Search

Background: In the 2022 mpox (monkeypox) outbreak, 79,000 global cases have been reported. Yet, limited dermatologic data have been published regarding lesion morphology and progression. Objective: The objective of this study was to characterize skin lesion morphology, symptomatology, and outcomes of mpox infection over time. Methods: The American Academy of Dermatology/International League of Dermatological Societies Dermatology COVID-19, Mpox, and Emerging Infections Registry captured deidentified patient cases of mpox entered by health care professionals. Results: From August 4 to November 13, 2022, 101 cases from 13 countries were entered, primarily by dermatologists (92%). Thirty-nine percent had fewer than 5 lesions. In 54% of cases, skin lesions were the first sign of infection. In the first 1-5 days of infection, papules (36%), vesicles (17%), and pustules (20%) predominated. By days 6-10, pustules (36%) were most common, followed by erosions/ulcers (27%) and crusts/scabs (24%). Crusts/scabs were the predominant morphology after day 11. Ten cases of morbilliform rash were reported. Scarring occurred in 13% of the cases. Limitations: Registry-reported data cannot address incidence. There is a potential reporting bias from the predilection to report cases with greater clinical severity. Discussion: These findings highlight differences in skin findings compared to historical outbreaks, notably the presence of skin lesions prior to systemic symptoms and low overall lesion counts. Scarring emerged as a major possible sequela.

The World Health Organization declared the global monkeypox outbreak a public health emergency of international concern in July 2022. In response, the American Academy of Dermatology and International League of Dermatological Societies expanded the existing COVID-19 Dermatology Registry to become the "AAD/ILDS Dermatology COVID-19, Monkeypox, and Emerging Infections Registry." The goal of the registry is to rapidly collate cases of monkeypox and other emerging infections and enable prompt dissemination of findings to front-line healthcare workers and other members of the medical community. The registry is now accepting reports of monkeypox cases and cutaneous reactions to monkeypox/smallpox vaccines. The success of this collaborative effort will depend on active case entry by the global dermatology community.

Skin-related neglected tropical diseases, or skin NTDs, comprise a group of NTDs that produce signs and symptoms on the skin, and includes at least nine diseases and disease groups. The World Health Organization launched the ‘Ending the neglect to attain the Sustainable Development Goals: a strategic framework for integrated control and management of skin-related neglected tropical diseases’ in June 2022, which this article summarises and sets out the way forward including guidance on how dermatologists and dermatological communities along with public health communities may support this initiative to contribute towards achieving skin care for everyone everywhere.

OBJECTIVE To determine the frequency of germline and somatic pathogenic BRCA1 and BRCA2 variants in patients with high-grade serous ovarian cancer tested by next-generation sequencing (NGS), with the aim of defining the best strategy to be implemented in future routine testing. DESIGN National retrospective audit. SETTING The All Wales Medical Genomics Service (AWMGS). POPULATION Patients with high-grade serous ovarian/fallopian tube/peritoneal cancer referred by oncologists to the AWMGS between February 2015 and February 2021 for germline and/or tumour testing of the BRCA1 and BRCA2 genes by NGS. METHODS Analysis of NGS data from germline and/or tumour testing. MAIN OUTCOME MEASURES Frequency of BRCA1 and BRCA2 pathogenic variants. RESULTS The overall observed germline/somatic pathogenic variant detection rate was 11.6% in the 844 patients included in this study, with a 9.2% (73/791) germline pathogenic variant detection rate. Parallel tumour and germline testing was carried out for 169 patients and the overall pathogenic variant detection rate for this cohort was 14.8%, with 6.5% (11/169) shown to have a somatic pathogenic variant. Two BRCA1 dosage variants were found during germline screens, representing 2.0% (2/98) of patients with a pathogenic variant that would have been missed through tumour testing alone. CONCLUSIONS Parallel germline and tumour BRCA1 and BRCA2 testing maximises the detection of pathogenic variants in patients with high-grade serous ovarian cancer. TWEETABLE ABSTRACT Parallel germline and tumour testing maximises BRCA pathogenic variant detection in ovarian cancer.

INTRODUCTION Skin cancer is the main cause of death in persons with albinism (PWA) in Africa. Education would minimize sun damage. OBJECTIVE To evaluate the efficacy and acceptance of a photoprotection educative and sunscreen (Umozi Max) package designed for PWA in reducing sunburns and skin cancer. PATIENTS AND METHODS A multicenter, noncontrolled, before-and-after, interventional study was conducted in PWA > 12 years of age, from February to May, 2019, in Malawi. During the baseline and the follow-up visits (at 8 and 15 weeks), subjects received an educational program designed to PWA and use of Umozi Max. At every visit, photoprotection behavior and knowledge were checked and cutaneous lesions were recorded. Univariate and bivariate analysis were performed. RESULTS A total of 210 PWA were analyzed, 50% males, with a mean age of 24.5 (SD 11.29) years. The percentage of people using sun protective clothing increased from 80% to 100% and sunscreen from 81.9% to 99.5%. People avoiding the midday sun increased by 38.9% (P

