Download “How can we achieve `Healthy skin for all`?” Jonathan

“How can we achieve 'Healthy skin for all’?”
Jonathan Jeyatheswaran
Introduction
Skin disease is one of the most common human illnesses, impacting on all
cultures and occurring at all ages, with three skin conditions in the ten most
prevalent diseases worldwide.1 International dermatology organisations have
posed the question of how to achieve healthy skin for all, with emphasis placed
on increasing awareness of the importance of skin and delivery of care to those
in need, especially developing countries.2,3 To address this question further,
topics including prevention, research funding and dermatology training will be
analysed as factors for achieving healthy skin for all.
Developing Countries
On a global scale, skin conditions were the fourth leading cause of nonfatal
disease burden in both low and high-income countries, emphasising need for
skin prevention and treatment in future global health prevention strategies.1 In
deprived regions there is a mismatch between demand and supply in terms of
dermatologists, healthcare workers, buildings and equipment.4 For example,
Ethiopia has a population of around 80 million people serviced by approximately
22 dermatologists practicing in urban areas, leaving Ethiopia’s rural population
without adequate care.5 With healthcare focused on life-threatening diseases,
concerns about skin disease may not be addressed leading to infection,
disfigurement and community ostracism.6 International task groups could be
sent to these areas to draw up guidelines on carrying out health needs
1
assessments that meet international requirements and funding should be
available to train more dermatologists to practice in resource-poor regions.4,7
Training healthcare professionals could be aided through voluntary work.6
Health Volunteers Overseas (HVO) has worked in partnership with the American
Academy of Dermatology, providing opportunities in developing countries for
dermatologists to share their skills by training local health providers in basic
skin care through bedside and didactic teaching.6 Training for dermatologists
and health workers should be specific to population need, with skin infections
more common in developing countries, particularly children.6,8,9 Involving more
women in dermatology education and training has helped in fostering
improvements in skin care for women and children worldwide.10
The purpose of the International Foundation of Dermatology (IFD) is to improve
dermatology education, training and programs such as the Regional Dermatology
Training Centre (RDTC) in Tanzania.7 Organisations such as IFD have built
strong relationships with industry, resulting in pharmaceutical companies aiding
advancements of international humanitarian initiatives such as Global Alliance
for the Elimination of Lymphatic Filariasis.7,11-13 Organisations similar to IFD
must continue to be funded and efforts made to expand networks in dermatology
between international organisations, to enable greater exchange of research,
which could result in more effective affordable treatment.7,14 Such collaborations
could result in the formation of an international resource, providing access to
data permitting greater understanding of global issues to the wider dermatology
community.7
2
Teledermatology services provide a diagnostically reliable method of increasing
access to expertise in resource-poor regions.15,16 Mobile teledermatology has
been introduced to overcome lack of internet in developing countries.17-19
Established teledermatology programs should be sustainable so a long-term
positive contribution is made to the community such as the Panamanian
Telemedicine and Telehealth Program.20 High standards of communication with
referring providers and teledermatology training are necessary to support
sustainable practices.15,21
Causes and clinical presentation of skin disease can be influenced by culture and
religion, particularly in developing countries.22,23 Allergic contact dermatitis has
been reported in Hindu women who wear the bindi, a red adhesive disc worn on
the forehead.22 In Asia, skin diseases such as vitiligo lead to emotional lability,
with a great psychosocial impact on women, where beauty is valued in the
arranged marriage market.24 Therefore, clinicians should consider patient’s
cultural heritage and religious practices to aid diagnosis and management of skin
disease.24,25
3
Prevention and Standards of Care
Approximately 2,200 deaths per year from skin cancer are mostly due to
malignant melanoma in the United Kingdom (UK).26 Incidence of melanoma and
non-melanoma skin cancer has increased over the past 50 years in fair skinned
populations in Europe, North America and Australia.27-30 Nevertheless, there
should be patient education about skin cancer regardless of race.31,32 Primary
risk factors for developing skin cancer include degree of sun exposure, skin type
and family history of skin cancer.33 However, new risk factors can emerge, with
more cases of melanoma reported in young adults.34,35 De Vries et al. (2012)
identified potential risk factors for skin cancer with consumption of specific food
items, medication use and stress.36 Relationships between skin cancer and other
conditions have been suggested such as that of melanoma and Parkinson’s
disease.37,38 Research and reviews of literature into risk factors of skin diseases
are continuously required to improve standards of prevention.
Prevention strategies are an effective method of maintaining healthy skin as
highlighted by increased percentage survival rates from melanoma when
detected in its early stages.39-41 There has been greater promotion of sunbed use,
especially amongst adolescent women, with endorsement of sunbeds by
celebrities.42 Skin cancer prevention should focus on changing the beliefs of
tanning appeal, emphasise the importance of sunscreen use and highlight the
need for skin self-examination.30,43 There should be promotion of ultraviolet
radiation protection through education (the SunSmart website) and regular
surveys of sun exposure.44-47 Implementing these methods will save lives, reduce
4
morbidity and generate major health system cost savings.48
Regular
assessments must be made of people’s awareness and attitudes to skin cancer
prevention. Reviewing methods used to raise awareness in primary care,
workplaces, the internet and through international campaigns such as
Euromelanoma is required.49-52 Consequently, standards of prevention can be
improved upon locally and globally.
Similar prevention methods could be implemented for other skin conditions
such as need for smoking cessation and education about how to use topical
treatments for psoriasis patients.53-57 Skin conditions could increase the risk of
patients suffering from other diseases such as the possible link between
psoriasis and cardiovascular disease.58-61 Accessible public information about
common skin conditions is provided by organisations such as The Psoriasis
Association and National Eczema Society.62,63 Dermatologists and other health
professionals should make patients aware of these organisations, which provide
reliable and updated information and raise awareness of new research findings.
