Treatment of Facial Basal Cell Carcinoma: A Review

Basal cell carcinomas (BCCs) are locally destructive malignancies of the skin. They are the most common type of cancer in the western world. The lifetime incidence may be up to 39%. UV exposure is the most common risk factor. The majority of these tumours occur on the head and neck. Despite BCCs being relatively indolent the high incidence means that their treatment now contributes a significant and increasing workload for the health service. A good understanding of the options available is important. Management decisions may be influenced by various factors including the patient's age and comorbidities and the lesion subtype and location. Due to the importance of a good cosmetic and curative outcome for facial BCCs treatment decisions may differ significantly to those that would be made for BCCs arising elsewhere. There is little good randomized controlled data available comparing treatment modalities. Although traditionally standard excision has been the treatment of choice various other options are available including: Mohs micrographic surgery, curettage and cautery, cryosurgery, radiotherapy, topical imiquimod, photodynamic therapy and topical 5-fluorouracil. We discuss and review the literature and evidence base for the treatment options that are currently available for facial BCCs

Comparison of the two most commonly used treatments for pyoderma gangrenosum: results of the STOP GAP randomised controlled trial

Objective To determine whether ciclosporin is superior to prednisolone for the treatment of pyoderma gangrenosum, a painful, ulcerating skin disease with a poor evidence base for management. Design Multicentre, parallel group, observer blind, randomised controlled trial. Setting 39 UK hospitals, recruiting from June 2009 to November 2012. Participants 121 patients (73 women, mean age 54 years) with clinician diagnosed pyoderma gangrenosum. Clinical diagnosis was revised in nine participants after randomisation, leaving 112 participants in the analysis set (59 ciclosporin; 53 rednisolone). Intervention Oral prednisolone 0.75 mg/kg/day compared with ciclosporin 4 mg/kg/day, to a maximum dose of 75 and 400 mg/day, respectively. Main outcome measures The primary outcome was speed of healing over six weeks, captured using digital images and assessed by blinded investigators. Secondary outcomes were time to healing, global treatment response, resolution of inflammation, self reported pain, quality of life, number of treatment failures, adverse reactions, and time to recurrence. Outcomes were assessed at baseline and six weeks and when the ulcer had healed (to a maximum of six months). Results Of the 112 participants, 108 had complete primary outcome data at baseline and six weeks (57 ciclosporin; 51 rednisolone). Groups were balanced at baseline. The mean (SD) speed of healing at six weeks was −0.21 (1.00) cm2/day in the ciclosporin group compared with −0.14 (0.42) cm2/day in the prednisolone group. The adjusted mean difference showed no between group difference (0.003 cm2/day, 95% confidence interval −0.20 to 0.21; P=0.97). By six months, ulcers had healed in 28/59 (47%) participants in the ciclosporin group compared with 25/53 (47%) in the prednisolone group. In those with healed ulcers, eight (30%) receiving ciclosporin and seven (28%) receiving prednisolone had a recurrence. Adverse reactions were similar for the two groups (68% ciclosporin and 66% prednisolone), but serious adverse reactions, especially infections, were more common in the prednisolone group. Conclusion Prednisolone and ciclosporin did not differ across a range of objective and patient reported outcomes. Treatment decisions for individual patients may be guided by the different side effect profiles of the two drugs and patient preference. Trial registration Current Controlled Trials ISRCTN35898459

Doxycycline versus prednisolone as an initial treatment strategy for bullous pemphigoid: a pragmatic non-inferiority randomised controlled trial

Background: Bullous pemphigoid (BP) is a blistering skin disorder with increased mortality. We tested whether a strategy of starting treatment with doxycycline conveys acceptable short-term blister control whilst conferring long-term safety advantages over starting treatment with oral corticosteroids.Methods: Pragmatic multi-centre parallel-group randomised controlled trial of adults with BP (≥3 blisters ≥2 sites and linear basement membrane IgG/C3) plus economic evaluation. Participants were randomised to doxycycline (200 mg/day) or prednisolone (0·5 mg/kg/day). Localised adjuvant potent topical corticosteroids