Panton–Valentine leucocidin (PVL) is a virulence factor produced by certain strains of Staphylococcus aureus (SA). Through its cytolytic action on the cell membranes of human polymorphonuclear neutrophils, PVL causes a range of pathologies collectively known as PVL-SA disease. The hallmark clinical signs of PVL-SA are recurrent boils and necrotizing skin and soft tissue infections (SSTIs) in otherwise healthy patients; however, it can lead to more severe and invasive presentations, including necrotizing haemorrhagic pneumonia, necrotizing fasciitis and purpura fulminans. Young adults with minimal previous exposure to healthcare settings tend to be at highest risk for acquiring PVL-SA disease, with close physical contact playing a central role in disease transmission. The prevalence of PVL-SA varies globally; however, this is often underestimated owing to a lack of routine PVL testing. In the UK, PVL-positive SA isolates have been rising over the past decade alongside an increasing prevalence of multidrug resistance in larger cities. This review article aims to raise awareness of the PVL toxin, to aid clinicians with diagnostic pointers and to provide guidance with treatment, with an emphasis on the need for further population-based studies.

Scabies is a parasitic disease of the skin that disproportionately affects disadvantaged populations. The disease causes considerable morbidity and leads to severe bacterial infection and immune-mediated disease. Scientific advances from the past 5 years suggest that scabies is amenable to population-level control, particularly through mass drug administration. In recognition of these issues, WHO added scabies to the list of neglected tropical diseases in 2017. To develop a global control programme, key operational research questions must now be addressed. Standardised approaches to diagnosis and methods for mapping are required to further understand the burden of disease. The safety of treatments for young children, including with ivermectin and moxidectin, should be investigated. Studies are needed to inform optimum implementation of mass treatment, including the threshold for intervention, target, dosing, and frequency. Frameworks for surveillance, monitoring, and evaluation of control strategies are also necessary.

The International Alliance for Global Health Dermatology (GLODERM) was formed in 2019 with the aim to unite efforts toward skin health, open to members from any health profession, any country, and at any stage of training. This article highlights the case for such an alliance; discusses existing opportunities and gaps in global health dermatology; describes the development of a new international alliance; proposes future directions; and reflects on lessons learned.

In order to deliver equal healthcare access to resource-poor settings, sustainable, cost-effective systems of communication should be used. As mobile phone use increases, remote care can be delivered via teledermatology using Apps. This commentary covers how WhatsApp could be used by dermatologists seeking to deliver healthcare in this context.

Many neglected tropical diseases (NTDs) affect the skin, causing considerable disability, stigma, and exacerbation of poverty. However, there has been relatively little investment into laboratory research, epidemiology, diagnostic tools or management strategies to control tropical skin disease. Integration may advance the control of skin disease across a range of domains, including mapping, diagnosis, clinical management, and community control measures such as mass drug administration. Examples of successful integration strategies include programs targeting scabies, impetigo, yaws, and diseases causing lymphoedema. Future strategies should build on these experiences and the experience of integration of other NTDs, strengthen existing health systems, and contribute toward the attainment of Universal Health Coverage. Strong partnerships and political support and will be necessary to achieve these goals.

Background:\ud Pyoderma gangrenosum (PG) is an uncommon dermatosis with a limited evidence base for treatment.\ud \ud Objective:\ud We sought to estimate the effectiveness of topical therapies in the treatment of patients with PG.\ud \ud Methods:\ud This was a retrospective cohort study of UK secondary care patients with a clinical diagnosis of PG that was suitable for topical treatment (recruited between July 2009 and June 2012). Participants received topical therapy after normal clinical practice (primarily topical corticosteroids [classes I-III] and tacrolimus 0.03% or 0.1%). The primary outcome was speed of healing at 6 weeks. Secondary outcomes included the following: proportion healed by 6 months; time to healing; global assessment; inflammation; pain; quality of life; treatment failure; and recurrence.\ud \ud Results:\ud Sixty-six patients (22-85 years of age) were enrolled. Clobetasol propionate 0.05% was the most commonly prescribed therapy. Overall, 28 of 66 (43.8%) ulcers healed by 6 months. The median time to healing was 145 days (95% confidence interval, 96 days to ∞). Initial ulcer size was a significant predictor of time to healing (hazard ratio, 0.94 [95% confidence interval, 0.88-1.00); P = .043). Four patients (15%) had a recurrence.\ud \ud Limitations:\ud Our study did not include a randomized comparator.\ud \ud Conclusion:\ud Topical therapy is potentially an effective first-line treatment for PG that avoids the possible side effects associated with systemic therapy. It remains unclear whether more severe disease will respond adequately to topical therapy alone.

