Search

Vaccines are urgently needed to control the coronavirus disease 2019 (COVID-19) pandemic. The aim of this study was to determine the acceptance of and willingness to purchase a hypothetical COVID-19 vaccine in the general population of Aceh, a holistic Shariah law implementation province in Indonesia. An online cross-sectional study was conducted using a quota sampling technique between 1 to 24 September 2021. To determine hypothetical vaccine acceptance, respondents were asked if they were willing to accept vaccines with combinations of either 50% or 95% effectiveness and either 5% or 20% risk of adverse effects. Willingness to purchase was assessed by asking whether the participants would pay for such vaccines at certain price points. Logistic regression analysis was used to assess the associated determinants. Out of 377 respondents included in the final analysis, 86.5% were willing to accept a COVID-19 vaccine with 95% effectiveness and 5% adverse effects. The acceptance rate dropped to 45.1% if the risk of adverse effects was 20%. Vaccines with 50% effectiveness and 5% adverse effects were acceptable to 42.2% but the acceptance went down to 17.2% if the risk of adverse effects increased to 20%. Multivariate analysis found that men were twice as likely to accept a vaccine with 95% effectiveness and 5% adverse effects compared to females (aOR: 2.01; 95% CI 1.05-3.86). We found that 156/377 (41.3%) of respondents were willing to purchase a COVID-19 vaccine and of these participants 71.1% were willing to pay between Indonesian Rupiah (IDR) 50,000-150,000 (US$ 3.33-10.00). In conclusion, the acceptance rate of a hypothetical COVID-19 vaccine varied based on effectiveness and the risk of adverse effects., Competing Interests: All the authors declare that there are no conflicts of interest., (© 2022 The Author(s).)

The emergence of acute, severe non hepA-E hepatitis of unknown etiology (ASHUE) has attracted global concern owing to the very young age of the patients and its unknown etiology. Although this condition has been linked to several possible causes, including viral infection, drugs and/or toxin exposure, the exact cause remains unknown; this makes treatment recommendation very difficult. In this review, we summarize recent updates on the clinical manifestations, complemented with laboratory results, case numbers with the global distribution and other epidemiological characteristics, and the possible etiologies. We also provide the proposed actions that could be undertaken to control and prevent further spread of this hepatitis. Since many etiological and pathological aspects of the acute non hepA-E hepatitis remain unclear, further research is needed to minimize the severe impact of this disease., Competing Interests: All the authors declare that there are no conflicts of interest., (© 2022 The Author(s).)

Background: Māori, the indigenous people of New Zealand, have traditionally used the kānuka tree as part of their healing system, Rongoā Māori, and the oil from the kānuka tree has demonstratable anti-inflammatory and anti-bacterial properties. This trial investigated the efficacy and safety of a 3% kānuka oil (KO) cream compared to vehicle control (VC) for the topical treatment of eczema. The trial was conducted through a nationwide community pharmacy research network., Methods: This single-blind, parallel-group, randomised, vehicle-controlled trial was undertaken in 11 research trained community pharmacies across New Zealand. Eighty adult participants with self-reported moderate-to-severe eczema, assessed by Patient Orientated Eczema Measure (POEM) were randomised by blinded investigators to apply 3% KO cream or VC topically, twice daily, for six weeks. Randomisation was stratified by site and eczema severity, moderate versus severe. Primary outcome was difference in POEM scores at week six between groups by intention to treat. The study is registered on the Australian New Zealand Clinical Trial Registry (ANZCTR) reference number, ACTRN12618001754235., Findings: Eighty participants were recruited between 17 May 2019 and 10 May 2021 (41 KO group, 39 VC group). Mean POEM score (standard deviation) improved between baseline and week six for KO group, 18·4 (4·4) to 6·8 (5·5), and VC group, 18·7 (4·5) to 9·8 (6·5); mean difference between groups (95% confidence interval) was -3·1 (-6·0 to -0·2), p  = 0·036. There were three adverse events reported in the KO group related to the intervention and two in the control group., Interpretation: The KO group had a significant improvement in POEM score compared to VC. Rates of adverse events and withdrawals were similar between groups with no serious adverse events reported. Treatment acceptability was high for both groups across all domains. Our results suggest that in adults with moderate-to-severe eczema, the addition of KO to a daily emollient regimen led to a reduction in POEM score compared to VC. KO may represent an effective, safe, and well tolerated treatment for moderate-to-severe eczema in adults., Funding: Hikurangi Bioactives (Ruatoria, New Zealand) and HoneyLab (Tauranga, New Zealand), supported by a grant from Callaghan Innovation., Competing Interests: All authors have completed the ICMJE uniform disclosure form. R.B., A.S., and N.S. declare funding from Hikuangi Bioactives and Honeylab to the MRINZ for the submitted work. All other authors declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work., (© 2022 The Author(s).)

