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Biomedical subjects

R A Sheehan-Dare

Publications and source records attributed to R A Sheehan-Dare.

At least 19 recordsLinked to original sources
PubMed2005

An evaluation of the role of a store-and-forward teledermatology system in skin cancer diagnosis and management.

There is currently much interest in the potential role of telemedicine in improving the delivery of dermatological care in the UK. The two teledermatology systems available at present are divided into live video and store-and-forward technology. We investigated the value of a store-and-forward teledermatology system in the diagnosis and management of lesions suspicious of skin cancer. A total of 163 store-and-forward referrals of patients with one lesion each were assessed independently by a Consultant and a third-year trainee dermatologist. The accuracy of diagnosis and appropriateness of management from these assessments was compared to a subsequent face-to-face consultation with the Consultant. Analysis of the Consultants' diagnoses showed that 48% were identical for teledermatology and conventional face-to-face consultations. A further 17% of teledermatology diagnoses included the actual clinical diagnosis as a possibility but 20% were either incorrect or a diagnosis could not be made. In the remaining 15% of cases the digital image was of insufficient quality for assessment. Of the trainee's reports, 44% were identical to the clinical diagnoses and another 20% included the clinical diagnosis as a possibility. The management plan was appropriate in 55% of the total teledermatology referrals assessed by the Consultants and in 52% assessed by the trainee when compared with the conventional consultation. This study illustrates that the store-and forward type telemedicine system has limited diagnostic accuracy for skin lesions. However, our results suggest that store-and-forward teledermatology may be suitable and safe for screening out clearly benign lesions but the study casts doubt on its efficiency.

Clinical Competence↗
PubMed2004

Survey of the practices of laser users in the UK in the treatment of port wine stains.

BACKGROUND: Laser treatment for the management of port wine stains (PWS) is well established but there are some variations in practices amongst clinicians in the UK. OBJECTIVES: To identify areas of consensus and highlight issues where sufficient variation existed to warrant further debate or clinical research using a postal questionnaire survey of clinicians carrying out laser treatments for PWS in the UK. METHODS: A 29-item questionnaire was constructed regarding the laser treatment of PWS and was sent to 55 members of the British Skin Laser Study Group in 2000. The questions related to the usual clinical practice of the respondents and facilities available. RESULTS: Completed questionnaires were returned from 45 clinicians (28 dermatologists, 14 plastic surgeons, two maxillofacial surgeons and one ENT surgeon) at 36 laser centres. The following areas of consensus were identified. The majority of centres used a pulsed dye laser (PDL) for the treatment of PWS, either alone or in conjunction with a KTP laser, and medical personnel assessed and treated patients. Written information and consent was obtained in 89% of centres before starting treatment. Test areas were usually performed before embarking on a full treatment by 98% of the clinicians. The majority of respondents (84%) considered 2-3 months as the optimum interval between treatments. All the clinicians were prepared to treat patients with skin types I-IV, but skin type VI was often not treated. The vast majority of laser users treated most PWS affecting the face, neck and upper limb. The majority of clinicians used local or topical anaesthesia frequently or sometimes in the treatment of PWS and 81% of the respondents used general anaesthesia, especially when treating children. When using the PDL, 91% of respondents selected an initial fluence based on experience and/or the appearance of the skin immediately after the laser pulse. Postoperatively, most clinicians advised patients to avoid the sun, avoid injury and use an emollient. Areas of variation in practice included some centres using non-medical in conjunction with medical staff to review and treat patients. The earliest age at which the clinician thought it appropriate to treat PWS varied from newborn to 8 years old; 25% of the clinicians who treat children would treat from the age of 2-3 months old and 34% would only treat patients over 1 year old. There was considerable variation in the initial fluence selected. The usual number of treatments given to each area of the PWS varied from 3 to 16. CONCLUSIONS: This survey has demonstrated a number of areas where there appears to be a consensus of opinion about laser treatment of PWS. However, issues where there are significant variations in practice have also been identified and require further evaluation to help direct further clinical research.

