A 56-year-old man was referred to our dermatology department for evaluation of skin lesions which had been previously diagnosed as chronic eczema and palmoplantar psoriasis by another dermatologist. He was applying an ultra-high-potency corticosteroid ointment for the same and since one month, was also taking cyclosporine tablets, without any result. For about 6 months prior to this, the patient had been experiencing photophobia, blurred vision and excessive tearing that affected only his left eye. He was diagnosed with pan-uveitis [Figure - 1] and was on treatment with systemic corticosteroids and peribulbar injections of triamcinolone acetonide. He also complained of a chronic and dull articular pain affecting the lower limbs (hips, knees, and ankles), which was occasionally treated with non-steroidal anti-inflammatory drugs with poor improvement. He was sent to our department for a dermatological evaluation to detect any possible correlation between the cutaneous lesions and the aforesaid symptoms.
A dermatoscope is a hand-held device for examining the appearance of the skin. Dermoscopy has become an increasingly used and valued tool in the assessment of various skin lesions, and more recently, inflammatory rashes. It is quick, cheap and when used correctly, dermoscopy is an essential tool in helping clinicians detect early stage skin cancer. Various national and international guidelines recommend routine use of dermoscopy in the assessment of pigmented lesions1,2 because it enhances melanoma detection rates3,4 and can help confirm the diagnosis of benign lesions such as haemangiomas and seborrhoeic keratoses. As with any skill, competency takes time to develop and a combination of various learning and assessment methods is best. The dermatology specialist training curriculum in the United Kingdom (UK) states that trainees should be competent in using a dermatoscope and interpreting findings, while recognizing the limitations of this tool5. Assessment of these clinical skill and behavioural competencies using direct observation of procedural skills (DOPS), case-based discussion (CBD), mini clinical examination (mini-CEX), and/or multisource feedback (MSF) is suggested. There is no specific guidance on what resources a trainee should use to achieve these competencies, nor on what is the minimum expected dermoscopy skillset at completion of specialist training.
Iadvl Textbook Of Dermatology Pdf 184
The aim of this survey was to explore dermoscopy use amongst dermatology specialist trainee registrars in the UK including frequency of use, how it is being taught and whether trainees feel their dermoscopy training has been adequate.
An online survey was designed and distributed to dermatology trainees in the United Kingdom using an email link and hard copies were distributed at a national dermoscopy course. Respondents who did not identify themselves as dermatology trainees were removed from the analysis. Responses were collected anonymously, then collated and analysed using SurveyMonkey computer software.
These results of this survey highlight the need for dermoscopy training to be reviewed within the UK national training curriculum for dermatology. Despite daily use by the vast majority, dermoscopy training is largely self-directed and highly variable amongst individual trainees. Of concern, a significant proportion of those who responded feel their dermoscopy skills are inadequate for their training stage. Of note, the 25% response rate means that the results of this survey may not be representative of dermatology trainees in the United Kingdom as a whole.
This is the first time that dermoscopy use has been explored through a national survey of dermatology trainees in the UK, to the best of our knowledge. A survey on dermoscopy use was carried out by The British Association of Dermatologists (BAD) in 20126 but the majority of responses were from dermatology consultants. This confirmed that 98.5% of respondents regularly used dermoscopy, while 81% had received any training. The most frequent source of training was UK based courses, which 62% of respondents reported attending. Of note, 39% of all respondents lacked confidence when making a diagnosis based on their interpretation of dermoscopy findings. It is not clear how many of those lacking in confidence were consultants, trainees or specialty doctors. Although the situation may have improved since 2012, these results do suggest that dermoscopy training needs have not been met for a proportion of doctors across the dermatology community.
In conclusion, we feel UK dermatology trainees and indeed any clinician who utilizes this tool, would benefit from a more standardized and integrated approach to dermoscopy teaching to ensure safe practice of this skill and deliver high quality evidence-based patient care.
The US Food and Drug Administration (USFDA) considers the following as biologics: any therapeutic serum, toxin, antitoxin, vaccine, virus, blood, blood component or derivative, allergenic product, analogous product, or derivatives applicable to the prevention, treatment, or cure of injuries or disease of man1. However, generally, biologics refer to protein molecules therapeutically used in various diseases so as to target specific points in the inflammatory cascade of these disorders 2. Hope for an improved tolerability, convenience in usage and lasting remissions, combined with increased knowledge of immune-pathogenesis of various cutaneous diseases has lead to the introduction of biologics as alternative immune-modulating agents in the field of dermatology.
Fusion proteins, also known as chimeric proteins, are proteins which are created by the fusion of the receptor domain of a human protein with the constant region of human IgG. The resultant fusion protein binds specifically to a ligand or co-receptor 53. The most commonly used fusion proteins in dermatology are briefly described below and enumerated in Box 1.
Cytokines are non-immunoglobulin proteins and glycoproteins produced by a wide variety of cells in the human body and released in response to any immune stimulus 74, 75. Recombinant cytokines or cytokine antagonists have been used as immunomodulators 76. The principal recombinant cytokines used in dermatology, enumerated in Box 1, are described below.
Many scoring systems for assessing the severity of various dermatological diseases exist. These scoring systems and other indices can be used for assessment of response to the use of biologics. For example, for evaluation of improvement in psoriasis, PASI (psoriasis area and severity index) and DLQI (dermatology life quality index) are recommended at 3 months initially and then every 6 months 113. Reduction in baseline PASI score of >75% is the standard used by FDA to assess the efficacy of a new psoriasis agent 115. Similarly in atopic eczemas, improvement is monitored based on the Eczema Area and Severity Index, Pruritus Severity Assessment and DLQI. Reduction of the Eczema Area and Severity Index score by 50% is considered excellent, 30-49% moderate and
To summarise, biologics represent the future of therapeutics, not only in dermatology but also in other fields of medicine. Among the various dermatological disorders where they are used, biologics have been most evaluated in psoriasis 116. However, the possibility of serious infections and the oncogenic potential combined with the high cost of the drugs limit their routine use at the present stage 117. Regular re-evaluation of efficacy and safety is essential if these agents are to be used to the maximum benefit of patients118.
William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative DermatologyDisclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMDServed as a speaker for various universities, dermatology societies, and dermatology departments.
Therapy: Review of the current information on establishing a treatment plan, including topical, systemic, and radiation therapy, as well as operative dermatology, wound healing, and emergency treatment. 2ff7e9595c
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