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A Week in My Dermatology Clinic

Dr Gillian Murphy is a consultant dermatologist and director of the national photobiology unit at Beaumont Hospital and the Mater Hospital in Dublin. 

When I was at school I wanted to be an artist. However, my father, who was a surgeon, said “no, you will do medicine,” and so I did. 

He said that I could do art in my spare time, but he failed to mention that I would not have any spare time. I became a dermatologist because I spent a year after qualifiying in Bangladesh, running a medical clinic in Saidpur, looking after patients with skin diseases such as leprosy that ruined their lives.

I’m very glad I am a dermatologist because skin disease can indeed ruin lives. There are 3,000 or so different skin diseases, hugely variable in severity and implications. Most problems can be treated, cured or managed. Mine is a happy job as most of my patients can be given a solution to their problem.

Part of a team

I work as part of a team where my wonderful secretaries (Monica in the Mater and Emma in Beaumont) organise the patients’ clinics and are the frontline for GPs and patients. I work closely with nurses with a special interest in dermatology who are hugely helpful in delivering treatments, allergy testing and imparting information to the patients. I work in both Beaumont Hospital and the Mater University Hospital with colleagues who are dedicated to their work and provide a very pleasant working atmosphere.

Monday is clinic day, with a morning and afternoon general clinic. One never knows what will come in the door, from a baby with a naevus sebaceous – a special type of birthmark – to patients more than 100 years old with various skin problems. Last week, I had the privilege of having a conversation with a man who shed a tear the day Michael Collins was killed: the only other person I know who remembered that day clearly was my father who sadly is no more.

We see people of all nationalities, too. One woman arrived in recently with minimal English but one of our nurses who is Russian saved the day by chatting fluently and knowledgeably to clarify the clinical problem. Communication is everything in medicine.

Tuesday is skin cancer day, starting with a multidisciplinary meeting between dermatology, plastic surgery, general surgery, oncology, radiotherapy and pathology. All aggressive skin cancers and melanomas are discussed at this meeting and management is agreed. This meeting is steadily getting busier and we are in dire need of a co-ordinator so if there is a smart nurse out there looking for a great job, please apply to Beaumont Hospital as we might have a position for you!

Straight after that meeting, I dash over to Beaumont Outpatients Department to a clinic where skin cancers are triaged so that no one is kept unduly waiting. I work with a team of bright young enthusiastic junior doctors who keep me on my toes. We see significant numbers of transplant patients, particularly renal transplant patients, and try to prevent them from getting skin cancer by intensive education about sun exposure. Beaumont Hospital is the National Renal Transplant Centre and the fact that patients live long enough to develop skin cancer is a testament to the success of the programme there. There are some patients attending who are more than 30 years post-transplant.

Each Tuesday we see patients with all types of skin cancer. We triage transplant patients with rapidly growing cancers within a week for surgery and if something requiring plastic surgical repair turns up, I share a joint dermatology/plastic surgery lunchtime slot with Brian Kneafsey, a plastic surgeon, who, overworked though he is, always sorts out the problem. It’s good to have obliging colleagues and a great service for the patient who gets seen on the day by the appropriate doctor.

On Tuesday afternoons, I deal with consults from the wards, and again I see all sorts of conditions. Quite a few people have turned up recently with cold sore-induced erythema multiforme – a dreadfully painful inflammatory reaction to the cold sore virus induced by sun exposure – as this is the season for it. Cellulitis is another very common nasty infection of the skin which can be very dangerous if neglected.

Allergy to hair dye has become more common due to the fashion for holiday henna tattoos as, unknown to people, there are large quantities of the chemical paraphenylene diamine in the tattoo which sensitises the person and when hair dye is used they can develop a horrid blistering reaction – enough to require hospital admission.

