Dermatology in practice - 2013

Comment: Debunking dermatology
Neill Hepburn
pp 3-3
With the Keogh review over and our new executive medical director in post, I have escaped to Wales for a couple of weeks of walking, eating, reading and chatting. I had promised to write this editorial on the first rainy day – so here we are on Day 3! That’s actually a bit unfair as it was sunny this morning, so we played tennis and then walked into Beaumaris for lunch. This issue of Dermatology in practice has a mixture of the common, the rare and the puzzling. Christina Green starts us off with a practical guide to peanut allergy, debunking many of the misconceptions often held by parents of children we see in the clinic. It is refreshing to read such a clear explanation of concepts like allergy and sensitisation; the interpretation of specific IgE levels; and the relationship between Type 1 and Type IV reactions. The article is worth sharing with patients and could shorten some of those tricky consultations.
Peanut allergy and the dermatologist
Christina Green
pp 4-6
It does not usually fall within the remit of a dermatologist to diagnose and manage patients with peanut allergy, particularly children. However, there is an important overlap with the work of consultant allergists who generally manage such patients, both with regards to sensitisation to peanuts and managing patients with eczema who also have food allergies. In this article, I hope to raise awareness of food allergy as a concomitant problem for children with atopic eczema, help point out the pitfalls of arriving at the correct diagnosis, and discuss some research which points towards possible new ways of managing such patients in the future. The number of young children with a diagnosis of peanut allergy doubled between 1997 and 2002. There are many theories as to why this increase has occurred, but at this time there are no definite answers.
Dapsone: what you need to know
Barry E Monk
pp 8-8
Although dapsone was first synthesised in 1908, it was only in 1950, when being used under the mistaken impression that dermatitis herpetiformis (DH) is caused by a bacterial infection, that its remarkable efficacy in this disorder was discovered. Today, the licensed indications for dapsone are, in addition to DH, as part of the multidrug treatment of leprosy and in the prophylaxis of pneumocystis infection in patients with HIV. However, although dapsone is an antimicrobial, it is the drug’s rather poorly understood anti-inflammatory effects that have led to its use in a wide range of dermatoses. In some of the rarer conditions, the evidence of efficacy inevitably relies on case reports and anecdotes, rather than coming from controlled trials. It is not an uncommon experience in dermatology clinics, when faced with a difficult therapeutic problem in a patient with a chronic inflammatory disorder in which first- or second-line treatments have already been tried but have failed, to find that ‘a trial of dapsone’ is suggested. Many of the disorders dapsone is used to treat are chronic ones. So, although dapsone therapy is rarely likely to be initiated in primary care, GPs may, from time to time, encounter patients who are on the drug and be asked to participate in the monitoring or prescribing of it. For this reason, it is important for them to be aware of some of the important side-effects that may be encountered, especially as these can be a little unusual.
A guide to national networking on epidermolysis bullosa
Tracy Adni and Adrian Heagerty
pp 10-13
Epidermolysis bullosa (EB) is an umbrella term used for a group of genetic skin fragility disorders characterised by blister formation in response to minimal trauma. While there are currently 29 separate conditions identified, involving abnormalities of 14 genes, EB can be classified into three main categories: EB simplex (EBS), involving intraepidermal separation with the genetic defect arising in keratin 5 or 14; junctional EB (JEB), comprising separation in the lamina lucida with the genetic abnormality in the collagen XVII gene and laminin-332; and dystrophic EB (DEB), with sublamina separation and a genetic abnormality occurring in the collagen VII gene type. EBS may affect only the hands and feet, but can, on occasion, be more widespread, whereas DEB and JEB are usually more generalised. The inheritance may be either autosomal dominant or autosomal recessive, the latter group usually having far more severe symptoms with more far-reaching consequences.
Stress and the skin
Reena Shah, Alia Ahmed and Anthony Bewley
pp 14-17
The skin is the largest organ of the body and, if not covered, is the one immediately on show. Not only does it represent an external barrier between our internal being and the outside world, but it is also a key feature we use to assess the well-being of those we come into contact with. Health and illness are caused by many different factors, producing multiple effects. The biopsychosocial model illustrates how health and illness are consequences of interactions between biological, psychological and social factors. The prevalence of patients seen with skin disease in primary care services is approximately 36.5% (patients with at least one skin problem). For 59% of patients, the skin condition was their main complaint to their GP. Given the rise in skin cancer statistics, it is fair to say that the percentage of skin disease is on the rise. Those who have physical health problems are more likely to develop mental health issues. Therefore, to provide true holistic care, it is crucial to recognise the impact that skin disorders can have on individuals and their families. The psychological factors could be perpetuating, or precipitating, the skin condition and could also be severely affecting the patient’s quality of life (QoL). Treating the skin condition in conjunction with the psychological factors can enhance the therapeutic relationship with the patient, which will, in turn, increase their adherence to treatment.
Monk's moments: An uncomfortable truth
Barry E Monk
pp 18-18
Dapsone is an unusual drug, with a range of indications from leprosy to vasculitis. Yet, it has an even more unusual history. Dapsone (diaminodiphenylsulfone) was first synthesised in 1908, but it was many years before its therapeutic potential was recognised. During the Second World War, Germany found itself at a significant disadvantage in lacking access to the newly discovered penicillin, which was available to the British and US troops. Much effort was directed into investigating derivatives of the early sulphonamide preparations, which had much weaker antibacterial effect. Josef Vonkennel was a leading dermatologist in Leipzig, an ardent Nazi and adviser on dermatology to the Schutzstaffel (SS). He established a research centre at Buchenwald concentration camp and began experimenting with the effects of dapsone on experimentally induced poison gas burns in inmates. His studies did indeed show that the agent had some therapeutic effects, albeit at the expense of the lives of many of his hapless victims.