Child↗
PubMed2003

Efficacy of pulsed dye laser treatment of port wine stain malformations of the lower limb.

BACKGROUND: There is relatively little information about treatment of port wine stains (PWS) of the lower limb. Few studies have specifically addressed the efficacy of pulsed dye laser (PDL) treatment of a PWS on the lower limb and there is no information on the relative efficacy at different sites on the lower limb. It has been suggested that treatment is not as successful when compared with the face and postinflammatory hyperpigmentation has been reported to be a significant problem. OBJECTIVES: To review retrospectively patients who attended for PDL treatment of PWS affecting the lower limb and assess the efficacy and adverse effects with particular reference to skin site. METHODS: A retrospective review was carried out of patients attending the Leeds Dermatology Laser Centre for treatment of a PWS on the lower limb with a 585-nm PDL. RESULTS: A total of 52 sites in 39 patients were treated: 17 on the thigh, 31 on the lower leg and four on the foot. The mean number of sessions per patient was 14, with an excellent outcome in seven treatment sites (13.5%), good in 13 (25%), moderate in 21 (40.4%) and poor outcome in 11 (21.1%). Patients were generally pleased with their results with a mean improvement of 7 on a scale of 0-10. Perifollicular persistence of the PWS was observed in six sites (11.5%). Adverse effects occurred in 36 patients (92.3%), most commonly hyperpigmentation (87%). Six patients (15.4%) developed atrophic scarring and four (10.3%) hypopigmentation. Atrophie blanche-like changes were seen in four patients on the lower leg. Hypertrophic scarring was not seen. CONCLUSIONS: Although physician-assessed good or excellent responses of 38.5% are lower than frequently reported for other skin sites and adverse effects may be more frequent, patient satisfaction with treatment was generally high. Patients with PWS on the lower limb merit a trial of PDL treatment.

Adolescent↗
PubMed2003

Prediction of outcome in the treatment of onychomycosis.

Patients with toenail onychomycosis remain a therapeutic challenge despite the introduction of new systemic therapies. Around 20% of patients remain uncured even with optimal oral therapy, but the reasons for treatment failure are unclear. Thus far there are no data to suggest that treatment failures can be identified on the basis of their presenting features or progress during treatment. In a series of patients, we have attempted to identify clinical parameters that determine the patient response to 12 weeks of oral terbinafine for confirmed dermatophyte onychomycosis. As part of a dose-defining randomized multicentre study, 35 patients were followed for 48 weeks. The unaffected nail length, growth rate, hyperkeratosis, onycholysis and presence of a dermatophytoma were assessed prospectively. To confirm our findings, at the end of the study period we analysed retrospectively photographs that had been taken regularly throughout the trial. The average degree of hyperkeratosis was less severe in the group achieving a disease-free nail, meaning clinical and mycological cure. For mycological cure alone, no predictive factors could be identified.

Administration, Oral↗
PubMed2001

Terminal hair growth after full thickness skin graft: Treatment with normal mode ruby laser.

BACKGROUND AND OBJECTIVE: Treatment of hirsutism is often unsatisfactory with many of the currently used methods providing only temporary improvement. The use of lasers for hair removal has shown promising results and treatment by using the normal mode ruby laser has provided reduction in hair numbers sustained on follow-up. We report a woman who developed terminal hair growth at the site of a full thickness skin graft and describe her successful treatment with the normal mode ruby laser.

Adult↗
PubMed2001

The use of lasers in dermatology.

There are now a range of lasers capable of effective treatment of vascular, pigmented and other skin lesions with a high degree of selectivity. Understanding the complex interactions between laser irradiation and often diverse lesion morphology is the key to determining the appropriateness of treatment.

Hair Removal↗
PubMed2000

Pulsed dye laser treatment of port-wine stains in pigmented skin.