Doxycycline versus prednisolone as an initial treatment strategy for bullous pemphigoid: a pragmatic non-inferiority randomised controlled trial

Background: Bullous pemphigoid (BP) is a blistering skin disorder with increased mortality. We tested whether a strategy of starting treatment with doxycycline conveys acceptable short-term blister control whilst conferring long-term safety advantages over starting treatment with oral corticosteroids. Methods: Pragmatic multi-centre parallel-group randomised controlled trial of adults with BP (≥3 blisters ≥2 sites and linear basement membrane IgG/C3) plus economic evaluation. Participants were randomised to doxycycline (200 mg/day) or prednisolone (0·5 mg/kg/day). Localised adjuvant potent topical corticosteroids (<30 g/week) was permitted weeks 1-3. The non-inferiority primary effectiveness outcome was the proportion of participants with ≤3 blisters at 6 weeks. We assumed that doxycycline would be 25% less effective than corticosteroids with a 37% acceptable margin of noninferiority. The primary safety outcome was the proportion with severe, life-threatening or fatal treatment-related adverse events by 52 weeks. Analysis used a regression model adjusting for baseline disease severity, age and Karnofsky score, with missing data imputed. Results: 132 patients were randomised to doxycycline and 121 to prednisolone from 54 UK and 7 German dermatology centres. Mean age was 77·7 years and 68.4% had moderate to severe baseline disease. For those starting doxycycline, 83/112 (74·1%) had ≤3 blisters at 6 weeks compared with 92/101 (91·1%) for prednisolone, a difference of 18·6% favouring prednisolone (upper limit of 90% CI, 26·1%, within the predefined 37% margin). Related severe, life-threatening and fatal events at 52 weeks were 18·5% for those starting doxycycline and 36·6% for prednisolone (mITT analysis), an adjusted difference of 19·0% (95% CI, 7·9%, 30·1%, p=0·001). Conclusions: A strategy of starting BP patients on doxycycline is non-inferior to standard treatment with oral prednisolone for short-term blister control and significantly safer long-term

Clinical outcomes and response to treatment of patients receiving topical treatments for pyoderma gangrenosum: a prospective cohort study

Background: pyoderma gangrenosum (PG) is an uncommon dermatosis with a limited evidence base for treatment. Objective: to estimate the effectiveness of topical therapies in the treatment of PG. Methods: prospective cohort study of UK secondary care patients with a clinical diagnosis of PG suitable for topical treatment (recruited July 2009 to June 2012). Participants received topical therapy following normal clinical practice (mainly Class I-III topical corticosteroids, tacrolimus 0.03% or 0.1%). Primary outcome: speed of healing at 6 weeks. Secondary outcomes: proportion healed by 6 months; time to healing; global assessment; inflammation; pain; quality-of-life; treatment failure and recurrence. Results: Sixty-six patients (22 to 85 years) were enrolled. Clobetasol propionate 0.05% was the most commonly prescribed therapy. Overall, 28/66 (43.8%) of ulcers healed by 6 months. Median time-to-healing was 145 days (95% CI: 96 days, ∞). Initial ulcer size was a significant predictor of time-to-healing (hazard ratio 0.94 (0.88;80 1.00); p = 0.043). Four patients (15%) had a recurrence. Limitations: No randomised comparator Conclusion: Topical therapy is potentially an effective first-line treatment for PG that avoids possible side effects associated with systemic therapy. It remains unclear whether more severe disease will respond adequately to topical therapy alone

Medical Education - Dermatology Training and Career Options in the U.K. for Indian Graduates

There has been a recent surge of overseas trainees arriving in the U.K. and applying for clinical attachments. Most of these doctors have obtained the Professional and Linguistic Assessment Board (P.L.A.B.) certificate prior to seeking training posts. The General Medical Council (G.M.C.) offers limited registration to trainees after obtaining a suitable post. After successful completion of a year, they can be considered for full registration. To avoid disappointments in fulfilling one′s goals in career progression, a good understanding of the training system needs to be obtained before embarking on a difficult and often lengthy career path

