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Read the latest articles relevant to your clinical practice, including exclusive insights from Healthed surveys and polls.

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Sophia Auld
  • Clinical Articles

Managing problematic behaviour in dementia

Nearly four in ten Australian aged care residents are prescribed an antipsychotic, despite the fact they often don’t work, have serious adverse effects, and are only recommended for managing dementia-related behaviours when other strategies have failed...

By Sophia Auld
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Clinical A/Prof Pradeep Jayasuriya
  • Clinical Articles

IV iron rapid push instead of infusion

The industry is promoting injecting undiluted IV iron, but is it safe and is it worth the risk?

By Clinical A/Prof Pradeep Jayasuriya
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Dr Jane Nankervis
  • Clinical Articles

Eczema – More Than Just an Itchy Rash

Eczema (eczematous inflammation) is the most common inflammatory disease of skin. These rashes are itchy and recognised by erythema, scale and vesicles, but can have secondary changes of infection, irritation or scratching. The term “dermatitis” is a broader, non-specific term which is not synonymous with eczema. There are three stages of evolution (acute, subacute and chronic) and numerous presentations depending on stage, age and aetiology. Histologically, the eczematous inflammatory processes have in common the spongiotic tissue reaction. Spongiosis refers to intra-epidermal oedema which resembles sponge.

Stages of eczema

Acute eczema

Clinical: Red, swollen, pebbly plaques. History of contact with specific allergen or chemicals. For the id reaction, the vesicles will occur at distant sites. Histology: Spongiosis, spongiotic vesiculation, intercellular oedema, perivascular dermal inflammation and occasional eosinophils.

Subacute eczema

Clinical: red, scaly lesions with indistinct borders, which may resemble psoriasis or fungal infections. Any allergic contact, asteatotic, atopic, nappy-related, chemical exposure, irritant contact, nummular, perioral-lick or stasis dermatitis may present this way. Histology: Less spongiosis and exocytosis (presence in the epidermis) of lymphocytes than acute form, and thickening (acanthosis) of the epidermis which may become psoriasiform. Parakeratosis, perivascular dermal inflammation and oedema are also present.

Chronic eczema

Clinical: Thick skin, skin lines accentuated (lichenified), fissures and excoriations. Caused by irritation of any subacute form, or appearing as lichen simplex chronicus. If the lichen simplex chronicus forms a local lump it is referred to as a prurigo nodularis. Histology: Hyperkeratosis, psoriasiform thickening of the epidermis, mild spongiosis, dermal mast cells and eosinophils. Lichen simplex chronicus will show marked hyperkeratosis, hypergranulosis, long epidermal ridges and vertical streaking of collagen in the dermis. Prurigo nodularis has thick, possibly excoriated, hyperkeratotic epidermis and marked dermal fibrosis and inflammation.

Specific types of eczema

Atopic dermatitis (atopic eczema)

Atopic dermatitis is an itchy, chronic relapsing skin disease which often start in childhood. There is a personal or family history of dry skin, eczema, hay fever, asthma and elevated serum IgE levels. There are essential and important clinical criteria, and the diagnosis requires exclusion of other conditions (e.g. scabies, contact dermatitis, psoriasis, photosensitive dermatosis). The pathogenesis and aetiology are not entirely clear and the disease is increasing in frequency.

Nummular dermatitis (discoid eczema)

Clinical: A chronic disorder of adults, of unknown aetiology, not related to atopy, but possibly to dry skin. Papules and papulovesicles coalesce to form nummular plaques 1-4 cm in diameter with oozing, crust, and scale. They are paler and les scaly than psoriasis. Most common sites of involvement are upper extremities, including the dorsal hands in women, and the lower extremities in men. Histology: Varies with duration. Spongiosis with mild acanthosis and exocytosis of inflammatory cells in earlier lesions. With time, the degree of acanthosis (thickening) increases. Additional features include scale-crust formation above the thickened epidermis and dermal perivascular inflammatory infiltrate.

Contact dermatitis

The substance could be an irritant or an allergen. Irritant (e.g. concentrated solvents, soaps) will cause a non-immunological reaction in any exposed person. Allergic reactions will occur in predisposed people on the basis of a delayed hypersensitivity reaction to a substance at low concentration and evolves rapidly at the site once sensitised. Occupational contact dermatitis is common and may be of irritant or allergenic (or both) types.