The aim of this study is to provide a more accurate representation of COVID-19's case fatality rate (CFR) by performing meta-analyses by continents and income, and by comparing the result with pooled estimates. We used multiple worldwide data sources on COVID-19 for every country reporting COVID-19 cases. On the basis of data, we performed random and fixed meta-analyses for CFR of COVID-19 by continents and income according to each individual calendar date. CFR was estimated based on the different geographical regions and levels of income using three models: pooled estimates, fixed- and random-model. In Asia, all three types of CFR initially remained approximately between 2.0% and 3.0%. In the case of pooled estimates and the fixed model results, CFR increased to 4.0%, by then gradually decreasing, while in the case of random-model, CFR remained under 2.0%. Similarly, in Europe, initially, the two types of CFR peaked at 9.0% and 10.0%, respectively. The random-model results showed an increase near 5.0%. In high-income countries, pooled estimates and fixed-model showed gradually increasing trends with a final pooled estimates and random-model reached about 8.0% and 4.0%, respectively. In middle-income, the pooled estimates and fixed-model have gradually increased reaching up to 4.5%. in low-income countries, CFRs remained similar between 1.5% and 3.0%. Our study emphasizes that COVID-19 CFR is not a fixed or static value. Rather, it is a dynamic estimate that changes with time, population, socioeconomic factors, and the mitigatory efforts of individual countries., (© 2022 Wiley Periodicals LLC.)

Importance: A clear dosing regimen for methotrexate in psoriasis is lacking, and this might lead to a suboptimal treatment. Because methotrexate is affordable and globally available, a uniform dosing regimen could potentially optimize the treatment of patients with psoriasis worldwide., Objective: To reach international consensus among psoriasis experts on a uniform dosing regimen for treatment with methotrexate in adult and pediatric patients with psoriasis and identify potential future research topics., Design, Setting, and Participants: Between September 2020 and March 2021, a survey study with a modified eDelphi procedure that was developed and distributed by the Amsterdam University Medical Center and completed by 180 participants worldwide (55 [30.6%] resided in non-Western countries) was conducted in 3 rounds. The proposals on which no consensus was reached were discussed in a conference meeting (June 2021). Participants voted on 21 proposals with a 9-point scale (1-3 disagree, 4-6 neither agree nor disagree, 7-9 agree) and were recruited through the Skin Inflammation and Psoriasis International Network and European Academy of Dermatology and Venereology in June 2020. Apart from being a dermatologist/dermatology resident, there were no specific criteria for participation in the survey. The participants worked mainly at a university hospital (97 [53.9%]) and were experienced in treating patients with psoriasis with methotrexate (163 [91.6%] had more than 10 years of experience)., Main Outcomes and Measures: In a survey with eDelphi procedure, we tried to reach consensus on 21 proposals. Consensus was defined as less than 15% voting disagree (1-3). For the consensus meeting, consensus was defined as less than 30% voting disagree., Results: Of 251 participants, 180 (71.7%) completed all 3 survey rounds, and 58 participants (23.1%) joined the conference meeting. Consensus was achieved on 11 proposals in round 1, 3 proposals in round 2, and 2 proposals in round 3. In the consensus meeting, consensus was achieved on 4 proposals. More research is needed, especially for the proposals on folic acid and the dosing of methotrexate for treating subpopulations such as children and vulnerable patients., Conclusions and Relevance: In this eDelphi consensus study, consensus was reached on 20 of 21 proposals involving methotrexate dosing in patients with psoriasis. This consensus may potentially be used to harmonize the treatment with methotrexate in patients with psoriasis.