A pilot study to compare the ability of health care practitioners to recognise and treat a range of skin conditions

Background Recent data suggests that skin conditions were the most common reason for patients to consult their GP with a new problem1. Healthcare practitioners (HCPs) including pharmacists and nurses are recognized possible alternative sources to the GP for advice and treatment. However little is known about their ability to recognise and treat skin conditions. The aim of the study was to compare the ability of these HCPs to identify and suggest suitable first line management strategies for a number of skin conditions. Ethical approval for the study was sought and deemed unnecessary. Method HCPs were invited to participate in the study remotely at a specifically designed website (www.hpdiagnosticstudy.co.uk.). Among the skin conditions included were melasma, pitted keratolysis, tinea corporis, a verruca, scabies, molluscum contagiosum, pityriasis rosea, polymorphic eruption of pregnancy (presenting as possible urticaria), a basal cell papilloma and pompholyx eczema. Participants were recruited using local primary care research networks. Pharmacists were additionally recruited by an advertisement in the community pharmacy press. All participants accessed the site through an electronic link sent by email and were given 7 days to complete the test, followed up by a reminder 7 days later. The web site consisted of 10 peer-reviewed case studies including a digital image of the condition and associated case history. Participants were required to identify: 1) the condition 2) the features supporting the diagnosis 3) an appropriate first-line treatment option. A summative dermatology total score was computed for each participant for correctly identifying all three aspects. Since the groups were unmatched, analysis of covariance (ANCOVA) was used to compare the mean total dermatology scores between the different HCPs. Covariates were identified by computing a Pearson’s r correlation between the total scores and potential confounders. Results A total of 60 HCPs (20 pharmacists, GPs and practice nurses) took part in the study. There were significant associations (p<0.01) between total dermatology score and gender (r = .49) and previous exposure to the skin condition (r = .50). These were therefore included as covariates in the ANCOVA model. The mean total dermatology scores for pharmacists, nurses and GPs were 16.3, 15.6 and 19.9 respectively and this difference was significant, F (2, 55) = 5.83, p = 0.005. The covariate gender also had a significant effect on total dermatology score, F (1, 55) = 7.11, p = 0.01. Post-hoc Sidak testing revealed that the difference in mean scores between GPs and both nurses and pharmacists was significant (p < 0.05). Conclusion These preliminary results not surprisingly suggest that the GP is the most appropriate source of advice and treatment for patients with skin problems. This pilot study suggests that pharmacists and practice nurses have similar diagnostic abilities for a number of common skin conditions however further investigation embracing a larger sample, is required to substantiate this conclusion Reference 1. Schofield JK, Fleming D, Grindlay D, Williams H. Skin conditions are the commonest new reason people present to general practitioners in England and Wales. Br J Dermatol. 2011;165(5):1044-50

An examination of the comparative ability of primary care health professionals in the recognition and treatment of a range of dermatological conditions

Background Recent data suggest that skin problems were the most common reason for patients visiting their GP in the UK. Healthcare professionals such as practice nurses and community pharmacists represent potential alternative sources of advice for patients with skin problems yet little is currently known about the diagnostic ability of these health professionals. Objectives The aim of the present study was to compare the ability of all three groups of primary care health professionals to recognise and recommend treatments for a number of different skin conditions. Methods A website containing 10 dermatological vignettes was developed with each case containing a digital image of the skin problem and an associated case history. Participants were required to identify: 1) the condition; 2) the features supporting the diagnosis; 3) an appropriate first-line treatment option. Results A total of 60 HCPs (20 pharmacists, GPs and practice nurses) took part in the study. The mean scores for pharmacists, nurses and GPs were 16.3, 15.6 and 19.9 respectively and this difference was significant, F (2, 55) = 5.83, p = 0.005. Post hoc Bonferroni testing revealed that the difference in mean scores between GPs and both nurses and pharmacists was significant (p < 0.05). Conclusion This study showed that the ability of GPs to recognise and manage skin conditions was superior to pharmacists and nurses and related to previous experience of the skin condition although further training in dermatology is likely to benefit all three groups. Keywords diagnosis, skin conditions, primary health care professional