Biomedical subjects
Publications and source records attributed to J A Cotterill.
Good communication is the key to damage limitation. A complaint by a patient should be treated as a medical emergency as early effective communication will almost always neutralise patient anger. Legible and appropriate clinical notes are also important. Patients with depression and dysmorphophobia are potentially litigious, underlying the importance of patient selection.
Potential patients in the developed world are increasingly turning to treatment with herbs. One of the most popular herbs taken for depression is St John's Wort, which contains the potential photosensitizer hypericin. 'Hypericism' is a term used to describe a state of skin sensitivity to visible light in animals following ingestion of hypericin-containing plants and feed. A patient who developed a severe phototoxic reaction to laser light at 532 nm and also an exaggerated and unexpectedly severe response to pulsed dye laser light at 585 nm is described. It subsequently transpired that the patient was taking St John's Wort at the time of laser treatment.
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A patient presenting with nodules in his tattoos was referred for laser treatment, following which there was a diagnosis of cutaneous and pulmonary sarcoidosis. Nodular change involving several different tattoo colours is characteristic of sarcoidosis.
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Sixteen patients, seven men and nine women, who committed suicide after presenting with dermatological problems to two dermatologists, are described. Most of the patients had either a body image disorder (dysmorphophobia) or acne. In addition, patients with long-standing and debilitating skin disease may become depressed enough to commit suicide and there is always an attendant risk of suicide in patients with established, severe psychiatric problems, who are referred to dermatologists with concurrent skin disorders. It is important to recognize that patients with dermatological non-disease, and particularly women with facial complaints, may be extremely depressed and at risk of suicide. Facial scarring, particularly in men, may be an 'at risk' factor for suicide, emphasizing the positive early therapeutic role of isotretinoin. Funding problems in regard to provision of this drug could have potentially fatal consequences. The provision of a liaison clinic within a dermatology department may have an important role in managing patients thought to be at risk of suicide.
BACKGROUND AND OBJECTIVE: The copper vapour laser (CVL) and the frequency doubled Nd:YAG laser (FDNYL) have been increasingly adopted as alternatives to the argon laser for treating vascular skin lesions. Automated scanning devices that permit the use of any of these lasers at 30-50 ms pulse widths are now widely used. The object of this study was to compare the CVL and FDNYL with the argon laser using pulse widths in the 30-50 ms range. STUDY DESIGN/MATERIALS AND METHODS: Thirty-one adult patients with red-purple or purple portwine stains (PWS) were treated with a CVL at 578 nm, a FDNYL at 532 nm, and an argon laser at 488/514 nm. Test areas were performed using a Hexascan delivery system and an energy fluence just sufficient to produce immediate tissue change. Pulse widths were maintained constant for each patient (mean 40 msec). The mean fluences used were 13.1 J/cm2, 13.2 J/cm2, and 13.0 J/cm2, respectively. Assessments were made after 4 months using a clinical fading score and an index of light absorbence derived from reflectance spectrophotometry. RESULTS: Fading scores were statistically significantly better with the CVL (score = 2.29) than the FDNYL (score = 1.83, P < 0.02) and the argon laser (score = 1.89, P < 0.003). The differences between the FDNYL and the argon laser were not significant. Although there was a trend toward lower light absorbence index with the CVL than the argon laser and FDNYL (scores = 177, 179 and 181, respectively), these differences were not statistically significant. CONCLUSIONS: Despite slightly better results with the CVL in terms of the fading produced, differences among the CVL, FDNYL, and argon lasers are small when 30-50 ms pulse widths are employed and are of doubtful clinical significance for darker PWS.
Dermatologic nondisease is a relatively common problem presenting to dermatologists with rich symptomatology in important body image areas such as the face, scalp, and genital area. There is no objective dermatologic change present on examination. The most common psychiatric disease present is depression. Suicide is common, especially in women with perceived facial problems.
Body dysmorphic disorder is one of the most difficult conditions to manage but a significant proportion of patients do respond to selective serotonin reuptake inhibitors. This group of drugs has helped to revolutionize the treatment of this common but disabling disorder of perceived body ugliness. The condition may affect up to 1% of the population in the United States. Patients often show obsessional features, and depression is common. Ever present is a risk of suicide in these patients.
Four patients with minocycline-induced cutaneous pigmentation were treated with the Q-switched ruby laser. The pigmentation resolved and there was no adverse effects.
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We report three patients who developed unusually aggressive squamous cell carcinomas after receiving long-term azathioprine treatment for dermatological disorders. Two patients gave a history suggestive of moderate to excessive sun exposure, and the third suffered from chronic actinic dermatitis. Hence, ultraviolet light damage may have been a significant cofactor in the development of these malignancies. Careful follow-up is necessary in patients who are taking azathioprine long term, and who have previously been excessively exposed to ultraviolet light (UVL), or in whom future exposure is likely to be excessive. We suggest that strict sun avoidance measures are followed by patients on long-term azathioprine, or that alternatives to azathioprine therapy are considered, especially in individuals inherently at risk of UVL damage, and in those already showing clinical signs of such damage.
Pyogenic granuloma, also known as lobular capillary haemangioma, is a solitary, benign vascular skin tumour. Although a single pyogenic granuloma is common, multiple eruptive pyogenic granulomas are extremely rare. We report the occurrence of multiple, eruptive pyogenic granulomas in a previously healthy 17-year-old girl. Over 200 lesions appeared spontaneously over an 8-month period. Lesions were initially treated with cryotherapy, and then with the pulsed dye laser, resulting in their complete clearance.
The copper vapour laser (CVL), emitting at 578 nm, has recently become available for treating vascular skin lesions. Its place in the management of port wine stains (PWS) requires clarification. We have compared a CVL with a pulsed tunable dye laser (PTDL; 585 nm) in 43 patients with macular, blanchable PWS. Test areas were performed with the CVL, using a Hexascan and an energy fluence just sufficient to produce immediate tissue change (mean fluence 18.2 J/cm2 and mean pulse width 50 ms). Test areas were performed with the PTDL using a 5-mm spot at 6.5 J/cm2. Assessments were made after 4 months, subjectively using a clinical fading score and objectively using an index of light absorbence derived from reflectance spectrophotometry. The fading produced by the PTDL was significantly better than the CVL, as determined by clinical assessment (mean fading scores 2.41 and 1.67, respectively, P < 0.0005) and reflectance spectrophotometry (mean absorbence index 149 and 157 respectively, P < 0.0005). These results indicate that the PTDL is the preferred treatment for most macular, blanchable PWS. However, in a proportion of lesions responses were equivalent with both lasers, and in a small proportion, the CVL produced a better response.