Excising basal cell carcinomas: comparing the performance of general practitioners, hospital skin specialists and other hospital specialists

Background.  General practitioners (GPs) are not encouraged to excise basal cell carcinomas (BCCs). Despite this, as many of 10% of BCCs may be excised by GPs. GPs may be able to have a greater role in the diagnosis and management of BCC, but much needs to be learnt before this can be advocated.
Objective.  To compare the practice of GPs, skin specialists (dermatologists and plastic surgeons) and other hospital specialists in excising BCCs.
Methods.  A retrospective analysis of all BCCs excised in the Grampian region between 1 January and 31 December 2005 was carried out In total, 1087 reports were rated for source, quality of clinical information provided and extent of excision.
Results.  GPs perform significantly less well than skin specialists when diagnosing and excising BCCs, but appear equal in diagnostic skill and better at excision than other hospital specialists. Non-specialized GPs appear to perform as well as GPs with special interest (GPwSI) in adequately excising BCCs. In 18.7% of all cases, the information supplied to the pathologist with the biopsy sample was inadequate to draw a conclusion.
Conclusions.  GPs compare unfavourably with skin specialists in diagnosing and excising BCCs. The performance of nonspecialized GPs does not appear to differ markedly from that of GPwSI. There is considerable room to optimize current GP performance, particularly with lesions of the head and neck, and it may be that novel approaches to GP training are required to achieve this. Structured request forms may improve the quality of clinical information provided when skin biopsies are submitted for pathological examination.     

Epidemiology and clinical pattern of psoriatic arthritis in Germany: a prospective interdisciplinary epidemiological study of 1511 patients with plaque-type psoriasis

Background  Because psoriatic arthritis (PsA) usually develops years after the first manifestation of skin symptoms, in many cases the initial diagnosis of PsA depends on the dermatologist.
Objectives  To investigate the prevalence and clinical pattern of PsA in a daily practice population of patients with psoriasis.
Methods  Patients were enrolled in an observational prospective cross-sectional cohort study at 48 community and academic centres. Demographic and medical parameters were recorded, including severity of skin symptoms (Psoriasis Area and Severity Index, PASI), previous and current treatments, concomitant diseases, and the impact of psoriasis on productivity and health-related quality of life (Dermatology Life Quality Index, DLQI). Patients with joint symptoms were referred to a rheumatologist for diagnosis and to record the activity and pattern of arthritis.
Results  Among 1511 patients 20·6% had PsA; in 85% of the cases PsA was newly diagnosed. Of these patients more than 95% had active arthritis and 53·0% had five or more joints affected. Polyarthritis (58·7%) was the most common manifestation pattern, followed by oligoarthritis (31·6%) and arthritis mutilans (4·9%). Distal interphalangeal involvement was present in 41·0% and dactylitis in 23·7% of the patients. Compared with patients without arthritis, patients with PsA had more severe skin symptoms (mean PASI 14·3 vs. 11·5), a lower quality of life (mean DLQI 11·6 vs. 7·7) and greater impairment of productivity parameters.
Conclusions  The findings are consistent with a high prevalence of undiagnosed cases of active PsA among patients with psoriasis seen by dermatologists. As many of these patients also have significant skin symptoms, treatment strategies are required that are equally effective in the control of skin and joint symptoms of psoriasis.     

Psychiatric comorbidity in adult eczema

Background  Atopic eczema (AE) is a common dermatological condition that causes significant problems in everyday life and high levels of illness-related stress in substantial proportions of patients. The extent to which adult AE is associated with clinically relevant psychiatric morbidity is unclear.
Objectives  To investigate the association between adult AE and major psychiatric/psychosomatic disorders.
Methods  Case–control study utilizing the GKV database Saxony, an interdisciplinary administrative outpatient database from Germany. All patients documented as having AE at least twice within the study period (2003–2004) ( n  =   3769, mean age 44 years) were individually matched by age and sex to 3769 controls without AE. Logistic regression models were fitted to investigate the relationship of AE with affective, stress-related, behaviour and schizophrenic disorders, considering sociodemographic characteristics, consulting behaviour and allergic comorbidities as potential confounding factors.
Results  Eczema was independently associated with affective [adjusted odds ratio (OR) 1·42, 95% confidence interval (CI) 1·13–1·79], stress-related (OR 1·55, 95% CI 1·35–1·77), behaviour (OR 1·52, 95% CI 1·03–2·23) and schizophrenic disorders (OR 2·12, 95% CI 1·22–3·71). For each psychiatric condition the likelihood of being affected significantly increased with each physician visit due to AE, suggesting that the risk of psychiatric comorbidity increases with the severity of AE.
Conclusions  This study indicates psychiatric comorbidity of adults with AE. Collaboration between dermatologists and mental health specialists may optimize medical care for a significant subgroup of patients with AE.     