Irritant contact dermatitis

Commonly provoked by environmental substance e.g. contact with water, detergents and other chemicals where the epidermal barrier is compromised, and subsequently occurs most commonly on the hands, but any site where external stimuli could be suspected. Histology: Mild spongiosis, epidermal cell (keratinocyte) necrosis, and neutrophilic infiltration of the epidermis.

Allergic contact dermatitis

Clinical: Exposure to, and absorption of an antigen through skin. Most allergens are weak and there may be repeated exposure before sensitisation. The shape and location of the rash are the best clues. Histology: Subacute, chronic dermatitis or acute dermatitis may be seen. The dermal inflammatory infiltrate predominately contains lymphocytes and other mononuclear cells. Occasional atypical T-cell infiltrates may simulate mycosis fungoides.

Stasis dermatitis

Clinical: Occurring on the legs where venous drainage is impaired. However, most patients with venous insufficiency do not develop dermatitis. Unfortunately, topical medicines used in this situation seem to have many potential sensitising agents. Histology: Mild spongiosis, foci of parakeratosis and scale crust. Dermal changes are prominent with neovascularisation, haemosiderin deposition and varying degrees of fibrosis (depending on chronicity) and there is often ulceration.

Seborrhoeic dermatitis

Seborrhoeic dermatitis is a common and chronic disease which most commonly occurs on the scalp and face secondary to toxic substances produced by yeasts (malassezia), but with genetic and environmental factors contributing. Histology: Spongiosis at the side of a hair follicle, often with overlying scale crust, which may be acute, subacute or chronic depending on the lesion biopsied. Neutrophils within the epidermis or stratum corneum requires a search for yeast on a PAS stain. More chronic lesions show progressive psoriasiform hyperplasia of the epidermis with less spongiosis. Mild oedema of the papillary dermis with a mild superficial perivascular infiltrate of lymphocytes, histiocytes and neutrophils.

Asteatotic eczema

Asteototic eczema develops as the result of very dry skin. It is most common in the elderly and on the lower limbs. Histology: Usually a mild subacute spongiotic dermatitis. Compact and irregular stratum corneum. Id reaction Clinical: ‘Autoeczematisation’: generalised eczema in response to a localised dermatosis or infection at a distant site. Can be a pompholyx-like reaction affecting hands or more generalised papular eruption. Will resolve when the acute initiating process is controlled. Histology: Mimics that of the initial localised dermatosis or shows a spongiotic reaction with varied intensity. Mild dermal oedema and lymphocytic infiltration are seen. References: Thomas Habif, Clinical Dermatology 6th edition 2016, Elsevier, chapters 3-5 Weedon’s Skin Pathology, 4th edition, editor James W Paterson, Churchill Livingstone Elsevier A.Bernard Ackerman, Histological Diagnosis of Inflammatory Skin Diseases, 2nd edition, Williams & Wilkins Dermnet skin disease atlas at dermnet.com and Dermnet NZ online at dermnet.nz.org
General Practice Pathology is a new regular column each authored by an Australian expert pathologist on a topic of particular relevance and interest to practising GPs. The authors provide this editorial, free of charge as part of an educational initiative developed and coordinated by Sonic Pathology.
By Dr Jane Nankervis
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Dr Linda Calabresi
  • Clinical Articles

The Gut Microbiome – Fad or The Future?