Clinical guidelines offer the opportunity for standardisation of diagnostic
procedures, their use guarantees equal access of patients to medical services and
they represent a scaffold for inexperienced physicians.64 These guidelines should
be regularly evaluated. Randomised control trials and systematic reviews should
be used when developing clinical guidelines and establishing treatment
efficacy.65,66 A wide range of non-clinical factors including patient, clinician and
practice-related factors can influence clinical decision-making.67 Examples of
5
these are treatment adherence and time constraints in clinic.67 Understanding of
non-clinical influences on decision-making is of principal importance.67
Clinical audits form part of clinical governance and are necessary for
safeguarding high standards of care.68,69 Mohs micrographic surgery audits
collected data including the recurrence rates of basal cell carcinoma and
complications of surgery.68,69 This data could help improve aspects of care in the
future and highlights the importance of auditing in dermatology.68,69
Self-management, Outcome Measures and Psychodermatology
Self-management is necessary for controlling skin conditions. For example, for
patients with high risk of melanoma, systematic self-examination with skin selfphotography is important and patients should remember to visit a trained doctor
yearly to be examined.70,71 Furthermore, patients suffering with skin disease
have to be fully aware of how to use treatments effectively and must be
conscious of the side effects associated with certain therapies. Patient-centred
communication and education in dermatology enhances levels of patient care
including self-management, fufills professional competencies requirements,
reduces medical errors, and improves health outcomes and patient satisfaction.72
Dermatologists must be taught effective techniques for verbal and non-verbal
communication, especially for difficult conversations in dermatology practice.72
Outcome measures are frequently used, such as quality of life (Dermatology Life
Quality Index) or severity (Psoriasis Area and Severity Index), and not process
6
measures that may assess key factors influencing such outcomes.73 Chronic
disease intervention should begin with assessment of patient’s prior knowledge,
personal competence, and patient identified outcomes such as the PersonCentred Dermatology Self-Care Index (PeDeSI) assessment which considers the
education and support needs of patients with long-term dermatological
conditions and aims to promote treatment concordance.73
Skin conditions including acne and psoriasis can affect psychological wellbeing.74 Acne may be associated with suicide, depression and higher levels of
unemployment.75 Psoriasis flare-ups can occur due to significant life events.76-78
A survey provides evidence suggesting that dermatologists are underprepared to
treat psychocutaneous disorders, with a lack of patient access to psychiatric
support noted in dermatology departments in the UK.79,80 Greater focus should
be placed on training dermatologists in pychodermatology. Treatments such as
cognitive-behavioural methods, hypnosis or progressive relaxation can help to
counteract stress and prevent flare-ups.81,82
Government and Commissioning Care
Quality of skin care may be at risk from political agendas focused on limitation
and prioritisation. It is important that international organisations have a role in
analysing healthcare reforms and collaborate to make clinical guidelines.7,83 The
aim of governments should be to provide the most effective and affordable
dermatology care to meet the population’s need.
7
Clinical commissioning groups have the obligation to obtain advice from
healthcare professionals and involve patients and the public in decisions
regarding delivery of skin care. Professional organisations such as the British
Association of Dermatologists (BAD) should have a primary role in illustrating to
government complexities in commissioning as shown by BAD, The Lessons for the
NHS: Commissioning a Dermatological Service, to improve the framework for
delivering efficient skin care.84,85
.
Research
The United States (US) federal deficit may see a decrease in National Institute of
Health (NIH) research money and Medicare funding of dermatology residency
positions.86 In 2006 the UK Clinical Research Collaboration published an analysis
of directly-funded UK research portfolios of the 11 largest government and
charity funders of health-related research.87 Of 20 health categories, ‘skin’
ranked eighteenth for funding.87 At the 2010 UK annual scientific meeting of The
Society for Academic Primary Care, of 257 abstracts featured, only one was
dermatological.87 Therefore, efforts must be made to improve dermatology
research funding including in countries with established healthcare systems.87
Dermatology must find new ways to fund research, possibly by encouraging
investigators to collaborate, making research more efficient.86 Funding should
follow the approach of the Milken prostate cancer model, which stimulates
research by cutting the waiting time for grant money, emphasises funding of
8
therapy-driven ideas, holds researchers accountable for results, and demands
collaboration across all disciplines and among institutions, private industry, and
academia.86 Another example is the Dermatology Foundation in the US that has
successfully supported future leaders who have chosen the study of skin health
and extended funding to important fields including paediatric dermatology and
dermatopathology.88 Furthermore, the foundation tracks career outcomes of
those who have received funding through career development awards (CDAs),
with a survey showing 80% of 181 past recipients of CDAs currently holding
positions in academic medicine.88,89
Primary care research in the UK is supported through the National School for
Primary Care Research and Primary Care Research Networks.87,90 Researchers
engage with the UK Dermatology Clinical Trials Network, which provides
support for developing trial ideas.87 Challenges facing expansion of primary care
dermatology research are engaging general practitioners (GPs) who do not have
a specific research interest and minimising the additional workload involved.87,90