Assessing diagnostic skill in dermatology: a comparison between general practitioners and dermatologists

This retrospective study was conducted to assess and compare the diagnostic accuracy between referring general practitioners and dermatologists with regard to skin conditions. Six hundred and fifty-six consecutive general practitioner referrals to a private dermatology practice and a dermatology outpatient department were assessed. The concordance rate in diagnoses from a wide spectrum of dermatological diseases was compared between general practitioners and dermatologists. Referring general practitioners agreed with dermatologists' clinical diagnosis and histology (when available) in 42% of cases. The concordance between general practitioners and dermatologists in the setting of non-biopsied cases is 45%. One hundred and fifty-one of 656 (23%) conditions had histological confirmation. Overall, general practitioners agreed with the histological diagnosis in 24% of cases and dermatologists agreed with the histological diagnosis in 77% of cases.     

Diagnostic and surgical accuracy and economic aspects of dermatological surgery - a pilot study

BACKGROUND: Good skin care for oncological dermatological patients includes efficacious excision to achieve tumour control and economically reasonable costs. This field concerns dermatologists as much as other surgical specialities. METHODS: Of 944 excisions and biopsies, we studied 114 epidermal carcinomas excised by plastic surgeons and dermatologists. This allowed us to compare the accuracy concerning oncological surgical aspects as well as the extrapolated costs produced by these two specialities. RESULTS: Dermatologists are significantly more accurate concerning total excision of epidermal tumours compared to plastic surgeons. CONCLUSION: From an economic point of view, plastic surgeons are increasingly more expensive than dermatologists. Most expenses are due to the use of a hospital operating room.     

Surgical excision of skin cancer: the importance of training

Background Skin cancers are the most common malignancy in New Zealand and their treatment imparts a huge burden on the healthcare system both in terms of the cost of surgical intervention and in treatment delivery (estimates are in excess of NZ$33 million per annum for the year 2000). Currently in New Zealand, skin cancers are excised by dermatologists, general practitioners (GPs), GPs with a special interest in skin surgery (GPSIs) and specialist surgeons with diverse training backgrounds including ear, nose and throat, ophthalmic and general surgeons. To date there is scant literature evaluating complete excision rates following surgical treatment of skin cancer between these vocational groups. Objectives To review retrospectively pathology reports from all skin excisions sent to one private pathology laboratory over three consecutive months. The aim was to investigate the margins of excision and completeness of skin cancer surgery performed by each vocational group. Methods A retrospective analysis of skin pathology reports was undertaken for a 3‐month period between April and June 2007. Raw data obtained from the pathology reports included diagnosis, completeness of excision, size of specimens, body site and vocational group of the medical practitioner performing the surgery. Results In total, 1532 lesions were excised: 432 benign and 1100 malignant. Six hundred and seven were from the head and neck. Dermatologists excised 276 lesions of which 93% were malignant, 55% were from the head and neck, and 0% were incompletely excised. GPs excised 633 lesions: 63% malignant, 30% head and neck, 23% incomplete excision of malignant lesions. GPSIs excised 368 lesions: 71% malignant, 35% head and neck, 21·5% incomplete malignant excision. Specialist surgeons excised 255 lesions: 72% malignant, 53% head and neck, 20% incomplete malignant excision. Conclusion GPs and GPSIs excised more benign lesions and had higher incomplete excision rates of skin cancer surgery than dermatologists. Incomplete excision rates for the vocational groups ranged from 0% to 45% depending on site and pathology.     