Which bacteria are colonising your gut is becoming increasingly important, Australian researchers say. More and more evidence is suggesting the gut microbiota has a significant role in both the cause and the cure of a wide range of gastrointestinal and hepatic diseases and conditions. According to a review in The Medical Journal of Australia, research shows that particular types of bacteria colonising the gut have been associated the development of inflammatory bowel disease (IBD), metabolic syndrome, non-alcoholic fatty liver disease (NAFLD), non-alcoholic steato-hepatitis (NASH), obesity and diabetes. We know that the bowel starts to be colonised by bacteria in utero. The make-up of an individual’s gut microbiota then depends on factors such as mode of delivery, breast-feeding, diet, illness and exposure to antibiotics. By the age of three, the gut microbiota resembles that of an adult. Observational studies have suggested a strong association between alterations in the microbiota because of environmental factors, and an increased risk of diseases. For instance, IBD was very rare in traditional Chinese populations, but studies have shown exposure to Western diets and medicines from a young age has increased the prevalence of this disease. “Asian adults who migrate from countries of low prevalence to countries of high prevalence do not have an increased risk of developing IBD, but their children experience the IBD incidence of their new country of residence,” the review authors said. Stronger evidence comes from studies into the exact nature of bacteria colonising the gut. It appears both the specific bacteria and the diversity of bacteria are important in disease pathogenesis. “For example, the presence of Proteus species at the time of Crohn’s disease resection is associated with early disease recurrence, while the presence of Faecalibacterium prauznitzii is protective against recurrence,” they said. Researchers have also found significant differences in the microbiota of people who develop severe alcoholic hepatitis and those who maintain normal hepatic function despite drinking the same amount of alcohol. Most importantly in the investigation of the role of the gut microbiota, is the emerging evidence that by altering the bacterial colonies in the gut we can alter the course of the disease. The classic example of this, of course, was the discovery of Helicobacter Pylori as the cause of peptic ulcer disease with treatment of this, dramatically changing health outcomes. But since then a lot of the research focus has been on faecal microbiota transplants (or poo transplants as they are commonly known). Mice studies have shown that a mouse will become fat if given a transplant of faecal bacteria from a fat donor mouse. Similarly, a similar result has been shown in a single trial of FMT from lean to obese humans, lowering triglyceride levels and increasing insulin sensitivity. FMT has also been shown to be an effective therapy for recurrent C.difficile infection and in active ulcerative colitis. And while the application of FMT as a treatment continues to be explored, investigators are also looking at how the microbiota can be changed through dietary means and how this can be used therapeutically. While probiotics have not been shown to be effective in the majority of inflammatory diseases, an anti-inflammatory diet combined with liquid formulated enteral nutrition has shown some success in Crohn’s disease. In short, the review authors suggest that the current interest in the gut microbiome is justified and has the potential to provide important therapeutic options in the future. “Microbial manipulation is an effective therapy, likely to have broadening implications,” they concluded.   Reference White LS, Van den Bogaerde J & Kamm M. The gut microbiota: cause and cure of gut diseases. Med J Aust. 2018 Oct 1; 209(7): 312-16. Available from: https://www.mja.com.au/journal/2018/209/7/gut-microbiota-cause-and-cure-gut-diseases doi: 10.5694/mja17.01067

By Dr Linda Calabresi
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Dr Linda Calabresi
  • Clinical Articles

