No abstract

The limited evidence does not demonstrate that Ginkgo biloba is effective for tinnitus when this is the primary complaint.

Modifications of the Epley (canalith repositioning) manoeuvre for posterior canal benign paroxysmal positional vertigo (BPPV) (Review)

Multiple periungual Bowen disease [BD; also known as squamous cell carcinoma (SCC) in situ] is rare. The pathogenesis of the disease is linked to human papilloma virus, and in some instances to chronic immunosuppression. The usual management of periungual BD is by local excision, Mohs micrographic surgery or distal phalanx amputation. Our patient was offered radiotherapy in the hope of maximizing residual function and minimizing morbidity from treatment. A good response was seen at 2 months post-radiotherapy, but this was followed by relapses at 4 and 6 months post-radiotherapy. Persistent anonychia resulted in improved access to the involved skin, making topical therapy possible. Radiotherapy can be a valuable management approach for periungual SCC/BD in locations where amputation could result in substantial disability.

The advice given in dermatology postoperative PILs across England and Wales is highly variable. A nationally agreed template or set of postoperative advice should be considered to improve consistency.

DISCUSSIONDimethyl fumarate, a fungicidal agent used in leather products was the cause of a major outbreak of allergic contact dermatitis >10 years ago. This was termed "sofa dermatitis" and led to recall of leather furniture from implicated suppliers. 1,2 Non-occupational contact allergy to OIT has not yet been reported in the UK to the best of our knowledge. By contrast, occupational allergic contact dermatitis is described: Young et al reported aPhD student developing hand dermatitis when working with OIT as a biocide 3 ; a further report described three workers experiencing hand dermatitis due to OIT used as a preservative in an adhesive factory. 4Non-occupational allergic contact dermatitis to OIT is described internationally, principally to leather products such as belts, shoes, watch straps, and pertinent leather upholstery on sofas. 5,6 A recent review has highlighted the presence of OIT in textiles, household detergents, metalworking fluids, and plastic cleaning towels. 7 Cross reactivity between MI and OIT is reportedly common, 5,8 although our patient did not react to MI or MCI. Isothiazolinones are used as preservatives in a wide variety of settings and cross reactions do not necessarily occur. This case highlights the importance of testing to a range of isothiazolinones and the importance of recognizing the changing landscape of allergen exposure. CONFLICT OF INTERESTNone to declare. ORCIDWilliam T. N. Hunt https://orcid.org/0000-0002-7680-0624

Mohs micrographic surgery (MMS) is considered the gold-standard treatment for basal cell carcinoma (BCC) particularly for sites with a high risk of incomplete excision such as the central face, for tumours with an aggressive growth pattern and consequent unpredictable subclinical extension and for recurrent tumours. However, the process is more time-consuming than for standard excision (SE), and the magnitude of benefit is uncertain. This article aims to provide a more complete picture of current evidence, including a review of cosmetic outcomes, tissue-sparing ability and cost-effectiveness of MMS. Although robust evidence is lacking, there is a large volume of observational data supporting a low recurrence rate after MMS. The risk of incomplete excision and higher recurrence rate of SE favours the use of MMS at high-risk sites. There is some low-certainty evidence that MMS results in a smaller defect size compared with SE, and that incomplete excision with SE results in larger defects. Larger defects may affect cosmetic outcome but there is no direct evidence that MMS improves cosmetic outcome compared with SE. There is conflicting evidence regarding the cost of MMS compared with SE, as some studies consider MMS less expensive than SE and others consider it more expensive, which may reflect the healthcare setting. A multicentre 10-year randomized controlled trial comparing MMS and SE in the treatment of high-risk BCC would be desirable, but is unlikely to be feasible or ethical. Collection of robust registry data capturing both MMS and SE outcomes would provide additional long-term outcomes.

This review presents and discusses the evidence for MMS to treat cutaneous squamous cell carcinoma (cSCC). The MEDLINE, Embase and Cochrane databases were searched; 39 papers were identified for recurrence and 2 papers for costeffectiveness. We included all clinical trials and observational studies, including retrospective reports, and excluded editorials and systematic reviews or meta-analyses. We categorized the evidence under the following headings: tumour recurrence, specific site outcomes (ear, lip, scalp and periocular), cSCC with perineural invasion, and cost-effectiveness. Although there are many observational studies indicating the potential benefits of MMS in the management of certain cSCCs, no randomized controlled trials (RCT) were identified. The evidence from comparitor studies suggests that MMS has a lower recurrence rate than that of other treatments for cSCC, including standard excision. Many studies identified were single-armed, but did demonstrate a low to very low recurrence rate of cSCC following MMS. A single recent study suggests MMS for intermediate cSCC is highly cost-effective compared with wide local excision when all-in costs are considered. Since the overall quality of included studies was mixed and highly heterogeneous, further methodologically robust studies with comparator arms or comprehensive long-term registry data would be valuable. It would be ideal to employ a definitive multicentre RCT but given the evidence to date and multiple advantages to MMS, the lack of clinical equipoise makes this difficult to justify. Comparison with current modalities would likely not be ethical/achievable on a like-for-like basis given MMS provides 100% margin assessment, enables histological clearance prior to reconstruction, and minimizes the removal of uninvolved tissue.