Interest could be raised in dermatology through more learning opportunities of
skin conditions in primary care settings at an undergraduate level.87,91
9
Training and The Future
Dermatology is a specialty reliant on excellent perceptual skills and pattern
recognition (non-analytical pattern recognition (NAPR)), with exposure to many
cases necessary.92,93 In the UK, undergraduate training is limited to only a few
weeks despite around 900,000 patients being referred from primary care to
hospital care each year.92 Cutaneous malignancies account for over a quarter of
all new cancers diagnosed in the UK.93 GPs are responsible for the initial
assessment of skin lesions (10-15% of primary care cases).91,92 However, GPs
need to see dermatology cases frequently enough to remain competent.92
Encouraging GPs to take up postgraduate dermatology degrees could improve
competency.94-96 Furthermore, dermatological surgery is an area GPs could
benefit from more training as specialist GPs had higher incomplete excision rates
for skin cancer surgery than dermatologists.97
Final year medical students should be able to take a dermatology history,
examine the skin, describe skin lesions, recognise cutaneous malignancies and
know when to ask for help.93,98,99 A survey-based study of education methods
and confidence levels found specialist clinical experiences and small-group
learning increased confidence levels of medical students in dermatology.100 More
dermatology teaching at undergraduate level is supported by an assessment of
management of skin disease by Foundation Year 1 (FY1) doctors with respect to
undergraduate dermatology experience.99,101,102 Longitudinal dermatology
placements offer undergraduate experience in diagnosis and management that
develops confidence for foundation practice.101
10
An audit of dermatological content of UK undergraduate curricula from medical
schools against the recommendations for a core undergraduate dermatology
curriculum published by the BAD, found evidence of good teaching on tumours,
psoriasis and acne.98 Nevertheless, more assessments of dermatology knowledge
in medical schools should be made to confirm students are fulfilling learning
outcomes. Dermatology teaching needs to ensure opportunities for learning in
the community are optimised by working with leads for primary care teaching.98
The audit found that not all curricula mentioned exploring a patient’s concerns,
‘describing skin lesions’ and recording findings accurately in patients’ notes.93,98
Clinical skills training and examination could incorporate more dermatology
themes.93 To raise awareness, expert patients could help students understand
the problems of living with chronic skin disease.98 Prosthetic melanomas could
be a useful tool in assessing skin cancer detection skills.103 The audit found
important topics such as meningococcaemia were omitted in some medical
schools.98 Hence, efforts could be made to focus on a greater breadth of
dermatology teaching.93,98
Dermatologists should be aware of the potential of the internet and social media
as a source of public health information and teaching.104,105 Social media
websites such as Facebook, Twitter and YouTube as well as Smartphone
applications such as the BAD, Dermatology: Medical Student Edition or online
resources including Dermatology handbook for Medical Students and Junior
Doctors by the BAD have advantages of low cost, user interaction and rapid
transmission of information to the wider community.105-112 However,
11
professional organisations such as the BAD must approve of content made
available to the public so that information provided is reliable.
The British Journal of Dermatology identified ‘ethnic skin’ as a the new era for
studying human cutaneous diversity.113,114 Understanding human cutaneous
diversity is important in cosmopolitan cities experiencing immigration.113
Dermatoses that may have been rare in practices are becoming more common.113
New combinations of ‘ethnic skin’ are born with new skin phenotypes and
genotypes due to intermarriage.113 Focus should be placed on the subject of
human cutaneous diversity to maintain high levels of skin care for future
generations.113,114
Conclusion
The question “how can we achieve ‘healthy skin for all’?” is challenging and
involves principal focus on populations with greatest need for skin care.
Continued research funding and collaboration is necessary, with improvements
and assessments of dermatology training and treatments also essential.
Nevertheless, more emphasis on prevention, self-management and primary care
management may provide the greatest progress towards achieving this goal.
Word Count: 2494
12
References
1.
Hay RJ, Johns NE, Williams HC, Bolliger IW, Delavalle B, Margolis DJ, et al.
The Global Burden of Skin Disease in 2010: An Analysis of the Prevalence and
Impact of Skin Conditions.J Invest Dermatol. 2013 Oct 28. PubMed PMID:
24166134.
2.
Ryan TJ. Healthy skin for all. International Committee of Dermatology.Int J
Dermatol. 1994 Dec;33(12):829-35. PubMed PMID: 7883403.
3.
Ryan TJ. United Nations and nongovernmental organizations. Healthy skin
for all. Dermatol Clin. 1994 Oct;12(4):611-20. PubMed PMID: 7805291.
4.
Hay RJ, Fuller LC. The assessment of dermatological needs in resource-
poor regions. Int J Dermatol. 2011 May;50(5):552-7. PubMed PMID: 21506971.
5.
Murgia V, Bilcha KD, Shibeshi D. Community dermatology in Debre
Markos: an attempt to define children's dermatological needs in a rural area of
Ethiopia. Int J Dermatol. 2010 Jun;49(6):666-71. PubMed PMID: 20618472.
6.
McKoy K, Rehmus W. American Academy of Dermatology and Health
Volunteers Overseas: a decade of partnership. J Am Acad Dermatol. 2013
Jul;69(1):162-3. PubMed PMID: 23768290.
7.
Hay RJ. The role of international dermatology organizations. Clin
Dermatol. 2012 Nov-Dec;30(6):668-71. PubMed PMID: 23068154.
8.
Shimelis ND, Asticcioli S, Baraldo M, Tirillini B, Lulekal E, Murgia V.
Researching accessible and affordable treatment for common dermatological
problems in developing countries. An Ethiopian experience. Int J Dermatol. 2012
Jul;51(7):790-5. PubMed PMID: 22715822.
13
9.
Hogewoning A, Amoah A, Bavinck JN, Boakye D, Yazdanbakhsh M,
Adegnika A, et al. Skin diseases among schoolchildren in Ghana, Gabon, and
Rwanda. Int J Dermatol. 2013 May;52(5):589-600. PubMed PMID: 23557028.
