A CPD Gateway Talk by Mr Manu Mehra.

manu.mehra@nhs.net

We spend a lot of time touching people’s skin.  But we’re mostly concerned with what’s going on underneath it.    As osteopaths it is not explicitly our responsibility to be checking for cancer or diagnosing fungal infections, but people have all sorts of lumps and bumps and it seems a waste of an opportunity if we get access to all this skin but can’t spot something that the patient might have missed and raise the alarm.

This particular talk was requested by people who had attended other CPD Gateway talks, which are mostly attended by manual therapists.    CPD Gateway put on evening lectures that last about 2 hours, given by experienced and personable medical people such as consultants or surgeons.  They are usually held in hotels, and they are civilized affairs, complete with egg sandwiches, jugs of coffee, slides, an undemanding pace and time for questions at the end.   I have found them valuable for finding out about what goes on in the medical consulting rooms and operating theatres that we normally only hear about second hand from patients.

I often find osteopathy or physiotherapy lectures vague, densely intellectual and sometimes hard to relate to practice.  Medicine, funnily enough, comes across as more simple and straightforward.  This was a talk that felt deceptively light and easy to follow, but contained heaps of interesting tips and information that Manu Mehra has gleaned from his years of experience in dermatology and minor surgery.  In the first half of the talk, he led us through some common conditions we might see on a patient:  eczema, psoriasis, vitiligo, impetigo, cold sores, scabies, athlete’s foot and verrucae.  Mmm, lovely…

We play our part helping with eczema, indirectly, in part, says a doctor

I always suspect that doctors regard me as some sort of charlatan or wannabe doctor  (it’s the Ernst effect), so it was gratifying to hear Mr Mehra discuss the role that stress plays in eczema flare ups, and tell us that in our own way, by touching and treating the patient, and thereby de-stressing them, we play a part in helping with eczema.  Someone phone the ASA right now.

A few handy tips for treating patients with eczema, or psoriasis

• He told us that if patients think that eczema is aggravated by our creams and oils, it’s likely that it’s just the rubbing that’s affecting them rather than our oils – but ask them to bring their diprobase or other cream in and use that for massage instead.
• BE SEEN to wash your hands.  The patient wants to see that.
• Acknowledge the condition discretely and respectfully, and check if it is sore or if they’re happy for it to be touched

What causes eczema?

Eczema is often genetic and is immune -based.  It “comes from within”, was his very zen way of putting it.  Less than 1 in 10 children have eczema which is triggered by a food allergy, and this is much less in adults.  And food allergy does not CAUSE eczema. Known irritant triggers are

1. swimming pool water
2. the weave of fabric (i.e. nothing to do with it being natural or synthetic, just the size of the weave, fancy that!)
3. central heating.

If patients have been to a naturopath who has suggested a food is the problem, he simply recommends that it is cut our for 6 weeks and a food diary is kept.  He doesn’t dismiss the idea.  However, he says he has rarely seen this proved in practice, and reckons that if you have an allergy which triggers eczema it will be very obvious and you will get other symptoms too – like an itchy mouth etc.

Psoriasis

Don’t know much about what causes psoriasis?  Don’t worry.  No one does.  I just love it when I hear this, and I realise it’s not just that I missed a lecture somewhere along the way.  Psoriasis affects about 2-3% of the UK population, runs in families, is worse with excessive alcohol, cigarette smoking and obesity, and there is associated arthropathy in 5% cases.

Vitiligo

We then saw an incredible image of a model called Winnie Harlow who has vitiligo.  Be entranced by more mesmerising images of her here.  There is very little you can do for vitiligo, which is another autoimmune condition.  (The link between skin and immunity, if you’re unclear, is that under threat the immune system is preparing itself to right infection in case there is a wound or physical stress.)  You can try topical steroid therapy or ultraviolet light treatment for vitiligo, but often camouflage and acceptance are all that can be done.

