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IAD President calls for increased resources in dermatology to help cope with rising demand
President of the Irish Association of Dermatologists (IAD) Dr Rosemarie Watson has called for more resources to cope with the increasing demand for dermatology services in Ireland, and for proper investment in the treatment of diabetic foot ulcers.
“Our speciality has its challenges. The rising paediatric and elderly population is putting increasing demand on our services. The rise of skin cancers, some of which need urgent attention, is pushing patients with inflammatory and other skin diseases, which severely affect quality of life, further down the waiting list.
“On the positive side, there has been more than a three-fold increase in consultants since I returned here to take up my post in 1992. At that time there were 10 public consultants, but more are needed, and how does one address that?” she commented during her opening address to the 50th Anniversary Spring Meeting.
Dr Watson said “outside-the-box thinking” was needed to make sure every euro was being well spent. She also noted that Ireland has internationally renowned dermatology clinicians and clinician scientists. These include current and past-Presidents of the British Association of Dermatology, and a past-President of the European Academy of Dermatology.
Welcoming Minister Varadkar to the Meeting Dr Watson said she had “every confidence “he would do his utmost to help dermatologists to deliver a dermatology service that offers timely access to all patients who need our expertise”.
Speaking to the Medical Independent (MI), Dr Watson described the Meeting as “an absolute success” and pointed out that “unprecedented numbers of all ages, over 200” attended, as well as over 60 nurses.
“The scientific programme was amazing. On the opening night the Minister gave a very comprehensive talk and we have great hope that he will find a way, along with the Department, to listen to us and our needs. We hope to talk to his people [about helping to solve outpatient waiting lists],” she said.
The speakers during the Meeting’s scientific sessions were “world famous” and gave very practical tips for delegates’ clinics. They also discussed the latest advances in science that are now going hand-in-hand with clinical practice, “so that was very, very enjoyable,” Dr Watson said.
“Prof Pietri was very well received, as was Prof Sibbald, who is a world leader in healing, who had some very practical tips. If we had someone with his expertise in Ireland, I think we could save the Government a lot of money because the management of diabetics is one of the most expensive things, apparently. A recent study in Wales showed the management of leg ulcers was using up 5 per cent of the health budget, so his tips were helpful and we all felt we would love to have him in our clinics with us.”
She also praised the quality of the presentations by the Association’s junior doctors as “most impressive”. There were 40 abstracts submitted for presentation but just a selection was presented due to time constraints.
“A lot of the projects were geared towards making treatments easier for patients and being aware of costs to the patients was also very important. We had some very practical areas covered by our poster session too, for example new advances in treatments for angiofibromas.
“We also saw a lovely poster… on how important it is to listen to the patient, because what you think may be the primary problem in the consultation may not be what the patient thinks is the primary issue. So that was very useful,” Dr Watson commented.
She also praised the presentation by Prof Alan Irvine on atopic dermatitis.
“It is wonderful that a small island like ours has the calibre of clinician scientists like him. He is recognised and respected all over the world and gave a very exciting talk about how far we have come with eczema, because it has fallen a bit behind psoriasis with regard to treatments in recent years, but that will all probably change in the next five years. Medicine is moving at such an explosive pace, we need these meetings on a regular basis to keep up to date.
“Of course, one of the most important parts of a meeting also are the conversations that happen in the corridors; lots of exchanges of ideas and support. We are kind to each other and look out for each other and I think that is a very important part of the meeting as well — the social aspect.”
Concluding, Dr Watson noted that the IAD has 70 active consultant members (a third working in Northern Ireland) and 30 trainees.
In the Republic, there are 33 consultants in public practice and 14 in exclusively private practice.
IAD Anniversary Meeting sees first Lifetime Achievement Award presented to Dr Joe Barnes
The IAD presented its first ever Lifetime Achievement Award to Dr Joe Barnes, a world-renowned dermatologist, at its 50th Anniversary Spring Meeting in Carton House, Maynooth.
Dr Barnes, who was born in November 1914, attended the Meeting with his wife of 66 years, Betty, and was introduced by Prof Frank Powell, who recounted the highlights of his distinguished professional and personal life.
Dr Barnes worked in leprosy hospitals and refugee centres throughout Africa and Asia during his medical career, and from 1939 to 1942 worked as the sole medical doctor in a 200-bed missionary hospital in rural Nigeria.
After returning to Ireland and training in obstetrics and later dermatology, he pursued a long-time interest in leprosy control and therapy. For two decades he practised as a leprotologist in various parts of West Africa before returning as consultant dermatologist at the Mater Hospital, Dublin. Throughout the next quarter century, in times of international crisis, he travelled to Biafra, the Congo, South East Asia, India and the Lebanon, and worked for the United Nations. Following his retirement from clinical practice he continued to lecture for many years, and was described by Prof Powell as always being “very courteous — the epitome of a gentleman”.
Speaking briefly upon receiving his award, Dr Barnes voiced his thanks and modestly claimed it should have gone to someone else — not least his wife Betty.
