Erin McMeniman

Diagnostic delay in hidradenitis suppurativa is a global problem.

DEAR EDITOR, Hidradenitis suppurativa (HS) is clinically defined with recognized diagnostic criteria and recognizable physical characteristics. Untreated, the disease causes significant morbidity. The prevalence varies between 0 0003% and 4% depending on the study population. Estimates from insurance databases suggest a prevalence of < 0 1%. This variation strongly suggests a significant selection bias or misclassification, and it may be speculated that not all patients present for care. This is reinforced by clinical experience and published evidence indicating a significant delay in diagnosis. This study explores the delay in diagnosis for patients with HS on an international level. The study (survey) was conducted in 2013. Observational data were collected during routine visits or extracted from case records. Because of the simple and obvious symptomatology of recurrent painful lesions present in restricted welldefined areas of the body, patients’ self-reported history was considered valid regarding onset of symptoms. Consecutive patients with HS and psoriasis were included from each participating centre during a period of 4 months or less. The data were anonymized by removing any names, addresses and social security numbers, and included age, sex, age at disease onset, age at diagnosis, delay in diagnosis, time from onset of symptoms to first physician contact, age at first medical contact, number of physicians seen prior to the diagnosis, family history and disease severity. If the diagnosis was made by a primary care physician or by a specialist other than a dermatologist prior to seeing a dermatologist, this was recorded as the date of the diagnosis. Individual centres were responsible for and obtained any locally required permissions and signed informed consent forms, for example ethics committee approval, in accordance with national registry and data protection rules. Patients diagnosed with HS or psoriasis (and confirmed by the investigator) were included. The primary outcome was quantification of the delay in diagnosis. Additionally, documentation was made of both the delay in visiting a physician (and so gaining access to specialist treatment) and the relative delay in diagnosis of HS compared with psoriasis with/without a family history. The severity of HS was determined by Hurley’s staging criteria: stage I, mild; stage II, moderate and stage III, severe. In patients with psoriasis, severity was evaluated by the Psoriasis Area and Severity Index: score < 7, mild; 7–12, moderate and > 12, severe. The t-test, Wilcoxon rank sum test and v-test were used where appropriate. Univariate and multivariate logistic regression analyses were used to identify factors predictive of significant diagnostic delay. Diagnostic delay > 2 years was defined as significant. Diagnosis, sex, age of onset, family history and disease severity were selected as potentially important

Clinical photography in dermatology: Ethical and medico‐legal considerations in the age of digital and smartphone technology

Clinical photography has long been an important aspect in the management of dermatological pathology and has many applications in contemporary dermatology practice. With the continuous evolution of digital and smartphone technology, clinicians must maintain ethical and medico‐legal standards. This article reviews how dermatology trainees are utilising this technology in their clinical practice and what procedures they follow when taking photos of patients. We review the ethical and legal considerations of clinical photography in dermatology and present a hypothetical medico‐legal scenario.

Risk factors in a cohort of patients with multiple primary melanoma

Background: There are various known familial and environmental risk factors that influence the risk for melanoma. This study sought to define the risk factors for multiple primary melanoma.

Efficacy of smartphone applications in high-risk pigmented lesions

Melanoma apps are smartphone applications that assess risk of pigmented lesions using a smartphone camera and underlying algorithm. We aimed to assess the capability of melanoma smartphone applications (apps) in making clinical decisions about risk, compared with lesion assessment by specialist trained dermatologists.

Mycophenolate mofetil in erosive genital lichen planus: A case and review of the literature

Erosive genital lichen planus is a disabling, inflammatory mucocutaneous condition that can cause significant patient morbidity and loss of function. Treatment initially involves topical corticosteroids but some patients can have severe treatment‐resistant courses requiring systemic immunosuppression. With potentially unfavorable adverse effect profiles and subsequent intolerance of these agents by patients, erosive lichen planus can ultimately be a challenging condition to treat effectively. We present a case of a 66‐year‐old woman with treatment‐resistant erosive genital lichen planus who was successfully managed with mycophenolate mofetil. Although there is only weak evidence for this agent in this condition, its role in dermatology is growing due to its efficacy and advantageous adverse effect profile and should therefore be considered in patients with treatment‐resistant erosive genital lichen planus.

Childhood obesity: how do Australian general practitioners feel about managing this growing health problem?

General practitioners (GPs) are ideally placed to identify and treat childhood obesity, but its prevalence continues to rise and evidence for effective GP interventions is lacking. Further analysis of the barriers to effective identification and management of childhood obesity is warranted. This survey aimed to explore how Queensland GPs feel about managing the growing problem of childhood obesity. A cross-sectional survey was sent to a random sample of 573 Queensland GPs about perceptions of diagnosis and management of childhood obesity. A total of 30% of GPs responded (n=170). The main perceived obstacles to identification of childhood obesity were uncertainty about definition criteria and how to calculate body mass index, and lack of access to body mass index percentile charts. The main perceived obstacles in managing childhood obesity were lack of financial incentive, time constraints, lack of health system support and parental resistance. Only 22% of respondents indicated awareness of the National Health and Medical Research Council guidelines for management of obese children and 92% had never used any formal clinical guidelines in assessment or management of childhood obesity. Addressing these barriers to identification of childhood obesity by GPs may facilitate more effective management. Strategies include greater emphasis on this issue in general practice training, financial incentives for diagnosis and management, incorporating clinical management guidelines into medical software, and increasing allied and community health support.

