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Letters
Volume 4, Issue 53, April 2024

April 2024 Correspondence


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I write in response to an article by Ediriweera et al titled ‘Acne: Unique considerations in skin of colour’ in the October 2023 issue of the Australian Journal of General Practice.1 The article featured a case study of a person of colour who presented with acne.

I do express my appreciation of the treatment of the above presentation. I have no doubt that my dermatology professor back in Nigeria would agree wholeheartedly with the approach to the management of her condition.

I do, however, want to point out one thing: Africa is a large continent of 52 countries of which Nigeria is one. Nigeria is an ethnically diverse country. A visit to the Nigerian High Commission in Canberra website states that Nigeria has 374 diverse and pure ethnic stocks/groups. Lumping them together as one group diminishes the uniqueness of each. I believe that a better way to identify this individual would be to refer to her as an African of Nigerian descent, as her ethnicity is unknown by yourselves. This avoids questions and the common Western habit of referring to Africa as a ‘country’ instead of a continent and, thus, her various countries as ethnicities.

Thank you for indulging me.

Author

Folasomi C Omowo MBBS, FRACGP, General Practitioner, Swan View Family Practice, Perth, WA

Competing interests: None.
Reference
  1. Ediriweera S, Gan C, Rodrigues M. Acne: Unique considerations in skin of colour. Aust J Gen Pract 2023;52(10):669–71. doi: 10.31128/AJGP-02-23-6720.

Reply

We write in reply to the letter that was submitted in response to our case study ‘Acne: Unique considerations in skin of colour’ in the October 2023 issue of the Australian Journal of General Practice.

Thank you for your engagement with the article and for your valuable input.

The point that there are numerous unique ethnic groups in Nigeria is indeed consistent with what is reported by the Nigerian High Commission in Canberra website and in other resources that describe the demography of ethnicity in Nigeria.1,2 Moreover, using accurate and appropriate wording to describe the ethnicity of individuals in research and literature can be complex but is important.3

We are in agreeance with the writer and acknowledge that it would have been more appropriate to describe the individual in our case study as an African of Nigerian descent.

Authors

Subhashi Ediriweera BBiomedSci, Melbourne Medical School, The University of Melbourne, Melbourne, Vic

Christian Gan BMedSci, MD, Honorary Dermatology Resident, Department of Dermatology, The Royal Children’s Hospital, Melbourne, Vic; Dermatology Resident, Department of Dermatology, St Vincent’s Hospital Melbourne, Melbourne, Vic

Michelle Rodrigues MBBS (Hons), FACD, Consultant Dermatologist, Department of Dermatology, The Royal Children’s Hospital, Melbourne, Vic; Honorary Senior Lecturer, Department of Paediatrics, The University of Melbourne, Melbourne, Vic; Founder, Dermatologist, Chroma Dermatology, Pigment and Skin of Colour Centre, Melbourne, Vic

Competing interests: MR has received honoraria for lectures and/or is a consultant for AbbVie, Sanofi, Pfizer and Bristol Myers Squibb (BMS); is on the BMS Advisory Board, as well as Medical Advisory Boards for BMS and the Global Vitiligo Foundation, the Communications Committee for the Global Vitiligo Foundation and National and International Committees for the Skin of Colour Society; is the Secretary General of the Asian Society for Pigment Cell Research and on the Council of the Vitiligo Association of Australia; and is Patron and Chair of the Dermatology Society for Undergraduates. SE and CG have no conflicts of interest to disclose.

References
  1. Reed HE, Mberu BU. Ethnicity, religion, and demographic behavior in Nigeria. In: Sáenz R, Embrick D, Rodríguez N, editors. The international handbook of the demography of race and ethnicity. Dordrecht: Springer, 2015; p. 419–54.
  2. Nigeria High Commission – Canberra. About Nigeria. Nigeria High Commission – Canberra, 2021. Available at https://nigeria-can.org.au/nigeria/ [Accessed 18 December 2023].
  3. Flanagin A, Frey T, Christiansen SL; AMA Manual of Style Committee. Updated guidance on the reporting of race and ethnicity in medical and science journals. JAMA 2021;326(7):621–27. doi:10.1001/jama.2021.13304.