“It was a great pleasure to offer a Lifetime Achievement Award to Dr Barnes. It was the first time we did this and I think when the time is right and we have the right person, we will do it again,” IAD President Dr Watson told MI.
Elsewhere, Prof Desmond Burrows, the inaugural Secretary of the IAD, told the story of how the IAD was created, during the Saturday meeting. He received a glowing introduction by Dr Rory Corbett, who was a former trainee of his in Belfast.
In the early 1960s, eminent Belfast dermatologist Dr Reginald Hall wrote to his colleagues in the Republic and suggested they foster a closer relationship with their Northern colleagues and come together to further educational research into skin diseases. The inaugural meeting of the Association was held in Belfast in October 1964 and the constitution of the North of England Dermatological Society was adopted, he explained.
It was agreed that meetings were to be in April in Dublin and the first Saturday in October in Belfast. The subscription of each ordinary member was set at two guineas.
A lot of things have changed in dermatology and the practice of medicine in the past 50 years, but the IAD has gone from strength-to-strength, and Minister Varadkar praised its North-South basis during his address to the Meeting.
Prof Burrows, like Dr Barnes, received a standing ovation following his speech and received a commemorative gift from Dr Watson.
Also during this session, Prof Eoin O’Brien outlined the background of the Irish Skin Foundation, which was created in 2011, and called on the IAD to continue to strengthen its links with the Foundation.
Minister voices his support for employing more dermatologists
Minister for Health Leo Varadkar wants to hire more consultant dermatologists to help address lengthy waiting lists and demand for dermatology services.
Addressing the IAD 50th Anniversary Spring Meeting in Maynooth, Minister Varadkar acknowledged that dermatology waiting lists are among the worst in the public sector. He said he wanted to talk to the profession about their ideas to reduce lists, especially for the very long waiters, and suggested changes to the GP referral pathway could help, adding that he was open to outsourcing to the private sector if absolutely necessary.
“I would be interested in advice on interim solutions on whether there is a better referral pathway… and I would be interested in the thoughts of your Association on how we might do that, and deal with some of those very long-waiters, about whom I am very concerned,” the Minister told the Meeting.
He said, being six years out of clinical practice, he thought there would have been a better referral pathway for dermatology at this stage, using an online system, photographs and teleconferencing.
“While we have done bits of that here and there, it is disappointing we do so little of that in Ireland. While dealing with waiting lists will have to involve the appointment of more consultants, there must be much better referral pathways, and I’m sure many of the referrals you get are unnecessary and by the time their appointment comes up, the problem has either gone away or got considerably worse. Obviously, that is even more worrying,” Minister Varadkar stated.
Meanwhile, he praised the IAD for “promoting dermatological collaboration on a North-South basis, and for building a strong relationship between both parts of the island”.
The Minister welcomed the re-establishment of the National Clinical Programme for Dermatology back in March. He said he didn’t “know as much about dermatology as maybe I should,” having just completed a one-month rotation in dermatology in St James’s Hospital, Dublin, under Dr Rosemarie Watson, but did learn a lot from it.
He also asked delegates at the meeting to “support and co-operate with” the HSE’s new hospital groups structure.
Appearance is important but cancer removal remains the key priority in Mohs surgery
When carrying out facial skin cancer surgery, doctors must not compromise their margins to achieve closure, as while appearance is important, full tumour removal is the priority, the IAD 50th Anniversary Spring Meeting heard.
Dr Vindy Ghura, Consultant Dermatologist and Mohs Surgeon, Salford Royal Hospital, Manchester, opened the Meeting with a detailed talk on the top ten ‘sins’ in facial skin cancer surgery.
Mohs surgery is a specialist technique for removing difficult non-melanoma skin cancers (basal cell carcinomas or rodent ulcers), and Dr Ghura is a noted expert in the field. He examines for the Royal College of Physicians and Cardiff University’s GP-Dermatology Diploma course and teaches on many courses, including the British Society for Dermatological Surgery (BSDS) annual skin surgery course.
Dr Vindy noted there is still a lot of debate about the ideal margin size, and he noted that 4mm gives a 95 per cent clearance rate.
He gave a number of practical tips on how to minimise facial scars during Mohs surgery, pointing out that this is a very important issue for patients and scar appearance can be quite good if appropriate planning and skill is used.
Tips for achieving the optimal scar included planning the excision and closure carefully, reducing tension across the scar line, ensuring there is excellent lighting in the operating theatre, and stretching the skin during excision, as well as having the blade at 90 degrees to the skin surface. Dr Vindy also promoted the use of undermining to reduce tension, as well as using subcutaneous sutures if there is tension, dead space and bleeding.
During his talk, Dr Vindy cautioned about the dangers of inadequate haemostasis. He told the audience that as well as needing to be aware of aspirin, NSAIDs, and warfarin usage, doctors should also ask patients about their use of alcohol, garlic, ginseng and ginger, all of which increase the risk of bleeding. He also stressed the need to be aware of the location and significance of Erb’s point when carrying out surgery on the neck. It is protected only by skin, a variable amount of fat and superficial fascia, he cautioned.