Malignant melanoma disguised in a tattoo.

A 76-year-old man with a medical history of malignant melanoma and non-melanoma skin cancer presented to the dermatologist for his 6-monthly skin examination. He was of English descent with type II skin and was raised in Queensland. He reported no lesions of concern. The examination revealed a 2-cm diameter pigmented lesion in his tattoo on his right upper arm (Fig. 1a). It was irregular in shape and symmetry and of variegated colour. He was unaware of this lesion at the time of the examination and prior to his tattoo, which was over 20 years old. There was no documented record of this pigmented lesion in his previous dermatology consultations. Dermoscopy was difficult (Fig. 1b), however, the features of asymmetry, globular structures, grey veil and an atypical network suggested a melanoma. An elliptical excision of the pigmented lesion was performed. The histopathology revealed macroscopically an irregular brown macule measuring 20 × 8 mm. Microscopically there was a melanoma in situ (Fig. 1c). Tattoos are not an established risk factor for melanoma. The English literature reports 16 cases of malignant melanoma developing in tattoos, and herein we present the 17th case. The pathogenesis of melanoma developing at tattoo sites is unknown and the association may be fortuitous. Further research is required to investigate the possibility of an association between melanocytic proliferation and tattoos. Other neoplastic lesions such as basal cell carcinoma and squamous cell carcinoma have been reported in association with tattoos. Some tattoo reactions, including pseudocarcinomatous or keratoacanthoma-like reactions, can be difficult to differentiate from true cutaneous malignancies. This case demonstrates that tattoo ink may camouflage the clinical signs of a melanoma. The assessment of pigmented lesions among a tattoo is difficult for patients on a macroscopic level, for dermatologists at a clinical and dermoscopic level, and for histopathologists at a microscopic level. The patient himself had not noticed this lesion in his tattoo despite a presumed increase in his awareness because of his personal history of melanoma. It is uncertain whether this was a truly new lesion or one that had been observed but thought benign, or not been detected on previous consultations. This emphasises the masking effect of tattoo ink, even in lesions this size, to patients and potentially to clinicians. The lesion may have been detected earlier if there was no tattoo. The dermatologist’s dermoscopy assessment was difficult as the tattoo ink interrupted and masked some of the signs for interpretation. The tattoo ink colour may additionally influence the diagnostic difficulty. The difficulties experienced in this patient have the potential for delayed or incorrect diagnoses or misdiagnoses, which can ultimately result in poorer patient outcomes. The increased prevalence of tattoos makes this an important complication, especially in Australia, with the highest incidence of melanoma worldwide. Approximately one in seven Australians has a tattoo, with the most popular age group from 20–39 years. This cohort is also least likely to

Skin protection behaviour and sex differences in melanoma location in patients with multiple primary melanomas.

Previous studies have shown that sunscreen usage, sun‐protection measures and self‐examination rates in patients with single primary melanomas (SPM) are similar to that in the general population. This study hypothesises that these rates would be different in a population with multiple primary melanomas (MPM). We further hypothesise that there would be a sex difference in melanoma location in patients with MPM. The objectives of this study were to determine skin protection measures, self‐examinations and melanoma location in a cohort of patients with MPM.

A clinical audit of high‐cost and off‐label drug use in dermatology

The use of high‐cost, off‐label, unsubsidised drugs has become valuable in the management of dermatology patients with challenging conditions unresponsive to conventional therapy. Currently, there is no dedicated funding and a paucity of evidence for such drugs. The aim of this audit was to review outcomes and costs.

Dermatoses of pregnancy: Nomenclature, misnomers, and myths

The most recent reclassification of dermatoses of pregnancy includes polymorphic eruption of pregnancy, atopic eruption of pregnancy, and pemphigoid gestationis; intrahepatic cholestasis of pregnancy, strictly not a dermatosis, was included in specific dermatoses of pregnancy for working purposes. Another dermatosis, pustular psoriasis of pregnancy, could be included for similar reasons. The nomenclature of these pregnancy-specific eruptions has been revised several times, generating potential confusion among practitioners. Clouding the picture further are misnomers that have been used to describe dermatoses of pregnancy. In addition, several cutaneous conditions that are associated with, but not specific to, pregnancy, have been misunderstood, which has resulted in certain myths among patients and physicians. In this contribution, we describe how the nomenclature of each dermatosis of pregnancy has evolved to fit the current classification scheme. We then identify several misnomers that have generated confusion within the scheme. Finally, we debunk several myths that have developed around cutaneous conditions outside of this scheme, in both mother and newborn.