The dichotomy index (I &lt, O), a quantitative estimate of the circadian regulation of daytime activity and sleep, predicted overall cancer survival and emergency hospitalization, supporting its integration in a mHealth platform. Modifiable causes of I &lt, O deterioration below 97.5%&mdash, (I &lt, O)low&mdash, were sought in 25 gastrointestinal cancer patients and 33 age- and sex-stratified controls. Rest-activity and temperature were tele-monitored with a wireless chest sensor, while daily activities, meals, and sleep were self-reported for one week. Salivary cortisol rhythm and dim light melatonin onset (DLMO) were determined. Circadian parameters were estimated using Hidden Markov modelling, and spectral analysis. Actionable predictors of (I &lt, O)low were identified through correlation and regression analyses. Median compliance with protocol exceeded 95%. Circadian disruption&mdash, was identified in 13 (52%) patients and four (12%) controls (p = 0.002). Cancer patients with (I &lt, O)low had lower median activity counts, worse fragmented sleep, and an abnormal or no circadian temperature rhythm compared to patients with I &lt, O exceeding 97.5%&mdash, O)high&mdash, (p &lt, 0.012). Six (I &lt, O)low patients had newly-diagnosed sleep conditions. Altered circadian coordination of rest-activity and chest surface temperature, physical inactivity, and irregular sleep were identified as modifiable determinants of (I &lt, O)low. Circadian rhythm and sleep tele-monitoring results support the design of specific interventions to improve outcomes within a patient-centered systems approach to health care.

801 Background: The relative amount of activity and rest over the 24-hours, as measured by the dichotomy index I < O from actimetry records, is an independent predictor of overall survival and quality of life, and an early warning signal for emergency hospitalisation. The IDEAs study aimed to determine the sleep, physical and circadian pathologies in pts during their daily routine at home, which could lower I < O and be modifiable through personalised interventions. Methods: The rest-activity and surface temperature patterns were monitored in real time using a tele-transmitting chest sensor and a GPRS-platform for one week in 25 pts, with a WHO performance status of 0-1 and metastatic GIC (colorectal, 56%). Each pt completed questionnaires including Chronotype, HADS, and Pittsburgh Sleep Index, filled a precise diary of daily activities, meals and sleep times, and the MD Anderson Symptoms Inventory daily. I < O counts the In-bed activity bouts per min that are below the median activity Out-of-bed. Other pt-specific circadian parameters were estimated with spectral analyses and Hidden Markov models (HMM). I < O predictors were identified through correlation and regression analyses. Results: A poor I < O was found for 13 pts (52%). Self-reported scores for sleep quality or physical fitness showed no significant differences according to I < O. Yet HMM-modelled rest-activity revealed that pts with poor I < O had lower activity out-of-bed (median activity counts per minute, 110 vs 52, p = 0.001) and fractionated sleep (probability of remaining at rest when asleep, 94% vs 90%, p = 0.01). Poor I < O was significantly associated with an abnormal circadian rhythm in chest surface temperature, that was either wrongly timed or suppressed, for 83% of the pts as compared to 25% of those with a good I < O (p = 0.012). Conclusions: Nearly half of the pts displayed altered circadian rest-activity rhythm, with poor sleep and low daytime activity. In most of them, the circadian rhythm in body temperature, which critically regulates sleep, was abnormal. Exploration and specific treatment of sleep and circadian disorders are warranted for improving outcomes in cancer pts. Clinical trial information: 233972.

In the 21st century, despite increased globalization through international travel for business, medical volunteerism, pleasure, and immigration/refugees into the United States, there is little published in the dermatology literature regarding the cutaneous manifestations of helminth infections. Approximately 17% of travelers seek medical care because of cutaneous disorders, many related to infectious etiologies. This review will focus on the cutaneous manifestations of helminth infections and is divided into 2 parts: part I focuses on nematode infections, and part II focuses on trematode and cestode infections. This review highlights the clinical manifestations, transmission, diagnosis, and treatment of helminth infections. Nematodes are roundworms that cause diseases with cutaneous manifestations, such as cutaneous larval migrans, onchocerciasis, filariasis, gnathostomiasis, loiasis, dracunculiasis, strongyloidiasis, ascariasis, streptocerciasis, dirofilariasis, and trichinosis. Tremadotes, also known as flukes, cause schistosomiasis, paragonimiasis, and fascioliasis. Cestodes (tapeworms) are flat, hermaphroditic parasites that cause diseases such as sparganosis, cysticercosis, and echinococcus.

BackgroundRadical hypofractionated thoracic radiotherapy is the most commonly used radiotherapy schedule for inoperable non-small-cell lung cancer (NSCLC) in the United Kingdom, despite a lack of level I evidence to support its use.PurposeTo supplement existing published retrospective data with a mature data series and provide further evidence to support the use of this schedule in routine clinical practice.Materials and methodsRetrospective analysis of all inoperable NSCLC cases treated with radical hypofractionated radiotherapy with or without induction chemotherapy in the North Wales Cancer Treatment Centre between 2001 and 2011.ResultsOf the 222 patients, 209 (94%) received 55 Gy in 20 fractions (#) and 13 (6%) received 52·5 Gy in 20#. Induction chemotherapy was administered in 121 (55%) cases. The median survival of 28·6 months (95% confidence interval 24·2–32·5) is comparable with previously published survival outcomes for this patient group.ConclusionThe growing body of evidence for this schedule, confirming survival outcomes comparable with internationally accepted results, is sufficient to support its future use in inoperable NSCLC.