BACKGROUND: Little information is available on pulsed dye laser treatment of darker Fitzpatrick skin types. METHODS: We retrospectively reviewed our clinical experience treating mainly facial (12/13) port-wine stains (PWSs) in 13 patients of skin type V, whose ages ranged from 3 to 65 years. RESULTS: The response was excellent in 2 patients, good or moderate in 4 each, slight in 1, and poor in 2. Hyperpigmentation occurred in 6 patients and hypopigmentation in 1, which improved despite continuing treatment. Limited atrophic scarring developed in two patients. Although these results were less good and side effects more frequent than described in skin types I to IV, 6 patients (46%) achieved a good or excellent response and 85 (87.6%) of the total 97 laser treatments were not associated with significant problems. CONCLUSION: Patients of skin type V with a PWS should not be excluded from pulsed dye laser therapy, provided that treatment expectations and risks are fully discussed.

Adolescent↗
PubMed1999

Atrophie blanche-like scarring after pulsed dye laser treatment.

Pulsed dye laser treatment is well established for the treatment of port-wine stains and other vascular skin lesions. Although hyperpigmentation is quite common, other side effects such as hypopigmentation and atrophic scarring occur infrequently, and hypertrophic scarring is rare.

Adult↗
PubMed1999

Improved response of plaque psoriasis after multiple treatments with topical 5-aminolaevulinic acid photodynamic therapy.

We investigated the clinical response of 10 patients with plaque psoriasis to multiple treatments with photodynamic therapy, using topical application of 5-aminolaevulinic acid followed by exposure to broad-band visible radiation. Treatment was performed up to 3 times per week, with a maximum of 12 treatments, using a light dose of 8 Jcm(-2) delivered at a dose-rate of 15 mW cm(-2). Eight patients showed a clinical response. Out of 19 treated sites, 4 cleared, 10 responded but did not clear and 5 showed no improvement. Of the 4 sites that cleared only 1 did so fully, after 7 treatments, 45 days after the start of therapy. Of the 10 sites that responded partially, the greatest reduction in scale, erythema and induration index occurred after a minimum of 3 and a maximum of 8 treatments. The intensity of 5-aminolaevulinic acid-induced protoporphyrin IX fluorescence, recorded prior to the first treatment, varied between sites on the same patient as well as between patients. There was also a variation in fluorescence intensity recorded from the same site immediately prior to subsequent treatments, although the pretreatment levels generally decreased as the study progressed and then increased as psoriasis relapsed. Biopsies confirmed that fluorescence was localized throughout the epidermis and stratum corneum, but the level was not consistent between sections taken within the same biopsy. We also observed fluorescence at sites distant from the ones that received 5-aminolaevulinic acid, which was not present prior to the start of the treatment programme, but found no evidence of elevated levels of plasma porphyrins. The level of discomfort associated with this therapy increased with increasing values of the calculated photodynamic dose, defined as the product of the initial photosensitizer concentration and the percentage reduction in fluorescence following irradiation. Therefore, although clinical efficacy improved with multiple treatments, unpredictable response and patient discomfort make ALA-PDT unsuitable for the treatment of psoriasis.

Administration, Topical↗
PubMed1997

Adverse reactions following pulsed tunable dye laser treatment of port wine stains in 701 patients.

The pulsed tunable dye laser (PTDL) is generally considered to have a very low incidence of adverse effects, allowing it to become the treatment of choice for the majority of port wine stains (PWS). The low incidence of adverse effects has led to difficulties in determining the true incidence and type of adverse effect seen with this laser. We therefore undertook a retrospective study of 701 patients with PWS, who received 3877 full treatments to determine the incidence and type of adverse effects seen following treatment with the PTDL. Blistering and crusting were seen in 5.9% an 0.7% of patients, respectively, but were transient events which usually healed without permanent sequelae. Hyper-pigmentation was the most frequently observed adverse effect seen in 9.1% of patients but generally showed gradual resolution over 6-12 months. Hypopigmentation was infrequent, seen in 1.4% of patients. The most significant adverse effects were atrophic and hypertrophic scarring seen in 4.3% and 0.7% of patients, respectively. Our observations show that there is a small but definite risk of atrophic scarring with a predisposition for younger patients. Hypertrophic scarring can occur albeit rarely and there may be predisposition towards the neck. In most cases test areas were not predictive of scarring. This underlines the need for a full discussion of scarring risk in patients with PWS undergoing treatment with the PTDL.