10.
Murrell DF, Ryan TJ, Bergfeld WF. Advancement of women in
dermatology.Int J Dermatol. 2011 May;50(5):593-600. PubMed PMID: 21506978.
11.
Addiss D, Global Alliance to Eliminate Lymphatic F. The 6th Meeting of the
Global Alliance to Eliminate Lymphatic Filariasis: A half-time review of lymphatic
filariasis elimination and its integration with the control of other neglected
tropical diseases. Parasit Vectors. 2010;3:100. PubMed PMID: 20961435.
Pubmed Central PMCID: 2984583.
12.
Hay R, Marks R. The International Foundation for Dermatology: an
exemplar of the increasingly diverse activities of the International League of
Dermatological Societies. Br J Dermatol. 2004 Apr;150(4):747-9. PubMed PMID:
15099372.
13.
Mavura D, Contreras-Ruiz J. Wound care in Tanzania at the Regional
Dermatological Training Centre. Adv Skin Wound Care. 2006 Oct;19(8):435-6.
PubMed PMID: 17008813.
14.
Lotti T, Handog EB, Hercogova J, Ramos ESM. International dermatology:
the many faces and challenges of the specialty in the global village. Dermatol Clin.
2008 Apr;26(2):183-90, v. PubMed PMID: 18346550.
15.
Armstrong AW, Kwong MW, Ledo L, Nesbitt TS, Shewry SL. Practice
models and challenges in teledermatology: a study of collective experiences from
teledermatologists. PloS One. 2011;6(12):e28687. PubMed PMID: 22194887.
Pubmed Central PMCID: 3237480.
14
16.
Kaddu S, Soyer HP, Gabler G, Kovarik C. The Africa Teledermatology
Project: preliminary experience with a sub-Saharan teledermatology and elearning program. J Am Acad Dermatol. 2009 Jul;61(1):155-7. PubMed PMID:
19539859.
17.
Tran K, Ayad M, Weinberg J, Cherng A, Chowdhury M, Monir S, et al.
Mobile teledermatology in the developing world: implications of a feasibility
study on 30 Egyptian patients with common skin diseases. J Am Acad Dermatol.
2011 Feb;64(2):302-9. PubMed PMID: 21094560.
18.
Zuo KJ, Guo D, Rao J. Mobile teledermatology: a promising future in
clinical practice. J Cutan Med Surg. 2013 Nov-Dec;17(6):387-91. PubMed PMID:
24138974.
19.
Osei-tutu A, Shih T, Rosen A, Amanquah N, Chowdhury M, Nijhawan RI, et
al. Mobile teledermatology in Ghana: sending and answering consults via mobile
platform. J Am Acad Dermatol. 2013 Aug;69(2):e90-1. PubMed PMID: 23866892.
20.
Vega S, Marciscano I, Holcomb M, Erps KA, Major J, Lopez AM, et al.
Testing a top-down strategy for establishing a sustainable telemedicine program
in a developing country: the Arizona telemedicine program-US Army-Republic of
Panama Initiative. Telemed J E Health. 2013 Oct;19(10):746-53. PubMed PMID:
23931731.
21.
Thomas J, Kumar P. The scope of teledermatology in India. Indian
Dermatol Online J. 2013 Apr;4(2):82-9. PubMed PMID: 23741661. Pubmed
Central PMCID: 3673398.
22.
Ladizinski B, Lee KC. Religion and the skin: devotional dermatoses. JAMA
Dermatol. 2013 Nov 1;149(11):1322. PubMed PMID: 24257584.
15
23.
Goodheart HP. "Devotional dermatoses": a new nosologic entity? J Am
Acad Dermatol. 2001 Mar;44(3):543. PubMed PMID: 11209135.
24.
Shenoi SD, Prabhu S. Role of cultural factors in the biopsychosocial model
of psychosomatic skin diseases: an Indian perspective. Clin Dermatol. 2013 JanFeb;31(1):62-5. PubMed PMID: 23245975.
25.
Patel T, Magdum A, Ghura V. Does fasting during Ramadan affect the use
of topical dermatological treatment by Muslim patients in the UK? Clin Exp
Dermatol. 2012 Oct;37(7):718-21. PubMed PMID: 22681415.
26.
Cancer Research UK. Skin Cancer - Facts About the Different Types of Skin
Cancer.Page last updated 25th September2009.
http://www.sunsmart.org.uk/skin-cancer-facts/about-skin-cancer/
(Accessed 10th December 2013)
27.
Erdmann F, Lortet-Tieulent J, Schuz J, Zeeb H, Greinert R, Breitbart EW, et
al. International trends in the incidence of malignant melanoma 1953-2008--are
recent generations at higher or lower risk? Int J Cancer. 2013 Jan 15;132(2):385400. PubMed PMID: 22532371.
28.
Eisemann N, Waldmann A, Geller AC, Weinstock MA, Volkmer B, Greinert
R, et al. Non-melanoma skin cancer incidence and impact of skin cancer
screening on incidence. J Invest Dermatol. 2014 Jan;134(1):43-50. PubMed PMID:
23877569.
29.
Goldenberg A, Nguyen BT, Brian Jiang SI. Knowledge, Understanding, and
Use of Preventive Strategies against Nonmelanoma Skin Cancer in Healthy and
Immunosuppressed Individuals Undergoing Mohs Surgery. Dermatol Surg.2013
Dec 19. PubMed PMID: 24354730.
16
30.
Konkolova R, Provaznikova DH, Jirakova A, Hercogova J. Can melanoma
therapy change attitudes toward prevention and tanning? Dermatol Ther. 2013
Oct 23. PubMed PMID: 24151966.