Drug rashes are very common in hospitalised patients and it is a challenge to work out which drug is the villain but we now have lymphocyte transformation tests, which can be very helpful in pinning down the culprit. I do all my dermatology surgery on Wednesdays. Since the economic crash, fewer people have health insurance and so the public service has absorbed huge extra numbers with fewer resources. All we can do is to ensure that all dangerous skin cancers are dealt with quickly so, as a consequence, people with less-aggressive problems are waiting. This would not be the case if we had additional resources, but in the meantime we grab all available extra spaces in theatre to try to minimise the waiting times for patients.

The nice thing about my surgery days is that the procedures are done with local anaesthesia so the patient is wide awake and we can have a great old chat and the patients don’t think about the actual procedure. And the great thing about surgery is that the problem gets solved. Thursday starts with a review of photosensitive patients. Ever since I did my training in St John’s Hospital for Skin Diseases in London, I have had a particular interest in the effects of ultraviolet radiation on the skin.

Some 20 per cent of the Irish are prone to polymorphic light eruption, which is a hugely annoying itchy bumpy rash, caused by sun exposure that wrecks many a holiday. Less common is solar urticaria, whereby within minutes the person breaks out in hives which are intensely itchy and so severe they absolutely can’t go outdoors – sunscreens often don’t work because it is not only ultraviolet radiation but visible light.

Eczema

A further dreadful problem is eczema caused by sun exposure, so severe that those who get it can feel suicidal. Sometimes doctors don’t know about these disorders and patients can go for years undiagnosed. By light testing these patients with special equipment in the national phototesting department (which I run in conjunction with medical physics in the Mater), it is possible to clarify the diagnosis and categorise the problem appropriately so patients can be treated. All patients learn to manage their problems and some who have severe photosensitivity can be desensitised so they can function normally.

There is another type of photosensitivity caused by a genetic disease called erythropoietic protoporphyria which, up until now, has been difficult to treat, but a new drug, afamelanotide, has been approved and it enables the patient to tolerate four times more light exposure. Happy days for these patients who also get a suntan as part of the effects of the drug without any exposure to the sun. Thursday afternoons is journal club and either our dermatology/pathology meeting where surgical cases are discussed or the North Leinster Dermatology meeting.

All the dermatologists north of the Liffey meet once a month to discuss patient management in complex cases. Patients come along to the meeting, which rotates around the various hospitals and get a very good service in terms of diagnosis and management issues. Friday is my favourite day. I have a busy general clinic with emergencies often added on.

The most common problems I see include psoriasis, eczema, acne and conditions such as lymphomas of the skin. The biggest problem for this clinic are the inappropriately long waiting lists. There seems no end to the demand for dermatology services. We need more nurses, more dermatologists and, in Beaumont, we absolutely need to have our phototherapy service up and running for the more than 100 people on the waiting list.

I know how beleaguered the hospital administration is but please allow me to treat my unfortunate patients with the treatment that is the best for them. We have wonderful new drugs for psoriasis coming through but they are wildly expensive and phototherapy, by comparison, is much more cost effective.

Psychological support Not all problems are easy to fix and for those finding it difficult to cope with a skin disease, we run a programme of psychological support in conjunction with the psychology department and my colleague Marina O’ Kane, which patients find immensely helpful. On Friday afternoons, I take another trip around the wards to ensure that all problems of the skin are sorted and then I have another afternoon clinic.

I also fit time into the day to prepare lectures. I was invited to speak on the subject of porphyria at the recent World Congress for Dermatology in Vancouver . I am the president of the European Society of Photodermatology and, in conjunction with the Americans, Chinese, Japanese and many other nations, am hosting a World Photodermatology Day to share discussions on the topic of photodermatology.

On Saturday I do a leisurely clinic from my rooms which suits busy people who can’t get time off work and definitely suits me too as it means I can’t do any housework. I think it proves that I love my job. My father was right, I’m glad I did medicine.

Full article appeared in The Irish Times on 19/8/15

Article by: Michelle McDonagh