Adolescent↗
PubMed1997

The variable response of plaque psoriasis after a single treatment with topical 5-aminolaevulinic acid photodynamic therapy.

We have investigated the clinical response of 22 patients with plaque psoriasis to photodynamic therapy using topical application of 5-aminolaevulinic acid followed by a single exposure to broad-band visible radiation. Light doses in the range 2-16 J/cm2 delivered at dose of 10-40 mW/ cm2 resulted in a variable clinical response. Seven (35%) patients showed clearing of psoriasis at some treated sites. The intensity of protoporphyrin IX fluorescence was recorded before, during and after treatment. Pre-illumination fluorescence intensity varied considerably between sites on the same patient and between patients. Protoporphyrin IX fluorescence recovered and persisted after treatment for up to 14 days and became higher than preillumination levels at 25% of sites. The rate of protoporphyrin IX photo-oxidation during treatment was proportional to both initial fluorescence intensity and incident light dose rate and was almost complete after 16 J/cm2. We have defined the photodynamic dose as the product of time-dependent protoporphyrin IX concentration and light dose and demonstrated that only in those patients who showed clearance of psoriasis was there a relationship between photodynamic dose and clinical response. Discomfort ranged from stinging through to burning, was significant in some patients and tended to be more severe with increasing photodynamic dose but was not predictable. Efficacy may improve by achieving consistent protoporphyrin IX levels or by using multiple treatments.

Aminolevulinic Acid↗
PubMed1996

Are copper vapour and frequency doubled Nd:YAG lasers superior to the argon laser for portwine stains at pulse widths of 30-50 milliseconds?

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.

Absorption↗
PubMed1996

The accumulation of protoporphyrin IX in plaque psoriasis after topical application of 5-aminolevulinic acid indicates a potential for superficial photodynamic therapy.

The success reported for the treatment of superficial skin carcinomas by photodynamic therapy with topical application of the photosensitizer precursor 5-aminolevulinic acid has therapeutic implications for the treatment of other skin disorders. This paper describes the accumulation of the photosensitizing agent protoporphyrin IX in areas of plaque psoriasis by monitoring of the fluorescence emission induced by low-intensity laser excitation at 488 nm. We present results from 15 patients with a total of 42 plaques and show that the characteristic fluorescence emission of protoporphyrin IX increases in intensity within the 6-h period following application of 5-ami-nolevulinic acid, suggesting that there is a potential for superficial photodynamic therapy. The rate of increase and maximum intensity of fluorescence emission was not directly related to the applied quantity of the precursor. The variability of the fluorescence intensity was as great between plaques at different sites on the same patient as between different patients. Also, the effect of plaque occlusion following application appeared insignificant. Although there was only limited enhancement of emission from areas of skin surrounding the plaque, a significant buildup of sensitizer was detected after several days in some areas of psoriasis that received no application.

Administration, Topical↗
PubMed1996

Digital calcification in systemic sclerosis: effective treatment with good tissue preservation using the carbon dioxide laser.

Tissue calcification of the fingers associated with limited systemic sclerosis is a common problem and is the source of considerable morbidity as it may be extremely tender and cause considerable functional disability. The current treatment of digital calcification is unsatisfactory. We evaluated the use of the carbon dioxide (CO2) laser in the management of this condition in six patients with the limited form of systemic sclerosis. A total of 21 areas of symptomatic digital calcification of the fingers were treated. Complete resolution of symptoms occurred in 12, moderate response with partial improvement was seen in five, little improvement was observed in two, and recurrence of calcinosis was found in two. The patient's average healing time was 6 weeks (range 4-10). The median duration of follow-up was 20 months (range 12-40). Postoperative infection was seen in two patients, and resolved completely in both with the use of topical and oral antibiotics. We found the CO2 laser a simple and effective treatment for most of the symptomatic lesions of digital calcification, and it may obviate the need for deforming surgery in many cases.

Adult↗