Noninfectious dermatological diseases associated with chronic exposure to mine tailings in a Peruvian district

Background  Mine tailings are metallic wastes which are deposited in the environment due to mining activity. Long-term exposure to these metals is harmful to human health.
Objective  To determine if chronic exposure to mine tailings constitutes a risk factor for the development of dermatological diseases in the district of San Mateo de Huanchor (Lima, Peru).
Methods  An observational case–control study was carried out in the communities of Mayoc, Daza and Tamboraque (exposed to mine tailings, case group) located in the district of San Mateo de Huanchor, and also in the communities of Choccna and Caruya (not exposed to mine tailings, control group) located in the same district. Out of 230 adults, 121 were exposed and 109 were not exposed to mine tailings and out of 135 children, 71 were exposed and 64 were not exposed to mine tailings.
Results  In the adult group, 71% of the exposed cases had some noninfectious dermatological disease while in the nonexposed group the frequency was 34% [ P  <   0·001; odds ratio (OR) 5·40; 95% confidence interval (CI) 3·02–9·68]. A statistically significant difference between groups was found for arsenical dermatitis, nonpruritic papulovesicular eruption, atopic dermatitis, contact dermatitis, seborrhoeic dermatitis and xerosis. In the paediatric population, 71 exposed and 64 nonexposed children were evaluated. Sixty-nine per cent of the exposed group had some noninfectious dermatological disease vs. 30% in the nonexposed group ( P  <   0·001; OR 6·00; 95% CI 2·71–13·31). A statistically significant difference between groups was found for xerosis and atopic dermatitis.
Conclusion  Chronic exposure to mine tailings represents a risk factor for development of noninfectious dermatological diseases in both adults and children.     

Pilot study of dual-wavelength (532 and 633 nm) laser Doppler imaging and infrared thermography of morphoea

Background  Little is known about the pathophysiology of localized scleroderma (skin fibrosis, also termed 'morphoea'), although it is likely that microvascular dysfunction is a contributing factor.
Objectives  Our aim was to investigate different components of blood flow in morphoea using infrared thermography and dual-wavelength laser Doppler imaging (LDI).
Methods  Eight plaques of morphoea (in eight patients) were studied. Skin temperature and blood flow were assessed in both affected (within plaque) and adjacent unaffected (perilesional) skin.
Results  Skin temperature (representing blood flow) was higher in all areas of morphoea when compared with uninvolved skin. Perfusion within the plaques was found to be increased, when compared with uninvolved skin; in all cases as imaged by red wavelength (633 nm) LDI (representing blood flow through large, thermoregulatory vessels) and in six of eight cases by green wavelength (532 nm) LDI (representing nutritive capillary blood flow). The median (range) skin temperature difference between plaque and perilesional skin was 1·1 (0·7–2·2) °C and the median (range) ratios of plaque/perilesional perfusion as measured by red and green wavelength LDI were 1·3 (1·1–1·9) and 1·1 (0·8–1·5) arbitrary perfusion units, respectively.
Conclusions  Microvascular perfusion is increased within morphoea plaques and the increased response detected by both thermography and red wavelength LDI, as compared with green wavelength LDI, suggests that the increase in perfusion is more marked in deeper, larger, rather than in superficial, smaller vessels.     

Loss-of-function polymorphisms in the filaggrin gene are associated with an increased susceptibility to chronic irritant contact dermatitis: a case-control study

Background  Polymorphisms in the filaggrin (FLG) gene, which result in loss of filaggrin production, may alter the skin barrier and are a well-known predisposing factor for atopic dermatitis.
Objectives  As a compromised skin barrier and atopic dermatitis are risk factors for chronic irritant contact dermatitis (CICD), our objective was to determine whether polymorphisms in the FLG gene contribute towards susceptibility to occupational CICD.
Methods  In a case–control study, the FLG polymorphisms R501X and 2282del4 were determined in 296 patients with CICD. Two hundred and seventeen apprentices in vocational training for high-risk occupations for CICD were chosen as controls. Data on skin diseases and conditions were collected by dermatologists from patients and by means of questionnaires from controls.
Results  Heterozygotes for R501X and 2282del4, FLG null alleles, were more frequent among patients with CICD (12·5%) compared with controls (6·9%), resulting in an odds ratio of 1·91 (95% confidence interval 1·02–3·59). Among patients who were carriers of a FLG null allele, we found a higher lifetime prevalence of flexural eczema (62% vs. 46%; P  = 0·04) and a higher atopy score (13 vs. 10 points; P  = 0·05) compared with noncarriers. In the apprentice group, signs of dermatitis before the start of the vocational training were four times more prevalent in carriers (43%) than in noncarriers (10%; P  < 0·001).
Conclusions  Our study shows that FLG null alleles are associated with increased susceptibility to CICD; whether or not the FLG null allele is an independent risk factor needs further study.     

