Managing actinic keratosis in primary care.

Actinic, or solar, keratosis is caused by chronic ultraviolet-induced damage to the epidermis. In the UK, 15-23% of individuals have actinic keratosis lesions. Risk factors include: advanced age; male gender; cumulative sun exposure or phototherapy; Fitzpatrick skin phototypes I-II; long-term immuno-suppression and genetic syndromes e.

Pseudomembranous changes in the dermis: A novel observation and potential clue for evolving lipodermatosclerosis?

Lipodermatosclerosis (LDS) is a well-recognized form of fibrosing panniculitis. Although chronic cases are readily diagnosed, early and evolving lesions may be clinically mistaken for cellulitis and other forms of panniculitis. Most pathologists are familiar with a pseudomembranous type of fat necrosis as a useful feature of chronic LDS.

Hailey-Hailey Disease With Coexistent Herpes Virus Infection: Insights Into the Diagnostic Conundrum of Herpetic/Pseudoherpetic Features in Cutaneous Acantholytic Disorders.

The specific histopathologic diagnosis of a primary acantholytic disorder takes into account the distribution and extent of acantholysis, presence or absence of dyskeratosis, nature of the dermal inflammatory cell infiltrate, and immunofluorescence findings. Herpes virus infection is a common cause of secondary acantholysis where distinctive viral cytopathic changes aid in making it a clear-cut diagnosis in majority of cases. We present a case of coexistence of Hailey-Hailey disease and herpes simplex virus infection to compare and contrast their histopathologic features.

Managing patients with hidradenitis suppurativa.

Hidradenitis suppurativa affects the apocrine-bearing areas of the skin. The onset is variable but usually occurs in the second and third decades of life, coinciding with development of the apocrine glands. The condition is characterised by painful, inflammatory papules and nodules which frequently progress to form abscesses, sinus tracts and hypertrophic scars.

Tailor systemic therapy to the patient with severe psoriasis.

There is no standard definition regarding the severity of psoriasis, and a number of factors should be considered, including the extent and stability of skin disease, involvement of joints, response to treatment, and impact on quality of life. Erythrodermic psoriasis and pustular psoriasis are severe conditions and the patient may be systemically unwell and febrile. NICE recommends that four key areas should be evaluated and recorded when assessing patients: severity, using the static Physician's Global Assessment (sPGA); disease impact on physical, psychological and social wellbeing using the Dermatology Life Quality Index (DLQI); the presence of psoriatic arthritis; and comorbidities.

Diagnosis directs treatment in fungal infections of the skin.

Dermatophyte fungi are confined to the keratin layer of the epidermis and include three genera: Microsporum, Epidermophyton and Trichophyton. These infections can be transmitted by human contact (anthropophilic), from the soil (geophilic) and by animal (zoophilic) spread. Dermatophyte infections usually present as an erythematous, scaly eruption, which may or may not be itchy.

Improving detection of non-melanoma skin cancer Non-melanoma skin cancer.

Basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) are clinically and pathologically distinct and both are locally invasive. However, while BCCs rarely metastasise, SCCs have the potential to do so especially when they arise on the ears or lips. UV radiation is the most important risk factor for non-melanoma skin cancer (NMSC).

Managing urticaria in primary care.

Urticaria is characterised by transient wheals that consist of a swollen palpable centre often surrounded by an erythematous flare, associated with itching or, less commonly, a burning sensation. Individual wheals usually disappear within 1 to 24 hours leaving normal skin. Wheals may be accompanied by angioedema, a more deep-seated flesh-coloured or erythematous swelling of skin or mucous membrane, which may last longer than 24 hours.

Improving the management of rosacea in primary care.

Rosacea is more common in women than men and occurs more frequently in fair-skinned individuals, usually in the middle years of life. It tends to localise to the cheeks, forehead, chin and nose, sometimes showing marked asymmetry. Only very occasionally does it involve areas other than the face.

Improving the management of seborrhoeic dermatitis.

Seborrhoeic dermatitis usually starts at puberty with a peak incidence at 40 years of age and is more common in males. Patients develop symmetrical, well demarcated, dull or yellowish red patches and plaques with overlying adherent, yellowish greasy scales. Seborrhoeic dermatitis has a distinctive distribution in areas rich in sebaceous glands - the scalp, eyebrows, glabella, nasolabial and nasofacial folds, cheeks, peri-auricular skin, pre-sternal and interscapular areas.

Alopecia areata: more than skin deep.

Alopecia areata is a chronic inflammatory non-scarring condition affecting the hair follicle that leads to hair loss ranging from small well defined patches to complete loss of all body hair. In about 80% of affected individuals there is spontaneous regrowth within a year. It can present at any age, although 60% of patients develop their first episode of hair loss before the age of 20.

Intense nocturnal itching should raise suspicion of scabies.

Scabies is caused by infestation with a parasitic mite Sarcoptes scabiei var hominis. The itch and rash appear to be largely the result of a delayed (type IV) allergic reaction to the mite, its eggs and excreta. Scabies is spread by a mite transferring to the skin surface of an unaffected person, usually by skin to skin contact with an infested person, but occasionally via contaminated bed linen, clothes or towels.

Improving outcomes in patients with psoriasis.

Psoriasis is a heterogeneous inflammatory disorder that targets the skin and joints. It affects 1.3-2% of the population.

Be vigilant for scurvy in high-risk groups.

Scurvy is caused by prolonged dietary deficiency of vitamin C, the plasma concentration of which appears inversely related to mortality from all causes. Its clinical importance relates principally to its role as a cofactor in a number of enzyme reactions involved in collagen synthesis, dysfunction of which disrupts connective tissue integrity, resulting in impaired wound healing and capillary bleeding. In the UK, overt scurvy is diagnosed only rarely.

Toxic epidermal necrolysis in a child successfully treated with infliximab.

A 7-year-old boy developed severe toxic epidermal necrolysis (TEN) secondary to carbamazepine and was transferred to our center after further deterioration despite receiving one dose of intravenous immunoglobulin. After administration of one dose of infliximab, there was a clear halting of progression of blistering and an apparent dramatic improvement. We consider it likely that the administration of infliximab led to the improvement in this child and that anti-tumor necrosis factor-alpha therapy may be a logical treatment for TEN, given the possible underlying pathologic process.

Improving the management of atopic eczema in primary care.

Although generally considered a childhood ailment, 38% of patients in the UK with atopic eczema are adults. The diagnosis of uncomplicated atopic eczema is based on clinical history and visual assessment. Atopic eczema may be complicated by secondary infection, particularly staphylococcal and streptococcal, and herpes simplex virus may cause eczema herpeticum, which is uncomfortable and potentially dangerous.

Epidermolysis bullosa simplex in Scotland caused by a spectrum of keratin mutations.

Epidermolysis bullosa simplex (EBS) is an inherited skin disorder caused by mutations in keratins K5 (keratin 5) and K14 (keratin 14), with fragility of basal keratinocytes leading to epidermal cytolysis and blistering. Patients present with widely varying severity and are classified in three main subtypes: EBS Weber-Cockayne (EBS-WC), EBS Köbner (EBS-K), and EBS Dowling-Meara (EBS-DM), based on distribution and pattern of blisters. We could identify K5/K14 mutations in 20 out of the 43 families registered as affected by dominant EBS in Scotland; with previous studies this covers 70% of all Scottish EBS patients, making this the most comprehensively analyzed EBS population.