Vulval Crohn's disease [VCD] is a challenging condition that can occur without gastrointestinal Crohn's disease [GCD]. We reviewed the clinical features and effects of therapy in a cohort of 22 patients with VCD to determine whether the presence of GCD affected the clinical presentation and treatment response. Of these, 64% had GCD and 65% of these presented with GCD prior to VCD. Fissuring, ulceration, and scarring were more common in those with VCD alone. Potent and ultra-potent topical steroids showed benefit in most patients. There was no clear evidence of sustained remission with metronidazole. Azathioprine was the most commonly used oral immunosuppressive agent, with an efficacy of 57%. Patients with both VCD and GCD had a better clinical response compared with those with VCD alone [70% and 25%, respectively]. Infliximab and adalimumab were effective in 56% and 71% of patients, respectively. Excision of redundant tissue was helpful in four patients. The absence of GCD may delay the diagnosis in women who present with vulval symptoms alone. The more active clinical features in those with VCD alone may represent a more aggressive condition, or the severity of the cutaneous disease may have been reduced by immunosuppression taken for GCD. Several patients obtained sustained remission in their GCD with anti-tumor necrosis factor alpha [anti-TNFα] agents while the VCD remained active.

Tinea capitis is the most important superficial fungal condition in children. It is often unrecognised but the presence of alopecia, scale and lymphadenopathy, especially in inner-city children should prompt investigation. An understanding of changing epidemiology and prevalence of causative organisms is important in deciding appropriate therapy. The use of diagnostic aids including dermoscopy is increasing and is reported to be helpful in identifying subtle signs. Trichophyton tonsurans accounts for the majority of cases in the UK and terbinafine is increasingly advocated as a safe and effective therapy. Exclusion from school is unnecessary provided the child is receiving appropriate systemic and topical therapy, but family members should be screened and carriers should receive treatment. Steroids and surgical treatments should be avoided. Treatment failure is common and may be multifactorial. Mycological cure after completing treatment should be sought and therefore follow up is necessary for Tinea capitis cases. Development of molecular diagnostic methods may improve our ability to diagnose Tinea capitis accurately and quickly in the future. Emerging new dermatophytoses affecting other anatomical sites are discussed which, although not common in the UK, may be seen due to increasing travel worldwide.

Background: Although healthy lifestyle behaviors have been shown to significantly reduce cardiovascular disease (CVD), offsetting even genetic risk, most CVD programs focus solely on risk scores rather than calculating health improvement. We sought to validate a newly developed quantitative composite healthy lifestyle behavioral score, the Optimal Health Impact Factor (OHIF), which captures behavioral change by attainment of thresholds established by clinical guidelines. Methods: Patients in the Integrative Cardiac Health Project’s 12-month Registry, a prospective lifestyle change program for the prevention of CVD, underwent traditional risk assessment by a nurse practitioner. Additionally, at baseline and 12-months, OHIF scores were calculated using validated questionnaires in the following four domains: nutrition (Rate-Your-Plate), exercise (minutes of continuous exercise per week), stress (Perceived Stress Scale) and sleep (Pittsburgh Sleep Quality Index). Each domain has a gradient of three behavioral threshold scores (not at goal, red=1; almost to goal, amber=2; at goal, green=3) for a maximum of 12 possible OHIF points representing optimal health behaviors. All patients received motivational health coaching by a multidisciplinary team. Data were analyzed by t-tests, comparing measures at baseline and at 12-months. Results: Of 225 consecutive completers (48% men, age 56.8 ± 12.9 years, 145 White, 54 Black, 26 other, 61% at high risk by family history of CVD in first order relatives), 160 (71%) showed clinically and statistically significant improvements in the four behavioral domains and selected laboratory data. Conclusions: Improvements in healthy lifestyle behaviors captured by the OHIF score correlate significantly with improvements in critical CVD risk factors, even in a population with high genetic risk. The OHIF score emphasizes gradients of positive lifestyle behavior change for both patient and provider to facilitate development of an actionable behavioral health plan to reduce CVD. Clinicians who calculate a CVD risk score may also find clinical value in calculating a composite OHIF score as a single measurable outcome tool for tracking behavioral changes longitudinally.

Purpose Toxic epidermal necrolysis (TEN) is a severe, life-threatening mucocutaneous disorder that frequently involves the ocular surface. This study aims to investigate the natural history and resolution of acute ocular involvement in patients with TEN admitted to the intensive care unit (ICU). Methods Case notes of patients admitted to ICU with TEN at a tertiary referral centre in a 9-year period were retrospectively reviewed. Patients’ characteristics, severity of ocular involvement, SCORTEN systemic severity score and treatment were correlated with resolution of ocular involvement and time to resolution. Results Nine out of 10 (90%) patients had ocular involvement with 4 graded as mild, 2 as moderate and 3 as severe. All had bilateral ocular disease. The median length of hospital stay was 28 days and the median time to resolution of ocular involvement was 19 days. Four out of 9 (44%) patients still had active ocular disease at the time of discharge. Only older age (p=0.032) and a milder grade of ocular disease (p=0.001) were significantly associated with resolution of ocular disease. In a multivariable Cox-regression model, only a milder grade of ocular disease remained independently associated with time to resolution of ocular disease (p=0.006). Conclusions Grading of acute ocular disease severity does not reflect systemic disease severity and is significantly associated with resolution and time to resolution of ocular involvement in TEN. The high rate of ocular involvement in patients with TEN and relatively large proportion of patients with active disease on discharge reiterates the need for constant ophthalmological monitoring of these patients.

