis and small areas of spongiosis, acantholysis and apoptotic keratinocytes were seen. Immunofluorescence was negative. The lesions improved with the treatment of secondary infection and minimal topical therapy with an emollient only. This case represents an unusual vesicular variant of pseudoverrucous papules and nodules, which has been reported only once previously.

Atypical meningiomas--a case series.

Meningiomas, in particular the Atypical (grade 2), vary greatly in their behaviour and prognosis. Over a 19 year period, we operated on 169 meningiomas (on 86 patients) and of those, 9 cases of atypical meningiomas were found which met the 2007 World Health Organization (WHO) classification. The 9 patients represented 5.3% of all meningiomas. The average presenting age was 51 years and average follow-up was 103 months with 5 patients passing away between 38 and 219 months after diagnosis. The time to first recurrence was 24 months with 1 patient suffering 12 recurrences and 2 cases having metastases. Although we had a small number of atypical meningiomas, we believe our paper highlights the unpredictable and difficult nature of these tumours.