31.
Korta DZ, Saggar V, Wu TP, Sanchez M. Racial differences in skin cancer
awareness and surveillance practices at a public hospital dermatology clinic. J
Am Acad Dermatol. 2013 Dec 8. PubMed PMID: 24332312.
32.
Maybury CM, Craythorne E, Martin B. An ulcerated nodule on the nose.
BMJ Case Rep. 2013;2013. PubMed PMID: 23595174.
33.
Cancer Research UK. Skin Cancer Risk Factors. Page last updated 20th
November 2013.
http://www.cancerresearchuk.org/cancerinfo/cancerstats/types/skin/riskfactors/skin-cancer-risk-factors
(Accessed 10th December 2013)
34.
Purdue MP, Freeman LE, Anderson WF, Tucker MA. Recent trends in
incidence of cutaneous melanoma among US Caucasian young adults. J Invest
Dermatol. 2008 Dec;128(12):2905-8. PubMed PMID: 18615112. Pubmed Central
PMCID: 2741632.
35.
Weir HK, Marrett LD, Cokkinides V, Barnholtz-Sloan J, Patel P, Tai E, et al.
Melanoma in adolescents and young adults (ages 15-39 years): United States,
1999-2006. J Am Acad Dermatol. 2011 Nov;65(5 Suppl 1):S38-49. PubMed PMID:
22018066. Pubmed Central PMCID: 3254089.
36.
de Vries E, Trakatelli M, Kalabalikis D, Ferrandiz L, Ruiz-de-Casas A,
Moreno-Ramirez D, et al. Known and potential new risk factors for skin cancer in
European populations: a multicentre case-control study. Br J Dermatol. 2012
Aug;167 Suppl 2:1-13. PubMed PMID: 22881582.
17
37.
Rugbjerg K, Friis S, Lassen CF, Ritz B, Olsen JH. Malignant melanoma,
breast cancer and other cancers in patients with Parkinson's disease. Int J
Cancer. 2012 Oct 15;131(8):1904-11. PubMed PMID: 22278152. Pubmed Central
PMCID: 3636769.
38.
Pan T, Li X, Jankovic J. The association between Parkinson's disease and
melanoma. Int J Cancer. 2011 May 15;128(10):2251-60. PubMed PMID:
21207412.
39.
Mitchell JK, Leslie KS. Melanoma death prevention: moving away from the
sun. J Am Acad Dermatol. 2013 Jun;68(6):e169-75. PubMed PMID: 23545369.
40.
Cokkinides V, Kirkland D, Andrews K, Sullivan K, Lichtenfeld JL. A profile
of skin cancer prevention media coverage in 2009. J Am Acad Dermatol. 2012
Oct;67(4):570-5. PubMed PMID: 22237018.
41.
Foote JA, Poole CM. Brief questions highlight the need for melanoma
information campaigns. J Cancer Educ. 2013 Dec;28(4):611-6. PubMed PMID:
23996205.
42.
Cho H, Hall JG, Kosmoski C, Fox RL, Mastin T. Tanning, skin cancer risk,
and prevention: a content analysis of eight popular magazines that target female
readers, 1997-2006. Health Commun. 2010 Jan;25(1):1-10. PubMed PMID:
20228954. Pubmed Central PMCID: 2836591.
43.
Gandini S, Stanganelli I, Magi S, Mazzoni L, Medri M, Agnoletti V, et al.
Melanoma attributable to sunbed use and tan seeking behaviours: an Italian
survey. Eur J Dermatol. 2013 Dec 12. PubMed PMID: 24334101.
44.
Bandi P, Cokkinides VE, Weinstock MA, Ward E. Sunburns, sun protection
and indoor tanning behaviors, and attitudes regarding sun protection benefits
18
and tan appeal among parents of U.S. adolescents-1998 compared to 2004.
Pediatr Dermatol. 2010 Jan-Feb;27(1):9-18. PubMed PMID: 20199403.
45.
Diffey BL, Norridge Z. Reported sun exposure, attitudes to sun protection
and perceptions of skin cancer risk: a survey of visitors to Cancer Research UK's
SunSmart campaign website. Br J Dermato. 2009 Jun;160(6):1292-8. PubMed
PMID: 19416235.
46.
Gavin A, Boyle R, Donnelly D, Donnelly C, Gordon S, McElwee G, et al.
Trends in skin cancer knowledge, sun protection practices and behaviours in the
Northern Ireland population. Eur J Public Health. 2012 Jun;22(3):408-12.
PubMed PMID: 22094579.
47.
Cancer Research UK. SunSmart.
http://www.sunsmart.org.uk/advice-and-prevention/
(Accessed 20th December 2013).
48.
Cancer Council Australia & The Australasian College of Dermatolgists .
Skin Cancer Prevention: A blue chip investement in health, Februrary 2009.
http://www.cancer.org.au/content/pdf/CancerControlPolicy/Publications/Medi
aMaterials/Skin_Cancer_Prevention-a_Blue_Chip_Investment.pdf
(Accessed 22nd December 2013).
49.
Butler DP, Lloyd-Lavery A, Archer CM, Turner R. Awareness of and
attitudes towards skin-cancer prevention: a survey of patients in the UK
presenting to their general practice. Clin Exp Dermatol. 2013 Jun;38(4):338-43.
PubMed PMID: 23530554.
50.
Forsea AM, Euromelanoma Working G, del Marmol V. Impact, challenges
and perspectives of Euromelanoma, a pan-European campaign of skin cancer
19
prevention. J Eur Acad Dermatol Venereol. 2013 Oct;27(10):1317-9. PubMed
PMID: 23294192.