The dermatophyte skin infections tinea capitis, tinea pedis and onychomycosis are common and challenging to treat. Our Drug review focusses on key points and advances in their management, followed by further sources of information.

Scabies is a common skin infestation globally, particularly in the developing world. With the launch of the International Alliance for the Control of Scabies (IACS) in 2012, this review aims to present the recent evidence of the current epidemiological situation for scabies across the globe. Mindful of the fact that the downstream complications of scabies infestations, pyoderma, streptococcal glomerulonephritis and subsequent chronic renal impairment and rheumatic fever, have been recognized as being more significant to global health than previously acknowledged, the review focusses also on the epidemiological evidence from developing countries.Scabies occurrence rates vary in the recent literature from 2.71 per 1000 to 46%. Although it is responsible for larger disease burdens and complications such as pyoderma and renal and heart disease in the tropics, scabies outbreaks in the developed world amongst vulnerable communities and health institutions contribute a significant cost to the health services managing them.Scabies remains common across the world, but is such a health issue in the developing world that the suggestion that it be considered a neglected tropical disease is a pertinent one. Standardized diagnostic criteria and even a point-of-care diagnostic test would be a major contribution to the understanding of this epidemic.

BACKGROUND Podoconiosis is a common cause of lymphoedema in barefoot workers in Ethiopia and other countries. It has severe consequences for patients' physical function, quality of life and economic status. AIMS To investigate stratum corneum (SC) hydration and transepidermal water loss (TEWL) in patients with podoconiosis compared with controls. METHODS In total, 55 patients and 20 controls were recruited. For each study subject, SC and TEWL measurements were taken, along with foot and lower leg circumferences. Measurements were compared between the patient and control groups. RESULTS Foot circumferences tended to be higher in patients with podoconiosis, with the mean foot:leg circumference ratio being 1·19 (95% confidence interval 1·11-1·28) times that for controls (P = 0·001). There was no detectable difference between patients and controls in TEWL values (P > 0·05); however, SC hydration was significantly lower in patients vs. controls for the foot (P = 0·004) and lower leg (P = 0·046) sites. CONCLUSIONS Patients with podoconiosis have significantly lower SC hydration in the skin of their lower legs and feet than controls, which may lead to cracking and splitting, and increased risk of lymphoedema and infection.

Neglected tropical diseases (NTDs) are communicable diseases that occur under conditions of poverty and are concentrated almost exclusively in impoverished populations in the developing world. NTDs affect more than 1000 million people in tropical and subtropical countries, costing developing economies billions of dollars every year. Effective control of NTDs can be achieved with the use of large-scale delivery of single-dose preventive chemotherapy (PC) or intensified disease management (IDM) or both, as is the case for some diseases such as lymphatic filariasis, trachoma, and yaws. Several NTDs exhibit significant cutaneous manifestations that are associated with long-term disfigurement and disability, including Buruli ulcer (BU); cutaneous leishmaniasis (CL); leprosy; mycetoma; yaws; hydrocele and lymphoedema (resulting from lymphatic filariasis); and depigmentation, subcutaneous nodules, severe itching, and hanging groin (resulting from onchocerciasis). Skin examination offers an opportunity to screen people in the communities or children in schools to identify multiple conditions in a single visit. This common approach to skin diseases justifies the integrated delivery of health care interventions to both increase cost-effectiveness and expand coverage. WHO’s Department of Control of NTDs (WHO/NTD) plans to promote an integrated strategy for the skin NTDs requiring IDM. Targeting skin NTDs also provides a platform for treatment of common skin conditions and, therefore, has wider public health benefits. An informal panel of experts (writing this manuscript) was established to help develop guidance in support of the new WHO strategic direction and to develop a proposal for a change in policy for the integrated control and management of the skin NTDs. A symposium at the 2015 ASTMH meeting[1] initiated a discussion of opportunities around integration of surveillance and control of NTDs that affect the skin, but this paper moves these ideas forward and includes some initial recommendations about how these opportunities could be realised. We aim to provide specific pragmatic information and actual recommendations about potential surveillance and management approaches.

The Task Force for Skin Care for All: Community Dermatology, when seeking to collate evidence for capacity to benefit, wanted to know how best to manage mobile populations. The task force met where there is most experience at a time of maximum migration to the Mediterranean islands and to Italy from Somalia, Sudan, Cote dIvoire, Tunisia, and Libya. Members attended the workshop hosted by Aldo Morrone at the San Gallicano Hospital, Rome, Italy. Issues discussed were the size of the problem, ethics and legality, potential value of the migrant, dermatologist as carer, challenges met by interpretation, good listening, and transcultural mediation. The experiences of the National Institute for Health Migration and Poverty at the San Gallicano Hospital in Rome, Ethiopia, Malta, and Lampedusa were key to the development of guidelines on cultural competence.