While biological treatments for chronic plaque psoriasis should be administered continuously to maximize and maintain efficacy, interruptions in therapy may be necessary for a number of reasons. We reviewed the evidence from clinical trials on efficacy, safety and immunogenicity in clinical trials for approved biologic agents for chronic plaque psoriasis. A systematic search of three major medical databases was performed and a total of 35 articles were included into the analysis, including 13 controlled trials. Trials assessing continuous therapy against dosing as-needed therapy (including infliximab, etanercept and secukinumab) have demonstrated superior efficacy for continuous regimes. However, randomized withdrawal trials for etanercept, adalimumab, ixekizumab, brodalumab, guselkumab, risankizumab and tildrakizumab, showed no significant impact on skin clearance rates in patients who are interrupted once and then re-treated. With the possible exception of infliximab, temporary interruption in biologic therapy appears to be safe and most agents will regain efficacy after re-introduction. J Drugs Dermatol. 2021;20(10):1063-1071. doi:10.36849/JDD.5716.

As the phase III COVID-19 vaccine trials excluded patients on immunosuppressive treatments, or patients with significant autoimmunity, the Australasian Medical Dermatology Group make the following preliminary recommendations around COVID-19 vaccination in dermatology patients on immunomodulatory and/or biologic agents. Vaccination against COVID-19 is strongly encouraged for all patients on immunomodulatory drugs and/or biologic agents. There are currently insufficient data to recommend one COVID-19 vaccine or vaccine type (mRNA, recombinant, inactivated virus) over another. No specific additional risk in patients on immunomodulatory or biologic therapies has so far been identified. Data on vaccine efficacy in patients on immunomodulatory or biologic therapies are missing, so standard vaccination protocols are recommended until otherwise advised., (© 2021 The Australasian College of Dermatologists.)

Increasingly, existing evidence indicates that methotrexate-associated liver injury is related to comorbid risk factors such as diabetes, alcoholism, and obesity, rather than to methotrexate itself. Despite this fact, significant effort continues to be expended in the monitoring of low-dose methotrexate in patients with psoriasis. The gold standard investigation has been liver biopsy, but this is associated with significant morbidity and mortality. As methotrexate-induced liver injury is uncommon, the risk/benefit ratio of liver biopsy has been questioned. Fortunately, a number of new technologies have been developed for the diagnosis of chronic liver disease, including transient elastography (TE). TE is a type of shear wave ultrasound elastography, which measures the speed of shear waves used to estimate hepatic tissue stiffness. Several meta-analyses show very high pooled sensitivity and specificity for the diagnosis of hepatic cirrhosis (87% and 91%, respectively) in a variety of chronic liver disorders. It has a negative predictive value for cirrhosis of >90% and a positive predictive value of 75%. Recent European guidelines now advocate the use of TE as the first-line test for the assessment of fibrosis in alcohol- or hepatitis-related liver disease, including nonalcoholic fatty liver disease (NAFLD). As the prevalence of obesity and metabolic syndrome, including NAFLD, is significantly elevated in patients with psoriasis, TE may be worth considering as a routine investigation for any patient with psoriasis. Although high-quality studies comparing TE with standard liver biopsy in the monitoring of psoriatics on low-dose methotrexate are lacking, the evidence from multiple small cohort studies and case series demonstrates its effectiveness. A recent Australasian position statement recommends that TE should be considered as a routine investigation for monitoring methotrexate therapy, repeated every 3 years if kPa <7.5 and yearly if kPa >7.5. Liver biopsy should be considered for patients with a kPa >9.5., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background/objectives: Rosacea is a chronic inflammatory disorder that affects up to 10% of the population. Standard treatments include topical azelaic acid and metronidazole or systemic tetracyclines. Isotretinoin has generally been restricted to severe disease, often at a dose of 0.5-1.0 mg/kg/day., Method: Retrospective review of open-label isotretinoin (initial dose 20 mg/day, with dose adjustments according to response), in patients with mild to moderate papulopustular rosacea., Results: Altogether 52 patients (33 women), mean age 48 years (range 18-86) were treated with isotretinoin over a 5-year period. All patients were commenced on 20-mg isotretinoin/day which was reduced to 10-20 mg once to five times a week (equivalent to 5 mg/day) in 67%, but increased in 15% (who all had additional acne) to 30-40 mg/day. In terms of dose/kg/day, 29% received ≤ 0.1 mg/kg/day, 46% received 0.11-0.25 mg/kg/day and 10% received > 0.5 mg/kg/day. Treatment was continued for 57 weeks (range 9-223). Six patients (12%) did not attend follow up. Of the remainder, in 91% (42/46) the rosacea had cleared or was excellent. One patient stopped isotretinoin because of its adverse effects. Two-fifths (44%) suffered no adverse effect. The most common side-effect was cheilitis in half (52%), which was mild in all but one patient., Conclusion: Very low-dose isotretinoin (e.g., 10-20 mg once to five times a week, equivalent to 5 mg/day) is an effective treatment for mild to moderate papulopustular rosacea and is well tolerated., (© 2016 The Australasian College of Dermatologists.)