Good news:  It’s quite hard to catch a skin infection

We looked at a few less-than-charming photos of cold sores, impetigo and scabies.     Although we might instinctively keep a healthy distance from obvious skin conditions, you do need wetness to catch things dermatologically.  You can catch impetigo if you take a wet finger, rub it in the impetigo, then rub it on your skin.  A verucca needs a magic combination of wet floor and microscopic cuts.

Acne

Acne remains pretty common, even through to middle age.  Systemic treatments are something dermatologists offer if safe to do so.  As a sobering aside – he told us that the number one skin disease causing suicide is scarring from acne on the shoulders and upper back of young men. You wouldn’t have guessed that, I bet.

SO CAN YOU SPOT SKIN CANCER?

There are, briefly, three common types of skin cancer:  one really bad, one medium bad, and one not nearly as bad as the other two.  Melanoma is the one you hear about a lot because it is the most dangerous.  Out of about 14 500 cases diagnosed per year ,  there are about 2,000 deaths.  The other sorts are BCC (basal cell carcinoma) which is the most common and least dangerous, and SCC (squamous cell carcinoma) which causes about 640 deaths out of 10,000 cases a year and is more urgent but not as urgent as melanoma.

GPs are under more pressure to spot cancers these days, and so they are referring any skin lesions on in case they have missed one.  However they have hardly any specific training, and speaking from bitter experience they have a long way to go.  I have had the same BCC misdiagnosed by four different GPs over an 8 year period.  I was confidently told it was  1) a wart, 2) infected psoriasis, 3) eczema and 4) “I’m not really sure what it is but I can reassure you that it’s definitely not cancer.”  Luckily, there’s a private skin clinic down the road, I had the necessary £130 to have it diagnosed by a dermatologist in about 1 second, and BCCs are very slow growing and never spread beyond the skin.  My GP surgery now has a system in place where they send a photo of anything they are unsure of to a dermatologist who tells them if they need to refer.  And just for the record, it’s not only sun-worshippers who get skin cancer.  Immuno-suppressed people get it too (as Mr Mehra reminded us, we are all throwing off cancers all the time).  And people like me, who can think of few more unpleasant ways of spending a day than lying around in the sun, but who grew up in Australia in the days when sun cream came in factors 2 or 4, you only put it on at the beach,  and you had ghost-pale, Irish skin more suited to the rays of the moon.

We looked at some pictures then, to see what the three different cancers looked like, and saw how they demonstrated the ABCD features (Asymmetry, Border irregularity, more than one shade of Colour, and Diameter), although you can discount diameter and just think ABC as some cancers are actually tinier than the 7mm specified by the D.  Mr Mehra interestingly talked about nature as having order, and growing in a demonstrably ordered way.  Cancers are often distinctive in that they look disordered in the way they grow.  You can also look at an area of pigmented lesions on the skin, and if you spot an “ugly duckling”, i.e. one that just looks different and a bit wrong, that is probably good enough to suggest they have it checked out too.

Don’t try to diagnose specific lesions 

Just when it seemed that we could have a stab at  recognising them, we were totally thrown by more pictures showing the many morphological subtypes.  Take it from me, you only have to spend 3 days compulsively googling “skin cancer images”, while you’re waiting for your histology results to come back, to realise just how many different forms it can take.  In a recent audit, Mr Mehra had an impressive clinical accuracy of 87% for SCCs; whereas the GPs studied had a clinical accuracy of 17%.  So nobody would expect us to identify specific cancers.  But if you do spot something odd, probably a solitary nodule, maybe with a scab or crust,  ask the appropriate questions (new?, changing?, bleeding?, fair skin?, sun exposure?, history of peeling?, ever had blistering sunburn?) and send them off to the GP to be on the safe side.

I emerged from this talk with much more confidence and incentive to look at people’s skin as part of my care for my patients.  I would recommend it if it comes on again.  It’s given me another small but important way I can be of service to my patients.

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If you want to refer a patient to Mr Mehra for a mole check or minor operation, he has a private clinic at

55 Carshalton Road

Sutton

Surrey

SM1 4LH

Tel:  020 8395 7985

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Many thanks to Mr Manu Mehra for taking the time and trouble to check this piece and make the many corrections and alterations necessary to ensure that it is accurate.