51.
Diao DY, Lee TK. Sun-protective behaviors in populations at high risk for
skin cancer. Psychol Res Behav Manag. 2013;7:9-18. PubMed PMID: 24379732.
Pubmed Central PMCID: 3873203.
52.
Wallis A, Andersen PA, Buller DB, Walkosz B, Lui L, Buller M, et al.
Adoption of Sun Safe Workplace Practices by Local Governments. J Public Health
Manag Pract. 2013 Nov 13. PubMed PMID: 24231670.
53.
Pouplard C, Gourraud PA, Meyer N, Livideanu CB, Lahfa M, Mazereeuw-
Hautier J, et al. Are we giving patients enough information on how to use topical
treatments? Analysis of 767 prescriptions in psoriasis. Br J Dermatol. 2011
Dec;165(6):1332-6. PubMed PMID: 21711325.
54.
Emre S, Metin A, Demirseren DD, Kilic S, Isikoglu S, Erel O. The
relationship between oxidative stress, smoking and the clinical severity of
psoriasis. J Eur Acad Dermatol Venereol. 2013 Mar;27(3):e370-5. PubMed PMID:
23004342.
55.
Li W, Han J, Choi HK, Qureshi AA. Smoking and risk of incident psoriasis
among women and men in the United States: a combined analysis. Am J
Epidemiol. 2012 Mar 1;175(5):402-13. PubMed PMID: 22247049. Pubmed
Central PMCID: 3329197.
56.
Armstrong AW, Armstrong EJ, Fuller EN, Sockolov ME, Voyles SV. Smoking
and pathogenesis of psoriasis: a review of oxidative, inflammatory and genetic
mechanisms. Br J Dermatol. 2011 Dec;165(6):1162-8. PubMed PMID: 21777217.
20
57.
Shelling ML, Kirsner RS. Failure to counsel patients with psoriasis to
decrease
alcohol
consumption
(and
smoking).
Arch
Dermatol.
2010
Dec;146(12):1370. PubMed PMID: 21173321.
58.
Maradit-Kremers H, Dierkhising RA, Crowson CS, Icen M, Ernste FC,
McEvoy MT. Risk and predictors of cardiovascular disease in psoriasis: a
population-based study. Int J Dermatol. 2013 Jan;52(1):32-40. PubMed PMID:
23278607. Pubmed Central PMCID: 3539170.
59.
Samarasekera EJ, Neilson JM, Warren RB, Parnham J, Smith CH. Incidence
of cardiovascular disease in individuals with psoriasis: a systematic review and
meta-analysis. J Invest Dermatol. 2013 Oct;133(10):2340-6. PubMed PMID:
23528816.
60.
Hugh J, Van Voorhees AS, Nijhawan RI, Bagel J, Lebwohl M, Blauvelt A, et
al. From the Medical Board of the National Psoriasis Foundation: The risk of
cardiovascular disease in individuals with psoriasis and the potential impact of
current therapies. J Am Acad Dermatol. 2014 Jan;70(1):168-77. PubMed PMID:
24184141.
61.
Strohal R, Kirby B, Puig L, the Psoriasis Expert P. Psoriasis beyond the
skin: an expert group consensus on the management of psoriatic arthritis and
common co-morbidities in patients with moderate-to-severe psoriasis. J Eur
Acad Dermatol Venereol. 2013 Dec 24. PubMed PMID: 24372845.
62.
The
Psoariasis
Association.
The
Psoariasis
Association.
https://www.psoriasis-association.org.uk
(Accessed 25th December 2013).
63.
National
Eczema
Society.
National
Eczema
Societ.y.2013.
http://www.eczema.org/.
21
(Accessed 25th December 2013).
64.
Darlenski R, Dencheva R, Kazandjieva J, Svinarov D, Tsankov N. Guidelines
in dermatology--quo vadis?: Facts and controversies. Clin Dermatol. 2010 SepOct;28(5):558-62. PubMed PMID: 20797519.
65.
Bath-Hextall F, Ozolins M, Armstrong SJ, Colver GB, Perkins W, Miller PS,
et al. Surgical excision versus imiquimod 5% cream for nodular and superficial
basal-cell carcinoma (SINS): a multicentre, non-inferiority, randomised
controlled trial. Lancet Oncol. 2014 Jan;15(1):96-105. PubMed PMID: 24332516.
66.
Williams HC, Dellavalle RP. The growth of clinical trials and systematic
reviews in informing dermatological patient care. J Invest Dermatol. 2012
Mar;132(3 Pt 2):1008-17. PubMed PMID: 22048732.
67.
Hajjaj FM, Salek MS, Basra MK, Finlay AY. Nonclinical influences, beyond
diagnosis and severity, on clinical decision making in dermatology:
understanding the gap between guidelines and practice. Br J Dermatol. 2010
Oct;163(4):789-99. PubMed PMID: 20854402.
68.
Macfarlane L, Waters A, Evans A, Affleck A, Fleming C. Seven years'
experience of Mohs micrographic surgery in a UK centre, and development of a
UK minimum dataset and audit standards. Clin Exp Dermatol. 2013
Apr;38(3):262-9. PubMed PMID: 23517356.
69.
Elliott TG, Thom GA, Litterick KA. Office based dermatological surgery and
Mohs surgery: a prospective audit of surgical procedures and complications in a
procedural dermatology practice. Australas J Dermatol. 2012 Nov;53(4):264-71.
PubMed PMID: 23043516.
22
70.