Background: The importance of the cumulative dose of isotretinoin with respect to relapse of acne vulgaris remains controversial. Although guidelines recommend 0.5-1.0 mg/kg/d to a minimum cumulative dose of 120 mg/kg, there has been a trend toward the use of lower daily dosages with no reference to cumulative dose., Objectives: This study aimed to determine the influence of daily and cumulative dosage on relapse in acne., Methods: Charts of patients with acne treated with isotretinoin were reviewed. Demographic details and daily cumulative doses and duration were compared between patients who received one course and two or more courses, respectively., Results: Of 1453 patients, 326 (22.4%) received a second course of treatment (study population). The remainder served as controls (n = 1127). Dosage varied from 10 mg/week to 1.1 mg/kg/d, cumulative dosage from 1 to >300 mg/kg, and duration of treatment from 8 weeks to 5 years. Compared with controls, patients who received a second course were more likely to be women (61 vs. 47%; P < 0.001) and received higher daily (0.71 vs. 0.58 mg/kg/d; P < 0.001) and cumulative (126 vs. 101 mg/kg; P < 0.001) doses. Patients treated with very low doses (e.g. 10 mg three times per week) and/or low cumulative doses (e.g. 25-50 mg/kg) did not relapse more often than controls., Conclusions: Neither daily nor cumulative dosages influenced relapse of acne vulgaris in patients treated with varying doses of isotretinoin as long as treatment was continued for ≥2 months after the acne had completely resolved., (© 2015 The International Society of Dermatology.)

Atopic eczema is a chronic inflammatory disease affecting about 30% of Australian and New Zealand children. Severe eczema costs over AUD 6000/year per child in direct medical, hospital and treatment costs as well as time off work for caregivers and untold distress for the family unit. In addition, it has a negative impact on a child's sleep, education, development and self-esteem. The treatment of atopic eczema is complex and multifaceted but a core component of therapy is to manage the inflammation with topical corticosteroids (TCS). Despite this, TCS are often underutilised by many parents due to corticosteroid phobia and unfounded concerns about their adverse effects. This has led to extended and unnecessary exacerbations of eczema for children. Contrary to popular perceptions, (TCS) use in paediatric eczema does not cause atrophy, hypopigmentation, hypertrichosis, osteoporosis, purpura or telangiectasia when used appropriately as per guidelines. In rare cases, prolonged and excessive use of potent TCS has contributed to striae, short-term hypothalamic-pituitary-adrenal axis alteration and ophthalmological disease. TCS use can also exacerbate periorificial rosacea. TCS are very effective treatments for eczema. When they are used to treat active eczema and stopped once the active inflammation has resolved, adverse effects are minimal. TCS should be the cornerstone treatment of atopic eczema in children., (© 2015 The Australasian College of Dermatologists.)