Serological association of beta and gamma human papillomaviruses with squamous cell carcinoma of the skin

Background  Cutaneous human papillomaviruses (HPVs) may play a role in the development of squamous cell carcinomas (SCC) of the skin.
Objectives  Available serological studies on HPV and skin SCC have analysed only few HPV types from the phylogenetic genus beta. The potential association of cutaneous HPV types from the genera alpha, gamma, mu and nu with skin SCC has not been thoroughly analysed so far.
Methods  Using multiplex serology, a method that allows analysing sera for antibodies to up to 100 different antigens simultaneously, we re-analysed an SCC case–control study in immunocompetent individuals (43 cases, 77 controls) for antibodies to L1 capsid proteins of 29 cutaneous and two mucosal HPV types from five different genera.
Results  Significantly increased SCC risks were observed for the beta HPV types 15, 17 and 38, as well as for the gamma HPV type 50, with type-specific odds ratios (ORs) ranging from 2·6 to 3·4. Significant associations were also found in cases of seropositivity for any type of the beta 2 species (OR 3·3, 95% confidence interval [CI] 1·2–8·7) and for any type of the gamma genus (OR 3·1, 95% CI 1·1–8·6). With regression models that included all HPV types and forward stepwise selection, two gamma HPV types (HPV 95, OR 25, 95% CI 1·2–509; HPV 50, OR 3·6, 95% CI 1·4–9·4) were each significantly associated with skin SCC.
Conclusions  Our study confirms a possible role of cutaneous HPV in the development of skin SCC. Future studies should include skin HPV types from more than only the beta genus, especially gamma types.     

Dermoscopy compared with naked eye examination for the diagnosis of primary melanoma: a meta-analysis of studies performed in a clinical setting

Background  Dermoscopy is a noninvasive technique that enables the clinician to perform direct microscopic examination of diagnostic features, not seen by the naked eye, in pigmented skin lesions. Diagnostic accuracy of dermoscopy has previously been assessed in meta-analyses including studies performed in experimental and clinical settings.
Objectives  To assess the diagnostic accuracy of dermoscopy for the diagnosis of melanoma compared with naked eye examination by performing a meta-analysis exclusively on studies performed in a clinical setting.
Methods  We searched for publications from 1987 to January 2008 and found nine eligible studies. The selected studies compare diagnostic accuracy of dermoscopy with naked eye examination using a valid reference test on consecutive patients with a defined clinical presentation, performed in a clinical setting. Hierarchical summary receiver operator curve analysis was used to estimate the relative diagnostic accuracy for clinical examination with, and without, the use of dermoscopy.
Results  We found the relative diagnostic odds ratio for melanoma, for dermoscopy compared with naked eye examination, to be 15·6 [95% confidence interval (CI) 2·9–83·7, P  = 0·016]; removal of two outlier studies changed this to 9·0 (95% CI 1·5–54·6, P  = 0·03).
Conclusions  Dermoscopy is more accurate than naked eye examination for the diagnosis of cutaneous melanoma in suspicious skin lesions when performed in the clinical setting.     