Screening for carotid artery stenosis in spouses of patients undergoing carotid endarterectomy

Rohan Arasu et al1 provided a well-conducted study of carotid artery stenosis and approaches for its diagnosis and management. As stated in the study, atherosclerosis is a systemic chronic arterial disease characterised by the buildup of cholesterol, lipid and calcium deposits within artery walls. Several risk factors, such as a high cholesterol diet, hypertension, tobacco smoke exposure, diabetes mellitus, obesity and a sedentary lifestyle, can be managed effectively to delay or prevent the onset of atherosclerosis.

Residing in a household with an individual with carotid artery stenosis and adhering to a comparable dietary regimen, being exposed to either active or passive tobacco smoke, or engaging in similar sedentary lifestyle practices can heighten one’s vulnerability to atherosclerosis. The spouses of 44 patients who underwent carotid artery endarterectomy at our clinic between 2019 and 2023 were screened with colour Doppler ultrasound for probable carotid artery stenosis or plaque presence. Among the 44 spouses, 13 (29.5%) had at least 2 mm of soft or mixed plaque at the carotid bifurication. In the Doppler ultrasound scan of a woman aged 73 years whose spouse underwent coronary artery bypass graft surgery and carotid endarterectomy, a mixed plaque was observed in the proximal left internal carotid artery, measuring up to 3.2 mm at its widest part and causing a significant stenosis of 50–69%. Catheter angiography for diagnosis of coronary and cartoris artery stenosis was scheduled. The angiography revealed 90% stenosis in the proximal region of the left internal carotid artery, and endarterectomy was performed (Figures 1,2). Based on Doppler ultrasound screenings, 16 individuals commenced antiplatelet monotherapy because of carotid artery stenosis and plaque.


Figure 1. Ninety per cent stenosis in the proximal left internal carotid artery (red arrow). Figure 2. Removed plaque.

Figure 1. Ninety per cent stenosis in the proximal left internal carotid artery (red arrow).

ECA, external carotid artery; ICA, internal carotid artery.

Figure 2. Removed plaque.


In our opinion, Doppler ultrasound screening of the spouses of patients who have undergone carotid endarterectomy, have shared a similar sedentary lifestyle and diet, and have lived in the same residence for many years is crucial for the timely detection and management of asymptomatic carotid artery stenosis.

Authors

Yasin Kılıç MD, Attending Surgeon, Ataturk University Hospital Department of Cardiovascular Surgery, Erzurum, Turkey

Izatullah Jalalzai MD, Chief Resident, Ataturk University Hospital Department of Cardiovascular Surgery, Erzurum, Turkey

Ebubekir Sönmez, Resident, Ataturk University Hospital Department Of Cardiovascular Surgery, Erzurum, Turkey

Bilgehan Erkut, Chief Physician, Ataturk University Hospital Department Of Cardiovascular Surgery, Erzurum, Turkey

Competing interests: None.

Reference
  1. Arasu R, Arasu A, Muller J. Carotid artery stenosis: An approach to its diagnosis and management. Aust J Gen Pract 2021;50(11):821–25. doi: 10.31128/AJGP-10-20-5664.

Research letter

Patient experience survey of people living with Hailey-Hailey disease

Hailey-Hailey disease (HHD) is a rare, inherited, chronic blistering disorder that causes fissuring and erosions, with an estimated prevalence of 1:50,000.1 Treatment is often challenging, with current evidence limited to case series and no published treatment guidelines available.

The purpose of this survey was to describe the experience of South Australians living with HHD and increase awareness of HHD in the general practice community.