Introduction: Although melanoma is rare in children, parental concern about skin lesions often results in specialist referral and/or excision of benign lesions., Aim: To review dermatology referrals of children with skin lesions to determine reason for referral, macroscopic and dermatoscopic features of referred lesions, diagnosis, management and histology for excised lesions., Methods: Referral letters, clinical and dermatoscopic images and outcomes were reviewed for skin lesions in children aged 0-18 years attending a teledermoscopy clinic over a 28-month period., Results: Eighty-nine children with 128 lesions accounted for 9% of all referrals to the teledermoscopy clinic. The mean age of the children was 12 years (range 2-18 years). A 'changing mole' was the most common reason for referral (35 children; 39%), followed by 'possible melanoma' (19; 21%), and congenital naevus (9; 10%). The majority of lesions were benign melanocytic naevi (112 lesions; 88%). No lesions were diagnosed as melanoma or non-melanoma skin cancer. A history of change was given for 61/112 lesions (54%). Five lesions were excised; histopathological diagnoses were two spindle cell tumours of Reed, two compound naevi and one Spitz naevus., Discussion: Change in a lesion, though a common trigger for referral, is less likely to indicate malignancy in children compared with adults and, as a sole criterion, does not necessitate specialist referral. Teledermoscopy clinics offer high quality macroscopic and dermatoscopic images and can assist in providing reassurance, where appropriate.

Drug-induced hypersensitivity syndrome (DIHS) is a multi-system syndrome resulting from an idiosyncratic reaction to medication. While it commonly results in multi-organ involvement, particularly the liver, there are few reports of DIHS causing cerebral vasculitis and neurological deficits. We report the case of a 63-year old woman with DIHS secondary to allopurinol leading to multiple neurological deficits with magnetic resonance imaging findings consistent with a cerebral vasculitis., (© 2013 The Authors Australasian Journal of Dermatology © 2013 The Australasian College of Dermatologists.)

Facial involvement of atopic eczema in young children can be difficult to manage. Chronic scratching and rubbing, combined with parental reluctance to use topical corticosteroids on the face, often results in recalcitrant facial eczema. While wet wraps are a useful management option for moderate/severe atopic eczema involving the trunk and limbs they are difficult to use on the face. We describe the use of a face-mask using a widely available adhesive hydrocolloid dressing (DuoDerm extra thin) in three children with recalcitrant facial atopic eczema. Symptomatic control of itch or soreness was obtained within hours and the facial atopic eczema was markedly improved by 7 days. The face-masks were easy to apply, each lasting 1-4 days. One patient had a single adjuvant application of a potent topical corticosteroid under the hydrocolloid dressing. All three patients had long remissions (greater than 3 months) of their facial eczema, although all continued to have significant eczema involving their trunk and limbs. Face-masks made from hydrocolloid dressings, with or without topical corticosteroids, are worth considering in children with recalcitrant facial eczema., (© 2012 The Author. Australasian Journal of Dermatology © 2012 The Australasian College of Dermatologists.)