Breast cancer diagnosed during pregnancy is a relatively uncommon event. This challenging situation presents clinicians with difficult decisions, often requiring a multidisciplinary approach at a time of heightened anxiety for the patient and their family. This paper describes the case of a young woman with metastatic breast cancer diagnosed in early pregnancy, and outlines how this complex clinical situation was managed.

The assessment of health needs is a key step in determining the nature and level of health service provision required in any global region. In dermatology, information on needs has provided information on the scale and impact of skin conditions in poor rural and urban populations. In such areas, additional problems in providing adequate services are access to trained health care professionals and cost to families and individuals, set against the background of a village-mixed economy. A further problem is health literacy, which may limit the use of services. However, some of the most comprehensive surveys of the prevalence of skin disease have been carried out in resource-poor countries, and attempts have been made to assess these along with their impact on individual disability. These studies and their outcomes are described in this article.

Many of the neglected tropical diseases (NTDs) have major skin manifestations. These skin-related NTDs or ‘skin NTDs’ cause significant morbidity and economic hardship in some of the poorest communities worldwide. We draw attention to the collective burden of skin disease and suggest that the skin be used as a platform for the integration of control activities for NTDs. The opportunities for integration are numerous, ranging from diagnosis and disease mapping to mass drug administration and morbidity management. The dermatology community has an important role to play, and will be expected to support research and control activities globally.

Scabies, believed to have been first described by Aristotle (384-322 bc) in ancient Greece, has been with humankind throughout the ages. During the past decade, there has been a resurgence of global interest in scabies owing to enhanced awareness of its detrimental effect on health. The World Health Organization recently added scabies to its list of neglected tropical diseases (NTDs), which are a group of diseases, primarily infectious, prevalent in tropical and subtropical world regions that cause enduring disfigurement and debilitation, leading to social stigma and the inability to work or attend school. The World Health Organization estimates that more than 1 billion people—about one-sixth of the world’s population—have 1 or more NTDs, which cost developing economies billions of dollars annually. With an NTD designation, the World Health Organization increases the spotlight on Sarcoptes scabiei and calls on organizations, governments, researchers, funders, and policymakers to respond. Why such attention on this mite that does not even burrow beyond the stratum corneum?

Background Early detection of several skin-related neglected tropical diseases (skin NTDs)–including leprosy, Buruli ulcer, yaws, and scabies- may be achieved through school surveys, but such an approach has seldom been tested systematically on a large scale in endemic countries. Additionally, a better understanding of the spectrum of skin diseases and the at-risk populations to be encountered during such surveys is necessary to facilitate the process. Methods We performed a school skin survey for selected NTDs and the spectrum of skin diseases, among primary schoolchildren aged 5 to 15 in Côte d’Ivoire, West Africa. This 2-phase survey took place in 49 schools from 16 villages in the Adzopé health district from November 2015 to January 2016. The first phase involved a rapid visual examination of the skin by local community healthcare workers (village nurses) to identify any skin abnormality. In a second phase, a specialized medical team including dermatologists performed a total skin examination of all screened students with any skin lesion and provided treatment where necessary. Results Of a total of 13,019 children, 3,504 screened positive for skin lesions and were listed for the next stage examination. The medical team examined 1,138 of these children. The overall prevalence of skin diseases was 25.6% (95% CI: 24.3–26.9%). The predominant diagnoses were fungal infections (n = 858, prevalence: 22.3%), followed by inflammatory skin diseases (n = 265, prevalence: 6.9%). Skin diseases were more common in boys and in children living along the main road with heavy traffic. One case of multi-bacillary type leprosy was detected early, along with 36 cases of scabies. Our survey was met with very good community acceptance. Conclusion We carried out the first large-scale integrated, two-phase pediatric multi-skin NTD survey in rural Côte d’Ivoire, effectively reaching a large population. We found a high prevalence of skin diseases in children, but only limited number of skin NTDs. With the lessons learned, we plan to expand the project to a wider area to further explore its potential to better integrate skin NTD screening in the public health agenda., Author summary Integration of neglected tropical diseases (NTDs) into the public health agenda has been a priority in global health for the last decade. A common feature shared by several NTDs is skin involvement. Conditions within this group of NTDs have now been classified as skin NTDs to promote wider NTD integration. Several skin NTDs including leprosy, Buruli ulcer, yaws, and scabies are co-endemic in Côte d’Ivoire, West Africa. As children are vulnerable to these diseases, we carried out the first large-scale integrated, multi-skin NTD school survey in a rural district of this country. Our strategy of involving community healthcare workers and dermatologists effectively reached a large population. However, the detection of skin NTDs may have been limited because of the low schooling and attendance rate. We found a high prevalence of skin diseases among schoolchildren (26%), possibly due to poor socio-economic status and air pollution, which requires more attention. This high prevalence of skin diseases posed a challenge for our project as the need for medications and those with dermatological skills exceeded our capacity to reach our initial target population. Our study provides important lessons that will aid the framing of future school skin surveys in sub-Saharan Africa.

