Although imiquimod clearly has an effect on LM, this analysis of available studies has helped to identify concerns about its use. Without controlled evidence and prolonged follow up, the use of imiquimod for LM must still be considered experimental.

Objectives-To determine the reasons for choosing between primary care out of hours centres and accident and emergency (A&E) departments for patients with primary care problems. Methods-Interviews using a semistructured approach of samples of patients attending A&E departments and general practitioner (GP) out of hours centres for primary care problems. Results-102 patient interviews were undertaken. Sixty two per cent of A&E attenders were unemployed compared with 41% of out of hours attenders. White people were more likely to attend A&E departments and Asians the out of hours centre (p<0.01) and unemployed were more likely to attend A&E departments (70% v 30%). Some 46.3% of A&E department attenders had not contacted their GP before attending; 81.3% of first time users of the out of hours centre found out about it on the day of interview. Those attending A&E thought waiting times at the out of hours centre would be 6.3 hours (median) compared with a median perceived time of 2.9 hours by those actually attending the out of hours centre. Actual time was actually much less. Conclusion-Once patients have used the GP out of hours centre they are more likely to use it again. Education should be targeted at young adults, the unemployed and white people. Patients should be encouraged to contact their GP before A&E department attendance for non-life threatening conditions. Waiting time perception may be an important reason for choice of service. (J Accid Emerg Med 2000;17:18-21) Keywords: out of hours care; primary care; patient choice General practice cooperatives are a comparatively new and successful provision of out of hours primary care in the United Kingdom. In these cooperatives groups of general practitioners (GPs) combine resources to provide emergency cover for their practices. Out of hours they usually run an emergency centre. Patients who telephone the GPs may be given advice, advised to attend the centre, or may receive a visit. However, patients continue to attend the accident and emergency (A&E) department with primary care problems out of hours. As primary care attenders to the A&E department can be managed more appropriately and more economically by the GP services, 1 the current state of aVairs represents a poor use of resources.Factors that have been shown to determine why patients choose A&E over general practice are travelling distance, 2 lack of knowledge of the range of GP services, 3 perceived need for immediate attention, 4 and more advanced technology. 5A small proportion of these patients are not registered with a GP, are visitors, or are homeless. 6 These results are from studies that were conducted before the inception of out of hours GP cooperatives, when GP deputising services were the mainstay of out of hours primary care. No study to date has determined the reasons for out of Figure 1 The age distribution of A&E and cooperative patients.

We present the case of an 80-year-old lady known to be sensitive to chlorocresol (4-chloro-3-methyl phenol) who developed severe erythrodermic exfoliative dermatitis with atypical features 2 weeks after commencing subcutaneous insulin. All medications except insulin were stopped, without major improvement. It was noted that the insulin contained m-cresol (m-methyl phenol) so a parabens-based insulin was substituted. There was a significant improvement in her clinical condition within 72 hr. Further patch and intradermal testing to the insulin and m-cresol was planned, but she developed a nosocomial infection and died. We hypothesize that the adverse cutaneous reaction was a systemic manifestation of cresol sensitivity, given the rapid clinical resolution on changing insulins and the previously demonstrated sensitivity to chlorocresol, particularly as cross-reactivity between different low molecular weight methyl phenols is documented. Local injection site reactions and systemic side-effects including nausea, diarrhoea and vomiting have previously been reported with cresol-containing insulins, although to our knowledge, this is the first reported case of a severe cutaneous reaction. It is important to be aware of m-cresol as a potential allergen, as it is contained in most commercially available insulins.

Congenital melanocytic naevi (CMN) can cause significant psychosocial morbidity, especially if they are in visually exposed areas. The preferred treatment is surgical excision, though not all lesions are amenable to this because anatomical location may preclude aesthetic and functional reconstruction. Three children with inoperable facial CMN were treated with Er:YAG resurfacing under general anaesthetic. Two children were Fitzpatrick skin type II, and one child was skin type VI. Treatment was performed at 4-9-monthly intervals. The procedure achieved significant lightening and thinning in all three cases, without scarring or dyspigmentation. One child developed herpes simplex infection in the treated area on one occasion, which was managed with oral aciclovir, and did not lead to scarring or preclude further treatment. We conclude that Er:YAG laser resurfacing is effective for CMN, even in darker skin types. The incidence of side-effects is low, although repeated treatment is necessary.