With 30 years of clinical use, it is appropriate to review the use of isotretinoin. We now understand that retinoids influence cellular growth, differentiation, morphogenesis and apoptosis, inhibit tumour promotion and malignant cell growth, exert immuno-modulatory actions and alter cellular cohesiveness. This has expanded the indications of isotretinoin from just acne and rosacea to a wide range of inflammatory and malignant skin disorders. While the standard dose of 0.5 to 1 mg/kg per day for 4 months to a cumulative dose of 120-140 mg/kg per day has served us well in the management of acne vulgaris, there is emerging evidence that much lower dosages (as low as 5 mg/day) are just as effective but have significantly fewer adverse effects. Relapse of acne vulgaris continues to be a problem but we are beginning to recognise that this is related less to the cumulative dose and more to the length of sebaceous gland suppression. Other factors important for relapse include a macrocomedonal pattern of acne, smoking and age, both younger (under 14 years) and older (over 25 years). After 30 years of use, we now understand why isotretinoin is such an effective drug. Not only does it clear acne in almost all patients, long-term remission can be achieved in 70-80% of patients with a single course. Important changes in the use of isotretinoin include using a lower daily dose for a longer period of time. New indications continue to emerge, particularly as a potential treatment for both intrinsic and extrinsic (photo) aging. Teratogenicity however, remains a very significant concern., (© 2012 The Author Australasian Journal of Dermatology © 2012 The Australasian College of Dermatologists.)

Acquired palmoplantar keratoderma (PPK) is a rare group of conditions with a number of aetiologies, including adverse reactions to drugs. Herein, we report a case of acquired PPK in association with influenza vaccination, confirmed by rechallenge., (© 2011 The Authors. Australasian Journal of Dermatology © 2011 The Australasian College of Dermatologists.)

Introduction: Population screening for melanoma remains controversial. There are no studies demonstrating that population screening increases survival. As prognosis of melanoma is directly related to Breslow thickness, a surrogate marker of survival is thickness of melanoma. The development of several self-referred, whole-body photography and sequential digital dermoscopy imaging services reflects the public's concern regarding melanoma., Aim: To assess the ability of one of these services to detect melanoma at an early, thin stage., Methods: Demographic and histological details from 100 melanomas diagnosed through self-referred whole-body photography and sequential digital dermoscopy imaging service compared to those diagnosed through traditional methods from data held by the New Zealand Cancer Registry., Results: There were 52 invasive and 48 in-situ melanomas: 90% superficial spreading type, 6% lentigo-maligna type and 4% nodular on histology. Forty-eight were diagnosed on first visit; the remainder by serial digital dermoscopy. Thirty-five percent of patients reported having had previous primary melanoma. In 60%, patients had been concerned by the lesion, the rest (40%) detected solely by screening. Patients diagnosed by whole-body photography and sequential digital dermoscopy screening had thinner melanomas compared to the Registry data: 69% <0.75 mm Breslow thickness compared to 52% (p=0.0216); only 1.9% thicker than 3 mm compared to 10.8% (p=0.067)., Discussion: Melanomas detected by self-referred, whole-body photography with sequential digital dermoscopy service are thinner than melanomas detected by traditional diagnostic methods. It remains to be determined whether earlier diagnosis results in improved survival.

Aim: To assess the quality of data included in the histology request form., Method: We prospectively reviewed the histology request forms of 375 consecutive skin lesions. In addition, the appropriateness of the surgical specimen was determined., Results: There were 196 women and 179 men with a mean age of 58.4 years. The majority of specimens (84.5%) derived from primary care. 233 lesions (62%) were removed by excision, 57 (15%) by shave, three by curettage, with 82 lesions (22%) by punch/incisional biopsy. The clinical diagnosis was either not specified in 56 cases (15%), or simply labelled as 'lesion' in 84 (22%) patients. In 140/375 cases (37%), no useful clinical information was available. The clinical diagnosis matched the histopathological diagnosis in 145 cases (39%). Sixty percent (78/131) of histologically confirmed malignant lesions had not been identified clinically as being malignant: only 2 of 12 (17%) melanomas, 33/74 (45%) BCCs and 18/45 SCCs (57%) were diagnosed clinically. The specimen type was considered inadequate to make a histopathological diagnosis in 25 cases (6.7%)., Conclusion: In over a third of histology requests, diagnostic clinical information was absent. In addition, punch biopsy was used in 40% of lesions where a melanoma was being considered clinically.