Shenoy R, Molenda MA, Mostow EN. The introduction of skin self-
photography as a supplement to skin self-examination for the detection of skin
cancer. J Am Acad Dermatol. 2014 Jan;70(1):e15. PubMed PMID: 24355279.
71.
De Giorgi V, Papi F, Giorgi L, Savarese I, Verdelli A, Scarfi F, et al. Skin self-
examination and the ABCDE rule in the early diagnosis of melanoma: is the game
over? Br J Dermatol. 2013 Jun;168(6):1370-1. PubMed PMID: 23738643.
72.
Nguyen TV, Hong J, Prose NS. Compassionate care: enhancing physician-
patient communication and education in dermatology: Part I: Patient-centered
communication. J Am Acad Dermatol. 2013 Mar;68(3):353 e1-8. PubMed PMID:
23394923.
73.
Cowdell F, Ersser SJ, Gradwell C, Thomas PW. The Person-Centered
Dermatology Self-Care Index: A Tool to Measure Education and Support Needs of
Patients With Long-term Skin Conditions. Arch Dermatol. 2012 Nov
1;148(11):1251-6. PubMed PMID: 23165828.
74.
DeWeerdt S. Psychodermatology: An emotional response. Nature. 2012
Dec 20;492(7429):S62-3. PubMed PMID: 23254976.
75.
Halvorsen JA, Stern RS, Dalgard F, Thoresen M, Bjertness E, Lien L.
Suicidal ideation, mental health problems, and social impairment are increased
in adolescents with acne: a population-based study. J Invest Dermatol. 2011
Feb;131(2):363-70. PubMed PMID: 20844551.
76.
Seidler EM, Kimball AB. Socioeconomic disability in psoriasis. Br J
Dermatol. 2009 Dec;161(6):1410-2. PubMed PMID: 19785599.
77.
Warren RB, Kleyn CE, Gulliver WP. Cumulative life course impairment in
psoriasis: patient perception of disease-related impairment throughout the life
course. Br J Dermatol. 2011 May;164 Suppl 1:1-14. PubMed PMID: 21477010.
23
78.
Kimball AB, Gieler U, Linder D, Sampogna F, Warren RB, Augustin M.
Psoriasis: is the impairment to a patient's life cumulative? J Eur Acad Dermatol
Venereol.2010 Sep;24(9):989-1004. PubMed PMID: 20477920.
79.
Gee SN, Zakhary L, Keuthen N, Kroshinsky D, Kimball AB. A survey
assessment of the recognition and treatment of psychocutaneous disorders in
the outpatient dermatology setting: how prepared are we? J Am Acad Dermatol.
2013 Jan;68(1):47-52. PubMed PMID: 22954748.
80.
Lowry CL, Shah R, Fleming C, Taylor R, Bewley A. A study of service
provision in psychocutaneous medicine. Clin Exp Dermatol. 2014 Jan;39(1):13-8.
PubMed PMID: 24341475.
81.
Shenefelt PD. Psychological interventions in the management of common
skin conditions. Psychol Res Behav Manag. 2010;3:51-63. PubMed PMID:
22110329. Pubmed Central PMCID: 3218765.
82.
Jafferany M, Vander Stoep A, Dumitrescu A, Hornung RL. The knowledge,
awareness, and practice patterns of dermatologists toward psychocutaneous
disorders: results of a survey study. Int J Dermatol. 2010 Jul;49(7):784-9.
PubMed PMID: 20618498.
83.
Alonso-Coello P, Irfan A, Sola I, Gich I, Delgado-Noguera M, Rigau D, et al.
The quality of clinical practice guidelines over the last two decades: a systematic
review of guideline appraisal studies. Qual Saf Health Care. 2010 Dec;19(6):e58.
PubMed PMID: 21127089.
84.
Tania Von Hospentha, British Association of Dermatologist, Clinical
Services Manager . Lessons for the NHS: Commisioning a Dermatological Service.
July2013.
:
http://www.bad.org.uk/Portals/_Bad/Clinical%20Services/Commissioning%20
24
Dermatology%20Services%20%20Lessons%20for%20the%20NHS%20FINAL.pdf
(Accessed 27th December 2013).
85.
British Association of Dermatologist, Clinical Services Unit. Guidance for
Commissiong Dermatology Services.
http://www.bad.org.uk/Portals/_Bad/Clinical%20Services/Guidance%20for%2
0Commissioning%20Derm%20Services%20v7%20tidied(2).pdf.
(Accessed 28th December 2013).
86.
Moy R, Antunes HC. Preserving dermatology. J Invest Dermatol. 2013
Sep;133(9):2113-5. PubMed PMID: 23949759.
87.
Ridd M, Thomas K, Wallace P, O'Sullivan F. Dermatology research in
primary care: why, what, and how? Br J Gen Pract. 2011 Feb;61(583):89-90.
PubMed PMID: 21276334. Pubmed Central PMCID: 3026146.
88.
Fairley JA, Krueger GG, Lessin SR, Leyden JJ, McBurney EI, Orlow SJ, et al.
The Dermatology Foundation: partnerships and programs focused on the future.
J Invest Dermatol. 2013 Apr;133(4):861-2. PubMed PMID: 23486423.
89.
de Guzman Strong C, Cornelius LA. Preparing the next generation in
academic medicine: recruiting and retaining the best. J Invest Dermatol. 2012
Mar;132(3 Pt 2):1018-25. PubMed PMID: 22330268.
90.
Sullivan F, Butler C, Cupples M, Kinmonth AL. Primary care research
networks in the United Kingdom. BMJ. 2007 May 26;334(7603):1093-4. PubMed
PMID: 17525452. Pubmed Central PMCID: 1877913.