Knowledge and attitude regarding human immunodeficiency virus/acquired immunodeficiency syndrome in dermatological outpatients

Background  Dermatologists are often the first-line specialists who recognize and diagnose human immunodeficiency virus (HIV) infection because of pathognomic skin signs. It is therefore important to investigate attitudes and knowledge regarding HIV/acquired immunodeficiency syndrome (AIDS) amongst dermatological patients in order to provide information for dermatologists and to draw their attention to the issues.
Objectives  Awareness of HIV/AIDS, its prevention, and hypothetical behaviour were surveyed in dermatological outpatients.
Patients/method  The anonymous cross-sectional survey was conducted with consecutive German-speaking outpatients aged 18–65 years, who registered at the dermatological outpatient's clinic (excluding venereology, genitourinary or HIV medicine) of the University of Munich (Germany).
Results  Three hundred forty-seven (77.5%) questionnaires were accepted for analysis. Most of the patients knew about HIV incurability (89.4%), HIV transmissibility during needle sharing (95.3%), or vaginal (87.4%) and anal intercourse (79.5%), as well as about HIV prevention by condom use (97.8%), and use of single needles (76.2%). However, knowledge gaps and misconceptions were detected regarding the risk of HIV transmission during oral sex, and the efficacy of sexual fidelity and avoidance of blood transfusions in HIV prevention. The lowest knowledge level (< 50% correct answers) was detected in patients aged 50–59 years, in unemployed, divorced/widowed, and in those without or with incomplete school education.
Conclusions  Patient education about HIV/AIDS in dermatological ambulant settings should be performed differentially with regard to socio-demographic factors, and focused on the topic of oral sexual HIV transmission and on some other specific misconceptions.

Conflicts of interest

None declared.     

Distribution of congenital melanocytic naevi and congenital naevus-like naevi in a survey of 3406 Italian schoolchildren

Background  Scanty information is available on the prevalence of congenital melanocytic naevi (CMN) and congenital naevus-like naevi (CNLN), particularly the small ones.
Objectives  To estimate the prevalence of CMN/CNLN in Italian schoolchildren, and to assess variations according to potential risk factors for melanoma.
Methods  We conducted a survey in 13 Italian areas on 3406 schoolchildren aged 12–17 years. Children were examined by dermatologists who assessed pigmentary traits and made a count of small (6–15 mm in diameter) and medium/large (> 15 mm) CMN/CNLN on 19 anatomical areas.
Results  Overall, 592 children (17·4%) had one or more CMN/CNLN. Prevalence of small CMN/CNLN was 16·1%, and that of medium/large CMN/CNLN was 1·8%. There was no difference between age groups and sexes. CMN/CNLN were more frequent in children with a higher number of common melanocytic naevi (multivariate odds ratio, OR = 7·1 for the highest vs. the lowest quartile), consistent in small (OR = 7·2) and medium/large CMN/CNLN (OR = 6·0). Family history of malignant melanoma (OR = 1·4) and personal history of diabetes (OR = 4·4) appeared to be directly, and sun exposure inversely associated with CMN/CNLN. No relation was evident between CMN/CNLN and pigmentary traits, anthropometric characteristics, dietary habits, freckles, sunburns, sunscreen use or history of selected diseases.
Conclusions  The association with family history of melanoma, the strong association with acquired melanocytic naevi, and the lack of association with pigmentary traits and sunburns suggest that CMN/CNLN may act as an independent risk marker for subjects at increased risk for cutaneous melanoma later in life.     

Incidence of primary cutaneous T-cell lymphoma in Norway

Background  Studies from different countries have reported an increased incidence of primary cutaneous lymphomas over the last decades.
Objectives  To estimate the incidence rates of primary cutaneous T-cell lymphoma (CTCL) and mycosis fungoides (MF)/Sézary syndrome (SS) in Norway, and to compare these rates with those reported from other countries.
Methods  Data from the Cancer Registry of Norway on non-Hodgkin lymphomas during the period 1980–2003 were analysed.
Results  In total, 337 cases of CTCL were reported to the Cancer Registry during the study period, of which 262 cases were classified as MF/SS. The incidence rate of CTCL increased significantly ( P _trend < 0·001) from 0·16 (95% confidence interval, CI 0·11–0·20) per 100 000 person-years in 1980–84 to 0·29 (95% CI 0·22–0·36) per 100 000 person-years in 2000–2003. The incidence of MF/SS also increased during the same period ( P _trend = 0·05) from 0·15 (95% CI 0·10–0·19) per 100 000 person-years to 0·18 (95% CI 0·13–0·24) per 100 000 person-years.
Conclusions  The incidence of both CTCL and MF/SS increased in Norway during the period 1980–2003.     