Reports of myiasis in humans in New Zealand are somewhat rare, and little attention has been paid to this issue in the local medical literature. A number of Diptera (fly) families present in New Zealand have been associated with cases of human myiasis: Calliphoridae (7 species), Fanniidae (2 species), Muscidae (3 species), Oestridae (4 species), Phoridae (3 species), Psychodidae (1 species), Sarcophagidae (2 species), Stratiomyidae (1 species) and Syrphidae (1 species). Despite these numbers, there have only been 6 published records and we obtained further 16 unpublished reports of myiasis acquired in New Zealand. Records of imported myiasis in humans are also rare, with only 2 published and 6 unpublished cases obtained. As many medical practitioners are unaware of myiasis or encounter it rarely, we provide a brief discussion of the clinical features and treatment.

Two arborists presented acutely with blistering eruptions affecting their forearms, hands, and fingers. The previous day, both men had pruned branches from a large fig tree, Ficus carica, which had sustained damaged during a storm. The following morning, both complained of a burning discomfort which rapidly evolved into erythema and bullae on skin that had been in direct contact with the tree branches. These symptoms gradually resolved over 4 to 6 weeks. Although phytophotodermatitis from Ficus carica has been reported, it is often poorly recognised and there is a need to raise awareness amongst arborists, orchardists, forestry workers, gardeners, and health professionals.

Aim: This audit was designed to compare current referral practice with the Ministry of Health elective services National Access Criteria for first Specialist Assessment (ACA) guidelines, to identify specific problems, and (if possible) to improve the use of acute dermatology services., Method: Information regarding referral source, information provided, urgency and diagnostic accuracy, time interval between referral and consultation date, and follow-up arrangements was collected via data sheet on each referral received. We confined the audit to acute referrals--ie, 'immediate and urgent cases' from general practitioners (GPs) that had been discussed with the dermatologist by phone, and internal referrals when an urgent consultation had been requested., Results: More acute referrals came from other hospital departments (74%) than from general practitioners (26%). Acute referrers, especially hospital teams, tended to overestimate the urgency with which a dermatological condition needed to be seen. Information about inpatients was often considered inadequate for triage. GP referrals contained more useful information. GP referral diagnostic accuracy is in keeping with other studies (approximately 50%) but the diagnostic accuracy of hospital doctors is well below this level. All acute referrals were seen within the recommended timeframe. Follow-up patterns were similar (whether referrals came from general practitioners or hospital teams) but for both groups there was a relatively high failure to attend rate., Conclusions: Inappropriate referrals are time-consuming and reduce our capacity for seeing community patients on the waiting list. To improve referral triage, we recommend that a referral letter that clearly specifies the information that should be provided. The majority of acute referrals did not comply with the ACA guidelines. We recommend applying the ACA guidelines to internal acute dermatology referrals (as well as those from GPs) to reduce unnecessary inpatient reviews, and to provide a better urgent service for those persons who truly require it.

Atopic dermatitis is an increasingly prevalent common childhood disease. While the majority of patients have mild disease, atopic dermatitis can cause considerable distress to patients and their caregivers, with significant social and financial cost to families. With a prevalence of 15 - 20% in Western countries, atopic dermatitis also has a considerable health and societal cost to the community. Many new treatments have been shown to be therapeutically effective, particularly in severe disease, including cyclosporin A (Neoral, Novartis AG), interferon, tacrolimus (Fujisawa Pharmaceutical Co. Ltd.) and iv. immunoglobulin. These are expensive when compared to standard treatments like emollients and topical corticosteroids and have significant adverse effects that limit their use. Additional costs related to monitoring are incurred and the long-term safety of these treatments is yet to be determined. However, an advantage over more traditional therapies is their ability to produce benefits even after treatment ceases. Treatments that produce long-term remissions have a greater likelihood of being cost-effective. With monetary constraints on healthcare and the importance governments place on reducing drug costs, economic evaluations are becoming an increasingly important factor for drug acceptance. Those evaluating cost-effectiveness should pay particular attention to the potential reduction in indirect and intangible costs. Unfortunately, there is a dearth of cost-effectiveness studies in atopic eczema and this needs to be addressed with some urgency.