91.
Kerr OA, Tidman MJ, Walker JJ, Aldridge RD, Benton EC. The profile of
dermatological
problems
in
primary
care.
Clin
Exp
Dermatol.
2010
Jun;35(4):380-3. PubMed PMID: 19874334.
25
92.
Rees J. The UK needs office dermatologists. BMJ. 2012;345:e6006.
PubMed PMID: 22966175.
93.
Aldridge RB, Maxwell SS, Rees JL. Dermatology undergraduate skin cancer
training: a disconnect between recommendations, clinical exposure and
competence. BMC Med Educ. 2012;12:27. PubMed PMID: 22569037. Pubmed
Central PMCID: 3391986.
94.
Finlay AY. Put the student in charge: take part in the biggest revolution
ever in teaching and learning in dermatology. Acta Derm Venereol. 2013
Jan;93(1):23-6. PubMed PMID: 22948480.
95.
Lam TP, Yeung CK, Lam KF. What are the learning outcomes of a short
postgraduate training course in dermatology for primary care doctors? BMC Med
Educ. 2011;11:20. PubMed PMID: 21575191. Pubmed Central PMCID: 3121723.
96.
University of Cardiff. Practical Dermatology (MSc/PgDip). 2014.
http://courses.cardiff.ac.uk/Postgraduate/course/detail/p257.html.
(Accessed 3rd January 2014)
97.
Salmon P, Mortimer N, Rademaker M, Adams L, Stanway A, Hill S. Surgical
excision of skin cancer: the importance of training. Br J Dermatol. 2010
Jan;162(1):117-22. PubMed PMID: 19818068.
98.
Davies E, Burge S. Audit of dermatological content of U.K. undergraduate
curricula. Br J Dermatol. 2009 May;160(5):999-1005. PubMed PMID: 19292717.
99.
McCleskey PE, Gilson RT, DeVillez RL. Medical Student Core Curriculum in
Dermatology Survey. J Am Acad Dermatol. 2009 Jul;61(1):30-5 e4. PubMed PMID:
19410336.
100.
Chiang YZ, Tan KT, Chiang YN, Burge SM, Griffiths CE, Verbov JL.
Evaluation of educational methods in dermatology and confidence levels: a
26
national survey of UK medical students. Int J Dermatol. 2011 Feb;50(2):198-202.
PubMed PMID: 21244386.
101.
Laws PM, Baker P, Singh M. Preparedness of Foundation Year 1 doctors in
dermatology. Clin Teach. 2012 Apr;9(2):108-11. PubMed PMID: 22405365.
102.
Kirshen C, Shoimer I, Wismer J, DesGroseilliers JP, Lui H. Teaching
dermatology to Canadian undergraduate medical students. J Cutan Med Surg.
2011 May-Jun;15(3):150-6. PubMed PMID: 21561583.
103.
Goulart JM, Dusza S, Pillsbury A, Soriano RP, Halpern AC, Marghoob AA.
Recognition of melanoma: a dermatologic clinical competency in medical student
education. J Am Acad Dermatol. 2012 Oct;67(4):606-11. PubMed PMID:
22281164.
104.
Amir M, Sampson BP, Endly D, Tamai JM, Henley J, Brewer AC, et al. Social
networking sites: emerging and essential tools for communication in
dermatology. JAMA Dermatol. 2014 Jan 1;150(1):56-60. PubMed PMID:
24196212.
105.
Travers RL. Social media in dermatology: moving to Web 2.0. Semin Cutan
Med Surg. 2012 Sep;31(3):168-73. PubMed PMID: 22929354.
106.
Vance K, Howe W, Dellavalle RP. Social internet sites as a source of public
health information. Dermatol Clin. 2009 Apr;27(2):133-6, vi. PubMed PMID:
19254656.
107.
George DR, Dreibelbis TD, Aumiller B. How we used two social media
tools to enhance aspects of active learning during lectures. Med Teach. 2013
Dec;35(12):985-8. PubMed PMID: 23902318.
27
108.
Franko OI, Tirrell TF. Smartphone app use among medical providers in
ACGME training programs. J Med Syst. 2012 Oct;36(5):3135-9. PubMed PMID:
22052129.
109.
Amir M, Sampson BP, Endly D, Tamai JM, Henley J, Brewer AC, et al. Social
Networking Sites: Emerging and Essential Tools for Communication in
Dermatology. JAMA Dermatol. 2013 Nov 6. PubMed PMID: 24196212.
110.
McCleskey PE. Clinic teaching made easy: a prospective study of the
American Academy of Dermatology core curriculum in primary care learners. J
Am Acad Dermatol. 2013 Aug;69(2):273-9. PubMed PMID: 23415684.
111.
Cipriano SD, Dybbro E, Boscardin CK, Shinkai K, Berger TG. Online
learning in a dermatology clerkship: piloting the new American Academy of
Dermatology Medical Student Core Curriculum. J Am Acad Dermatol. 2013
Aug;69(2):267-72. PubMed PMID: 23683728.
112.
Bristish
Association
of
Dermatologists.
Medical
Students.
2014
http://www.bad.org.uk/site/616/default.aspx.
(Accessed 5th January 2014).
113.
Jablonski NG. 'Ethnic skin' and why the study of human cutaneous
diversity is important. Br J Dermatol. 2013 Oct;169 Suppl 3:v. PubMed PMID:
24098907.
114.
Dadzie OE. Ushering in a new era for studying human cutaneous diversity.
Br J Dermatol. 2013 Oct;169 Suppl 3:iii-iv. PubMed PMID: 24098906.
28
29