Speaking to the Medical Independent (MI), Dr Vindy said there are many excellent dermatology surgeons in Ireland who face increasing demand for skin cancer surgery.
“Do not compromise the tumour clearance by making the margins smaller — you make the surgery easier but you leave some of the tumour in, which is pointless. That was my number one message to Irish doctors from my talk,” he told MI.
Better management of lower-leg ulcers is urged
Up to 85 per cent of all lower-limb amputations start with foot ulcers so dermatologists must prioritise effective and consistent care of any lower limb skin problems in diabetics as early as possible, the IAD Spring Meeting heard.
International expert in the field of wound care, Prof Gary Sibbald, Professor of Medicine and Public Health, University of Toronto, gave a wide-ranging presentation on the latest updates in wound care for dermatologists.
He noted that diabetic foot ulcers are frequently poorly managed, leading to avoidable amputations and long-term morbidity, as well as being a significant cost to health services.
“The big things to prevent a diabetic foot ulcer is a screening test, to stop smoking and proper footwear with support. They often need inserts if there are calluses,” he said, asking the audience of dermatologists if they felt confident in identifying diabetics at risk of leg ulcers.
Prof Sibbald advised those interested in screening for diabetic foot ulcers to go to his website, www.diabeticfootscreen.com, which contains a validated, practical 60-second screening tool.
He said as Ireland’s population ages, it is vitally important that clinicians look at ways to provide better care for patients suffering from wounds as a result of local excess skin pressure or other medical conditions.
Meanwhile, despite there being a number of advances in the field of wound care, such as artificial skin substitutes and biological agents, “they represent appropriate treatment for less than 5 per cent of all the patients we see” and do not work if the preparations are not correct, Prof Sibbald told the Meeting. So basic good local care is still the most important thing, he stressed. He recommends sanitary pads as a cheap, effective wound dressing, adding that foams are overused.
Speaking to MI, Prof Sibbald said: “When you want to wick moisture away from the wound and get fluid lock, use sanitary napkins and diaper technology. There are dressings with fluid locks that are much cheaper than foam dressings but sanitary napkins are a cheap and cheerful way to do it.”
Dermatologists have key role in treatment of lupus patients
Systemic lupus erythematosus (SLE) causes significant dermatological issues, which are underappreciated and undertreated, according to one of the world’s foremost experts on the autoimmune disease.
Prof Michelle Petri, Professor of Medicine, John Hopkins University School of Medicine, gave a very well-received update on SLE at the Meeting. She stressed the key role dermatologists have in treating the disease, in particular with quality of life in the treatment of its associated rashes, hair loss and scaly skin lesions.
She noted that the incidence of rheumatoid arthritis is decreasing worldwide but the incidence of lupus is on the rise and it affects women primarily: “And even the diagnosis of lupus is delayed because physicians don’t recognise it,” she added.
One of Prof Petri’s key treatment recommendations for SLE is “yes to plaquenil [hydroxychloroquine] and no to prednisone, the ‘P’ stands for poison”. She said it is now well known that even low doses of prednisone increases permanent organ damage by 80 per cent in these patients. In addition, SLE patients are sensitive to UV light and she said it is in the spring that she sees most skin flares, similar to arthritis, while renal flares are seen more in the autumn or winter.
Prof Petri pointed out that it is not usually the disease itself that kills SLE patients, it is the damage it causes to organs as well as treatment effects, resulting in significant cardiovascular mortality. In addition, 80 per cent of lupus patients have some form of cognitive impairment at 10 years’ post-diagnosis, Prof Petri told the Meeting.
External childcare increases the risk of developing eczema
Children with older siblings and who attend crèches are more likely to develop eczema, delegates attending the recent IAD 50th Anniversary Spring Meeting heard.
Prof Alan Irvine, Consultant Paediatric Dermatologist, Our Lady’s Children’s Hospital, Crumlin, Dublin, highlighted the latest research findings in atopic dermatitis (AD), including his own notable work.
He pointed out that 80 per cent of people who develop eczema get it before the age of two years, and there has been a huge increase in eczema worldwide, which he attributed to environmental components such as urban living.
Filaggrin mutations significantly increase the risk of developing eczema and lead to more serious disease which is harder to treat, as well as increasing the risk of other allergies and asthma.
Prof Irvine said that it is now possible to identify babies at birth with filaggrin mutations with about “97-98 per cent accuracy” by assessing their skin barrier.
“So we can type children at birth, very early, and we hope to be able to use that to stratify them very early,” he commented. Thus combining family history and transepidermal water loss really helps identify the odds of developing eczema.
“And imagine if we could take these children and apply a treatment that prevents them from ever getting eczema. Wouldn’t that be amazing, and we could also prevent other allergies like this.”
Summarising a unifying theory of early AD pathogenesis, Prof Irvine said skin barrier events are important, with maladaption to environmental change a key interaction. Relative humidity seems very important but the mechanisms behind this are unknown, he said. However, correction in early life could be very important in altering the life course of eczema, he reiterated.
For now, aggressive eczema treatment early on in young children should thus be considered, Prof Irvine concluded.