Although prediabetes is associated with increased cardiovascular disease (CVD) risk, it is not often targeted in CVD prevention programs. We sought to evaluate the impact of a tailored prediabetes program to reverse prediabetes and lower CVD risk. Consecutive subjects of the Integrative Cardiac

A study of agricultural practices around New Philadelphia, Illinois, and a comparison of these practices with those in the regions from whence the New Philadelphia residents came, tests the definitions of Upland South, Midland, and Northern (or Yankee) subsistence traditions. Using data from the U.S. census reports and agriculture schedules from 1840 and 1850, the choices of crops and livestock made by farmers in New York, Ohio, and Kentucky are compared to those made in the New Philadelphia community. Regional differences are found to have existed which influenced the farmers who lived in the area of that town in western Illinois. This study provides a firmer understanding of the subsistence and economic practices of the community.

Three years of research at the New Philadelphia site in western Illinois have provided the opportunity to integrate archaeological and documentary information to improve the understanding of family organization, economic patterns, and subsistence activities in this small, racially integrated, agrarian community. Analysis of the faunal remains recovered, and the study of available historical records, permit one to compare and contrast households within the town site, and to explore how the different regional backgrounds of the town’s residents affected their livelihoods. Patterns of migration, regional origin, social organization, and intricate familial relationships are continuing to emerge even as new data are being collected. Because of its small size and its discrete and relatively recent existence, New Philadelphia presents a unique opportunity to study the entire history of a community in minute detail.

Although fungal skin infections are common, they can be challenging to treat. Our Drug review provides useful tips and warns of the pitfalls in management, followed by sources of further information. Copyright © 2009 Wiley Interface Ltd

The aim of this review is to update the latest epidemiological situation in Europe, explore recent issues in recognition and emerging opportunities in diagnosis and look at progressions in treatment. Papers reviewed have, in the main, been published within the last 2 years.The predominantly responsible organism varies with country. Trichophyton tonsurans accounts for 50-90% of cases in the UK, Microsporum canis is commonest in Central and Southern Europe and T. violaceum in Greece and Belgium. Confirming the diagnosis of tinea capitis is best undertaken with more than one sampling method to include scraping of scalp, and either scalp massage brush, toothbrush, moistened cotton gauze swab or cytobrush to increase sensitivity. Advances in the speed of species identification is offered by the novel PCR-based detection/identification scheme, and although not yet commercially available, with potential turnaround times of24 h this will offer a significant advance in the speed of diagnosis, allowing treatment to be organism tailored. Although griseofulvin remains the only licensed treatment in the UK and a meta-analysis confirms it is effective against the major tinea capitis pathogens, a new granule formulation of terbinafine has been shown to be more effective against T. tonsurans.With the evolving organism profile across Europe, obtaining an accurate diagnosis and species identification is crucial. Using more than one sampling method followed by rapid species identification techniques will facilitate this. Although there are no changes in specific product license to include children, the production of a child-friendly formulation of terbinafine will contribute to improved compliance.

OBJECTIVE To develop and test a robust clinical staging system for podoconiosis, a geochemical disease in individuals exposed to red clay soil. METHODS We adapted the Dreyer system for staging filarial lymphoedema and tested it in four re-iterative field tests conducted in an area of high-podoconiosis prevalence in Southern Ethiopia. The system has five stages according to proximal spread of disease and presence of dermal nodules, ridges and bands. We measured the 1-week repeatability and the inter-observer agreement of the final staging system. RESULTS The five-stage system is readily understood by community workers with little health training. Kappa for 1-week repeatability was 0.88 (95% CI 0.80-0.96), for agreement between health professionals was 0.71 (95% CI 0.60-0.82), while that between health professionals and community podoconiosis agents without formal health training averaged 0.64 (95% CI 0.52-0.78). CONCLUSIONS This simple staging system with good inter-observer agreement and repeatability can assist in the management and further study of podoconiosis.

Cause and transmission Several different dermatophytes can cause tinea capitis but the current inner-city epidemic is attributed to Trichophyton tonsurans, which is anthropophilic, ie is easily transmitted between humans. It is also an endothrix, meaning the spores invade the hair shaft, as opposed to an ectothrix, which rests on the surface. Studies from central London suggest a prevalence of around 2.5 per cent, with up to one in four children infected in one class examined.1 Prior to T. tonsurans gaining ground in the UK, Microsporum canis was the most common cause of tinea capitis. An ectothrix and zoophilic, M. canis is usually transmitted animal to human rather than person to person. Typically this fungus is contracted on holiday from contact with infected stray cats or dogs. Clinical presentation For inner-city children, it is reasonable to presume scalp problems are due to tinea capitis until proven otherwise. Although obvious indicators such as a scaly patch of hair loss are easily spotted, the presently common T. tonsurans is responsible for a range of clinical presentations and so diagnosis can be a little more challenging. Clinical presentations include: scaly circular patches of hair loss, pustules, diffuse scale-like dandruff, and kerion with associated lymphadenopathy, an inflamed, boggy, painful tumour that may be studded with pustules (see Figure 1). It has a predilection for chil