Alcohol – the ignored breast cancer risk factor

Drinking alcohol has been proven to increase the risk of developing breast cancer in over 100 studies, but both the general public and health professionals continue to ignore the issue. According to UK researchers, alcohol use is now estimated to be a major causative factor in between 5% to 11% of all breast cancer cases, but in their study, published in BMJ Open, less than one in five women attending a mammogram knew of the risk of alcohol, and – perhaps more worrying – less than half of the staff at the breast centre identified alcohol as a breast cancer risk factor. The mixed methodology study included over 200 woman attending a breast clinic for breast imaging – about half were symptomatic and the other half presented just for routine screening. These woman were surveyed along with over 30 staff. Following the survey a series of focus groups were conducted with both the women and the staff. Looking at different risk factors, almost one third of all participants identified obesity as a risk, and almost half recognised smoking as problematic. But alcohol? Only 16% in the screening group and 23% in the symptomatic group knew of any association between alcohol and breast cancer. “The study confirms that knowledge of alcohol as a modifiable risk factor for breast cancer is low,” the study authors said. The survey and focus groups also showed that many women did not know how much alcohol was in a standard drink such as a pint of beer or a glass of wine. So, as the authors point out, the dilemma is how will we ever modify this modifiable risk factor if people don’t even know about it and are unaware how to even assess their own alcohol consumption. The researchers suggest that the routine mammogram represents an ideal opportunity to intervene. Here is the time and the place where breast cancer will be front of mind – here is the time and place to increase awareness of alcohol as a breast cancer risk factors, assess a woman’s current alcohol consumption and suggest ways and means of reducing this if appropriate. Concerns that incorporating such a preventative strategy into a routine breast screening appointment might deter women from attending, appeared unfounded, the study noted. “Many women participating in this study reacted positively to the suggestion of adding information on cancer prevention, in general, to . . . breast screening or clinic attendances, although there was ambivalence by staff delivering it,” the researchers said. This ambivalence appeared to stem from a degree of uncertainty in relation to cancer risk factors, a lack of time available to discuss these issues with patients and a sense that it wasn’t their role to be providing this intervention. The other major barrier to conducting these assessments and implementing these preventative measures is motivation. In this study, two thirds of all participants drank alcohol. This is fairly representative of the population as a whole, with previous UK research showing that almost 80% of women had drunk alcohol in the past year, and more than one fifth of women aged 45 to 64 drank more than two standard drinks a day on average. “Home drinking is an embedded social practice, which may be resistant to change, and this normalisation of alcohol use by health professionals may account for some of the ambivalence they have to discuss alcohol consumption as a risk factor for breast cancer with patients,” they said. But this needs to change. There is plenty of evidence that alcohol brief interventions can be effective in reducing alcohol consumption. In fact the authors say, simply answering questions on alcohol consumption can result in behaviour change. “It is interesting to note that while it has become routine practice to assess patients in breast clinics for a possible inherited susceptibility to breast cancer and refer on for family history or genetics investigation, there is currently no equivalent pathway for patients who have potentially modifiable lifestyle risk factors, including alcohol use,” the researchers said.   Reference Sinclair J, McCann M, Sheldon E, Gordon I, Brierley-Jones L, Copson E. The acceptability of addressing alcohol consumption as a modifiable risk factor for breast cancer: a mixed method study within breast screening services and symptomatic breast clinics. BMJ open 2019 Jun 17; 9(6): e027371. DOI: 10.1136/bmjopen-2018-027371

By Dr Linda Calabresi
Better eating improves depression in young people
Dr Linda Calabresi
  • Clinical Articles

Better eating improves depression in young people

Improving a young person’s diet might be the key to helping them overcome their depressive symptoms, according to new Australian research. In a randomised controlled trial of just over 100 people with elevated levels of depression symptoms and a regular diet that was assessed as poor, researchers found that those allocated to the ‘diet change’ group, on average improved to the point of having no clinically significant symptoms after just three weeks. This was in stark contrast to the ‘habitual diet control group’ who unsurprisingly, showed no improvement in symptoms over the duration of the study.

By Dr Linda Calabresi
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Dr Linda Calabresi
  • Clinical Articles

Digital therapy effective for ADHD

It seems like the perfect solution doesn’t it? An effective therapy for children with ADHD that doesn’t involve drugs. Well, according to a randomised controlled trial just published in The Lancet, US researchers may have made an important step towards finding just that.

By Dr Linda Calabresi
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Dr Linda Calabresi
  • Clinical Articles

Infant sleep problems can signal future emotional issues

Babies with severe sleep problems are more likely to have anxiety issues as they grow up, Australian researchers say. That’s the rather depressing conclusion following the prospective Maternal Health Study, that looked at almost 1500 mother-baby pairs from 15 weeks gestation to when the child turned 10.

By Dr Linda Calabresi
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A/Prof Suzanne Nielsen
  • Clinical Articles

New opioid restrictions now in place

Opioids are strong medicines used for pain. The new rules – including reducing pack sizes and restrictions around prescribing – are part of a range of changes planned for prescription opioid medicines to be phased in over the next year or so.

By A/Prof Suzanne Nielsen
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Dr Linda Calabresi
  • Clinical Articles

Probiotics in clinical practice

Probiotics can be used to support a healthy immune system, reducing the incidence and severity of infections, in particular respiratory tract infections.

By Dr Linda Calabresi
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Dr Linda Calabresi
  • Clinical Articles

Final word on menopausal hormone therapy?

By Dr Linda Calabresi
Medical,Technology,,Doctor,Use,Ai,Robots,For,Diagnosis,,Care,,And
Dr Linda Calabresi
  • Clinical Articles

Taking Vitamin D to prevent COVID-19

By Dr Linda Calabresi

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