An online survey was completed by people living with HHD. Recruitment was conducted via public and private dermatology clinics and online patient support groups between February and May 2023. Categorical, free-text and EuroQol-visual analogue scale (EQ-VAS) questions were posed to participants,2 who were asked to provide a global assessment of their health. Scores ranged between 0 (worst imaginable health) and 100 (best imaginable health).

Of the 17 participants, 76.5% were women (n=13); 70.6% of participants were over 30 years of age, with the most common age group being 51–60 years (35.3%). Among the participants, 94.1% were diagnosed with HHD by a dermatologist, with 88.2% having symptoms for over one year prior to diagnosis and 29.4% experiencing symptoms for over five years. All respondents had tried multiple treatments for HHD, with a mean of six treatments attempted (range 2–15). Low-dose naltrexone was most commonly cited as an effective treatment (by 29.4% of respondents). The mean EQ-VAS score was 26.8 (median 20). In the free-text section, ‘lack of awareness and research’ within the medical community and ‘pain’ were cited as significant issues by 35.3% and 11.8% of respondents, respectively (see Box 1).

Box 1. Illustrative quotes

Lack of awareness and research

Lack of GP knowledge is a major problem that especially impacts access to assistance in between dermatologist appointments.

It’s not fair that most doctors could not care less about this disease. They don’t even know about it.

Feel disheartened there is not much research out there.

Someone please find something that will keep this curse at bay.

Pain

It’s got to be the worst disease out here. I’ve never experienced so much pain.

It can be painful and embarrassing. I hope it doesn’t get as bad as my mom has it.

GP, general practitioner.

Our study supports the small amount of available evidence highlighting the pain and quality of life effects experienced by people living with HHD.3 The median EQ-VAS score in a systematic review of psoriasis studies was 65.1,4 compared to 26.8 in this study. The descriptions of pain experienced by the respondents in the present study highlight its frequency in dermatological conditions; in a study by Misery et al, skin pain was reported by 36% of respondents.5 The poor awareness of HHD is corroborated by the prolonged delay in diagnosis, with 30% of participants reporting symptoms for five years prior to diagnosis, coupled with the free-text responses. Although the sample size is small, this study represents approximately 50% of South Australians living with HHD. This study has identified areas of improvement – namely further research for effective treatment and dissemination of information on HHD diagnosis and treatment for general practitioners. Further research is clearly needed. This study is a pilot with the goal to extend to other Australian states and develop an HHD registry.

Authors

Lucinda Adams MBBS, Medical Registrar, Department of Medicine, Alice Springs Hospital, Alice Springs, NT

Hoang Ly MBBS, FACD, Head of Department, Department of Dermatology, Flinders Medical Centre, Adelaide, SA

Competing interests: None.

References
  1. Rogner DF, Lammer J, Zink A, Hamm H. Darier and Hailey-Hailey disease: Update 2021. J Dtsch Dermatol Ges 2021;19(10):1478–501. doi: 10.1111/ddg.14619.
  2. Lin DY, Cheok TS, Kaambwa B, et al. Evaluation of the EQ-5D-5L, EQ-VAS stand-alone component and Oxford knee score in the Australian knee arthroplasty population utilising minimally important difference, concurrent validity, predictive validity and responsiveness. Health Qual Life Outcomes 2023;21(1):41. doi: 10.1186/s12955-023-02126-w.
  3. Gisondi P, Sampogna F, Annessi G, Girolomoni G, Abeni D. Severe impairment of quality of life in Hailey-Hailey disease. Acta Derm Venereol 2005;85(2):132–35. doi: 10.1080/00015550410025462.
  4. Møller AH, Erntoft S, Vinding GR, Jemec GB. A systematic literature review to compare quality of life in psoriasis with other chronic diseases using EQ-5D-derived utility values. Patient Relat Outcome Meas 2015;6:167–77. doi: 10.2147/PROM.S81428.
  5. Misery L, Saint Aroman M, Zkik A, et al. Chronic pain in patients with skin disorders. Acta Derm Venereol 2017;97(8):986–88. doi: 10.2340/00015555-2694.
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