Doctors-in-training often receive an inadequate dermatology education. Furthermore, studies have highlighted the underrepresentation of skin of colour (SOC) in dermatological teaching, learning resources and research. Our image-based questionnaire, distributed to all internal medicine trainees in southwest England, highlighted knowledge gaps regarding SOC among training physicians. It is intrinsically more challenging for clinicians to confidently formulate dermatological diagnoses in SOC.In this review, we provide guidance for physicians to help make the diagnostic process more straightforward. First, we outline how skin colour is determined and classified. We discuss how inflammation presents in SOC, with the typical 'erythema' that physicians often associate with inflammation being a less prominent feature in darker skin tones. We then summarise nine important conditions that we believe physicians working in all specialties should be able to identify in patients with SOC, covering both conditions encountered on the medical take and conditions disproportionately affecting individuals with SOC. The population of the UK is rapidly diversifying; thus, as physicians, we have a professional duty to educate ourselves on dermatological conditions in SOC to provide the best quality of care for all our patients, regardless of their skin type.
Evidence suggests that the prevalence of depression and suicide in those with acne is higher than in the general population. There have also been case reports of suicide in patients taking isotretinoin for acne, although there is a lack of evidence to suggest a true causality. We know that many people with acne and acne scars struggle with impacts on emotions, social/daily activities, study, work and relationships. A prospective cohort study was undertaken, including 150 consecutive new patients in our acne clinics from 7 December 2021 to 5 July 2022 as part of a service evaluation. This project was registered with our local research and innovation team. We captured a snapshot of the demographics of our patients, including baseline Generalised Anxiety Disorder Assessments (GAD-7), Patient Health Questionnaires (PHQ-9) and pre-existing mental health problems. Mean age was 26 years (range 17–46). Sixty-four per cent of patients were women and 36% were men. Thirty per cent of patients reported a previous/current mental health problem, the most common being anxiety (19.3%) and depression (18.0%). The most common medications taken previously or currently were sertraline (4.0%) and propranolol (4.0%). Initial PHQ-9 scores ranged from 0 to 29 points: 49.1% had a score of ≥ 5; 29.1% a score of ≥ 10; and 18.2% a score of ≥ 15. As a comparison, in July–August 2021, the prevalence of depression (classified as a PHQ-8 of ≥ 10) was 32% in women and 20% in men aged 16–29 years in the UK. Rates of depression in our patient cohort were therefore similar to those in the general population in this age group. Interestingly, in the general population, 17% of those aged ≥ 16 years experienced depression during this time. This is significantly higher than the prepandemic prevalence rate of 10%. Initial GAD-7 scores in our cohort ranged from 0 to 21 points: 58.7% had a score of ≥ 5; 30.3% a score of ≥ 10; and 11.0% a score of ≥ 15. As a comparison, in September–October 2021, an estimated 28% of those 16–29 years old experienced moderate–severe anxiety in the UK (GAD-7 equivalent to ≥ 10), and the prevalence was higher in women. Anxiety levels were therefore similar in our cohort compared with the general population. The prevalence of anxiety and depression is high in young adults, which has increased with the COVID-19 pandemic, and the prevalence in our acne cohort is similar to that of the general population of a similar age. It remains that those with moderate–severe acne, regardless of what treatment is received, should be screened and monitored for anxiety and depression.
Delusional infestation (DI) is the fixed, false belief of pathogenic infestation of the skin or body, despite no supporting medical evidence. Patients may be difficult to treat successfully, because of their reluctance to accept referral or involvement of psychiatric services. Research consistently supports assessment of this cohort in multidisciplinary psychodermatology clinics, where integrated medical and psychiatric care can be seamlessly provided. The British Association of Dermatologists (BAD) All Parliamentary Group has recommended increased psychodermatology services across the UK, but provision is still scanty. We report a review of 49 consecutive patients (12 men and 37 women) with a diagnosis of DI assessed in a regional psychodermatology service. Mean patient age was 63 years (range 41–92). Mean duration of symptoms before attending was 4.9 years. Forty-one (84%) patients complained of living creatures, with the other eight (16%) perceiving fibres or other inanimate objects. Perception of nonliving material was strongly associated with substance misuse. Low-dose antipsychotics were prescribed in 44 (90%) patients. Risperidone (n = 39; 89%) and olanzapine (n = 5; 11%) were the drugs prescribed. Medications were well tolerated, with no significant adverse side-effects reported. Twenty-three (47%) responded to treatment. Four patients developed full-blown psychotic disorders. We were unable to engage 13 (27%) patients in treatment, and in three (6%), the treatment outcomes were unknown. Responders had a mean time to presentation of 3.7 years vs. nonresponders who had symptoms for an average of 5.9 years. Ten (20%) patients admitted to current or previous substance misuse. Twenty-one (43%) had a history of psychiatric disease. Substance misuse and established psychiatric disorders were associated with poorer engagement and response. Response to treatment and engagement with services is multifactorial. This review demonstrated that delays in presentation are associated with poorer outcomes (Romanov DV, Lepping P, Bewley A et al. Longer duration of untreated psychosis is associated with poorer outcomes for patients with delusional infestation. Acta Derm Venereol 2018; 98:848–54). In 2016, early intervention in psychosis services was introduced as a National Institute for Health and Care Excellence standard in the UK. In psychiatry, there is well-established evidence of the relationship between delays in treatment of psychosis and poorer outcomes. The BAD guidelines have recently been published to encourage more widespread prescribing of low-dose antipsychotics to expedite treatment. Our review highlights that all patients with DI face significant delays to treatment, which may adversely impact or increase the complexity of clinical presentations. This review emphasizes the importance of early assessment and supports the expansion of psychodermatology services.
At the University of Bristol, the dermatology curriculum was updated in 2020 to incorporate more teaching on skin of colour. In this article we summarise the findings of our cross-sectional study to establish whether improving teaching content on skin of colour results in a more confident cohort of students with better diagnostic skills in skin of colour.
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