In the 21st century, despite increased globalization through international travel for business, medical volunteerism, pleasure, and immigration/refugees into the United States, there is little published in the dermatology literature regarding the cutaneous manifestations of helminth infections. Approximately 17% of travelers seek medical care because of cutaneous disorders, many related to infectious etiologies. This review will focus on the cutaneous manifestations of helminth infections and is divided into 2 parts: part I focuses on nematode infections, and part II focuses on trematode and cestode infections. This review highlights the clinical manifestations, transmission, diagnosis, and treatment of helminth infections. Nematodes are roundworms that cause diseases with cutaneous manifestations, such as cutaneous larval migrans, onchocerciasis, filariasis, gnathostomiasis, loiasis, dracunculiasis, strongyloidiasis, ascariasis, streptocerciasis, dirofilariasis, and trichinosis. Tremadotes, also known as flukes, cause schistosomiasis, paragonimiasis, and fascioliasis. Cestodes (tapeworms) are flat, hermaphroditic parasites that cause diseases such as sparganosis, cysticercosis, and echinococcus.

The Task Force for Skin Care for All: Community Dermatology, when seeking to collate evidence for capacity to benefit, wanted to know how best to manage mobile populations. The task force met where there is most experience at a time of maximum migration to the Mediterranean islands and to Italy from Somalia, Sudan, Cote d'Ivoire, Tunisia, and Libya. Members attended the workshop hosted by Aldo Morrone at the San Gallicano Hospital, Rome, Italy. Issues discussed were the size of the problem, ethics and legality, potential value of the migrant, dermatologist as carer, challenges met by interpretation, good listening, and transcultural mediation. The experiences of the National Institute for Health Migration and Poverty at the San Gallicano Hospital in Rome, Ethiopia, Malta, and Lampedusa were key to the development of guidelines on cultural competence.

Scabies, the human skin disease caused by infestation by the mite Sarcoptes scabiei var. hominis, causes considerable morbidity and mortality through direct effects and as a result of secondary bacterial infection. Scabies is a truly neglected disease, largely absent from the global health agenda, and its huge burden of disease is largely underappreciated. We contend that coordinated, global efforts to control this ubiquitous pathogenic mite are both important and achievable.

The assessment of health needs is a key step in determining the nature and level of health service provision required in any global region. In dermatology, information on needs has provided information on the scale and impact of skin conditions in poor rural and urban populations. In such areas, additional problems in providing adequate services are access to trained health care professionals and cost to families and individuals, set against the background of a village-mixed economy. A further problem is health literacy, which may limit the use of services. However, some of the most comprehensive surveys of the prevalence of skin disease have been carried out in resource-poor countries, and attempts have been made to assess these along with their impact on individual disability. These studies and their outcomes are described in this article.

Molluscum contagiosum is a common viral infection of the skin that frequently affects children. Lesions take between 6 and 18 months to resolve spontaneously and are a source of great embarrassment to both caretakers and children, often affecting attendance at school and limiting social activity. Treatment options to date have been poorly tolerated by children but recent studies have suggested that potassium hydroxide may be beneficial. This double-blind, randomized, placebo-controlled study compared 10% potassium hydroxide with placebo (normal saline). Twenty patients, aged 2 to 12 years, were recruited. Parents applied a solution twice daily to lesional skin until signs of inflammation appeared. Children were examined by the same observer on days 0, 15, 30, 60, and 90. Seventy percent of children receiving topical potassium hydroxide cleared, compared with 20% in the placebo group. Further dosing studies are required to identify whether weaker concentrations of potassium hydroxide are as efficacious, with less irritancy.

Purpose of review Podoconiosis is a noncommunicable disease producing lymphoedema of the lower limbs; it affects predominantly barefoot agricultural workers in the tropics. Why should this be of interest to a journal of infectious disease? For many years this disease has not been widely recognized as distinct from lymphatic filariasis and yet it may affect about 10% of populations in volcanic tropical highlands. It produces considerable morbidity associated with limb lymphoedema, impacting on economically productive age groups. As it does not fall into the briefs of infectious or chronic disease initiatives of the World Health Organization, it has been difficult to attract funds for research and for the development of community management approaches. The aim of this review is to describe details of the clinical features, management, epidemiological significance and evidence for the underlying aetiology of this poorly understood condition. Recent findings A recent comprehensive study in Ethiopia by Destas et al. identified a mean zonal prevalence of 5.46% of the population with 64% being in the economically productive age group. Otherwise there are no other contemporary epidemiological publications in this field. Summary Podoconiosis is thought to be a geochemical disease induced by the absorption of ultrafine silica particles from the soil (konia) through the skin of the feet (podos) in susceptible individuals, leading to a progressive obliterative endolymphangitis.