Is contact allergy to disperse dyes and related substances associated with textile dermatitis?

Background  Disperse dyes (DDs) are the most common sensitizers among textile dyes, but there is little knowledge of the clinical relevance of positive patch test reactions.
Objective  To investigate if patient-reported textile-related skin problems can be explained by contact allergy to eight different DDs and/or to chemically related substances, by occupation or by atopic constitution, and if the skin problems are influenced by age or sex.
Methods  A questionnaire on textile-related skin problems was answered by 858 of 982 consecutively patch tested patients in Malmö, Sweden and in Leuven, Belgium. The baseline series used for patch testing was supplemented with a textile dye mix (TDM) consisting of the eight DDs and with the separate dyes. The association between textile-related skin problems and contact allergy to the DDs and other risk factors was investigated using multiple logistic regression analysis.
Results  Eighteen per cent of the patients suspected textiles as a cause of their skin problems. Atopic constitution and female sex were risk factors for skin reactions. Synthetic materials were the most common textiles to give skin problems. A significant association was found between self-reported textile-related skin problems and contact allergy to para -phenylenediamine (PPD) [adjusted odds ratio (OR) 2·1; 95% confidence interval (CI) 1·0–4·3]. A similar, but more imprecise, adjusted OR was found for TDM (OR 1·9; 95% CI 0·57–5·6). Contact allergy to black rubber mix was too rare to be evaluated.
Conclusions  Contact allergy to PPD was a more prevalent indicator for skin reactions to textiles than the TDM used in this study.     

Exclusive breastfeeding and incident atopic dermatitis in childhood: a systematic review and meta-analysis of prospective cohort studies

Background  Breastfeeding is undisputedly preferable to formula feeding for infant nutrition because of its nutritional, immunological and psychological benefits. However, studies on the association between breastfeeding and development of atopic dermatitis (AD) have shown inconsistent results.
Objectives  To examine the association between exclusive breastfeeding for at least 3 months after birth and the development of AD in childhood.
Methods  An electronic literature search of MEDLINE (January 1966–May 2008) and EMBASE (1980–May 2008) was conducted. Prospective cohort studies that met the predetermined criteria were independently assessed by three reviewers. The pooled effect estimate was calculated by random effects model. Heterogeneity across the studies was investigated by meta-regression analysis.
Results  Twenty-one studies with 27 study populations were included for meta-analysis. The summary odds ratio (OR) for the effect of exclusive breastfeeding on the risk of AD was 0·89 (95% confidence interval, CI 0·76–1·04). Heterogeneity was found across the studies (χ² = 83·6, d.f. = 26; P <  0·001). Breastfeeding was associated with a decreased risk of AD (OR 0·70; 95% CI 0·50–0·99) when analysis was restricted to the studies comparing breastfeeding with conventional formula feeding. The pooled OR for study populations with atopic heredity was 0·78 (95% CI 0·58–1·05).
Conclusions  There is no strong evidence of a protective effect of exclusive breastfeeding for at least 3 months against AD, even among children with a positive family history.     

Filaggrin mutations may confer susceptibility to chronic hand eczema characterized by combined allergic and irritant contact dermatitis

Background  The pathogenesis of chronic hand eczema (CHE) is multifactorial and involves both endogenous predisposition and environmental triggers.
Objectives  Filaggrin is a structural protein of the cornified envelope and important for the formation of the epidermal skin barrier. The aim of this investigation was to evaluate the role of mutations in the filaggrin gene ( FLG ) in the development of CHE.
Methods  In total, 122 German patients with clearly defined CHE subtypes were screened for the FLG variants R501X and 2282del4 by polymerase chain reaction and restriction enzyme digest analysis. The prevalence of these variants in CHE patients was compared with that in 95 healthy individuals.
Results  Overall, allele frequency and the number of mutation carriers were similar in both the CHE and control groups. When classified according to clearly defined CHE subtypes, however, the nonfunctional FLG variants showed an association with CHE involving an aetiological combination of contact allergy and irritant factors [ P  = 0·04; P (exact test) = 0·06; P (difference in rates) = 0·09; 95% confidence interval (CI) 0–56·8)], or with excessive daily exposure to water and irritants [ P  = 0·003; P (difference in rates) < 0·001; 95% CI 29·3–67·9].
Conclusion  Heterozygosity for nonfunctional mutations in the FLG gene may contribute to the manifestation and maintenance of a particular CHE subtype that is characterized by the combination of allergic and irritant contact dermatitis.     

A comparison of dermatologists', surgeons' and general practitioners' surgical management of cutaneous melanoma

BACKGROUND: Current guidelines for the surgical management of melanoma aim to bring a combined consensus approach to the surgery of melanoma. Whether different outcomes for melanoma are related to the specialist who treats the patient is unknown. OBJECTIVES: To examine the clinicopathological features and surgical management of patients with primary cutaneous malignant melanoma treated by dermatologists, general surgeons, plastic surgeons and general practitioners (GPs). We also examined if the category of specialist had an effect on the survival outcome for the patient. METHODS: A retrospective, observational study of patients registered on a specialist database that records the clinicopathological features, surgical treatment and follow-up information of patients with malignant melanoma in Scotland. The patients had invasive primary cutaneous malignant melanoma without evidence of metastasis at the time of surgery, diagnosed between 1979 and 1997, with follow-up to the end of December 1999. Clinicopathological characteristics and surgical treatment of patients were compared for the four groups of specialist, as were overall survival (OS), disease-free survival (DFS) and recurrence-free interval (RF). RESULTS: Of 1536 patients, 663 (43%) were treated initially by a dermatologist, 486 (32%) by a general surgeon, 257 (17%) by a plastic surgeon and 130 (8%) by a GP. The proportion of patients managed by dermatologists rose over the lifetime of the study. Compared with the other specialists, the patients treated by general and plastic surgeons were older; a higher proportion of female patients was managed by dermatologists; median tumour thickness, lesion diameter and frequency of ulceration were all greater in the general surgeon-treated group; plastic surgeons treated a higher proportion of lentigo maligna melanomas; and general surgeons and GPs saw a higher proportion of nodular melanomas. Over 90% of patients managed by a dermatologist or GP underwent wider local excision following initial excision, compared with 43% and 25%, respectively, in the general and plastic surgery groups. General surgeons used wider excision margins than the other specialists. OS, DFS and RF were significantly better in the dermatology group compared with the general and plastic surgery groups. CONCLUSIONS: This study showed that dermatologists manage an increasing majority of melanoma patients and that there were significant differences in the surgical treatment of melanoma between dermatologists and surgeons. Survival was significantly better in the dermatology-treated group, suggesting that dermatologists should have a central role in melanoma management.     

Cutaneous side-effects in patients on long-term treatment with epidermal growth factor receptor inhibitors

Background  Acute and subacute cutaneous side-effects of epidermal growth factor receptor inhibitors (EGFRIs) are very frequent and well known. Much less is known about the chronic cutaneous effects of these drugs and about their potential psychosocial impact on patients.
Objectives  We performed a retrospective study of patients treated with EGFRIs for more than 6 months.
Methods  All patients had a detailed dermatological examination. The primary cancer, associated chemotherapies, skin treatment, evolution of skin symptoms and their impact on quality of life (QoL) as evaluated by the Dermatology Life Quality Index (DLQI) were noted.
Results  Seven men and nine women were identified. The mean length of EGFRI treatment was 10 months (range 6–27). At the time of examination, all patients (100%) had cutaneous side-effects. Grade I or II folliculitis was found in 37·5% of the patients. Additional skin manifestations were xerosis (100%), mucositis (69%), hair abnormalities (87·5%), eyelash trichomegaly (62·5%), facial hypertrichosis (56%), painful paronychia (56%) and onycholysis (44%). Dose reduction or EGFRI discontinuation for skin toxicity were needed in six patients (37·5%). DLQI evaluation showed a moderate to strong impact on QoL in four patients (25%).
Conclusions  Cutaneous side-effects are found in 100% of patients treated with EGFRIs for more than 6 months and have a significant effect on patients' QoL. The clinical spectrum of skin manifestation varies over time. As the use of EGFRIs rapidly increases, it is critical for us to improve our knowledge in the understanding and managment of these skin manifestations.