Examination of Witnesses (Questions 583-599)
28 FEBRUARY 2007
MRS MARGARET
COX, PROFESSOR
DAVID GAWKRODGER,
DR CLIVE
GRATTAN AND
DR SHUAIB
NASSER
Q583 Chairman: May I thank you for coming
today to give evidence to this sub-committee of the Science and
Technology Select Committee. The proceedings will be webcast today.
I am Lady Finlay and I chair this Committee. All members of the
Committee have declared their interests on a separate document,
so we will not be going through a declaration of interests in
relation to different questions today. I would like to begin by
asking you if you would introduce yourselves to the Committee
and then we will proceed with our questioning. It would be very
helpful if you would make sure that you do speak up because, even
though there are microphones, the acoustics in this room are not
always the easiest. So, if you could speak clearly, that would
be much appreciated. Let us begin with you, Professor Gawkrodger.
Professor Gawkrodger: My name is David
Gawkrodger and I a consultant dermatologist in Sheffield and Honorary
Professor of Dermatology. I have been the President of the British
Contact Dermatitis Society. I have an interest in contact dermatitis
and occupational skin problems. I am also the Treasurer of the
British Association of Dermatologists.
Mrs Cox: I am Margaret Cox and I am the
Chief Executive of the National Eczema Society, a registered charity
which exists to support people who have eczema. I also have eczema
myself.
Dr Nasser: I am Shuaib Nasser and I am
a consultant allergist in Cambridge and I am a full-time NHS consultant
at Addenbrooke's Hospital. I am also the Chairman of the Standards
of Care Committee of the British Society for Allergy and Clinical
Immunology. My interest is in all aspects of allergy and asthma.
Dr Grattan: I am Clive Grattan and I
am a consultant dermatologist. My base hospital is the Norfolk
& Norwich University Hospital where I see allergy and I see
general dermatology. I also work one day a week at St John's Institute
of Dermatology at St Thomas' Hospital as part of the cutaneous
allergy group where I am Head of the urticaria clinic.
Q584 Chairman: I wonder if perhaps—and
this will be principally for the two dermatologists here—you
could describe to us the main forms of allergic dermatological
disease.
Professor Gawkrodger: It depends a little
on how you define allergy but, taking into account what I think
the remit of this inquiry is, I would classify the allergic skin
disorders as being atopic dermatitis, contact dermatitis, urticaria
and drug eruptions. There are other skin diseases which have an
immunological basis but I think they are probably not generally
regarded as being allergic.
Dr Grattan: I agree entirely. It is important
though to recognise that many patients who present with atopic
dermatitis often appear to have endogenous constitutional behaviour
to their disease that appears to bear little relationship to allergy
and furthermore urticaria, which is my special interest subject,
is often an internal problem as opposed to an allergic problem
and whilst allergy may cause urticaria, there are many instances
when it does not.
Q585 Chairman: Dr Nasser, do you
wish to add anything to that?
Dr Nasser: The only thing that I would
like to add is angio-oedema, which is a subset of urticaria, is
another skin condition which presents slightly differently and
can occur in association with urticaria or in isolation and indeed
may result from a drug-related disorder.
Q586 Chairman: Am I correct in thinking
that you are the lead person on the urticaria guidelines for the
British Society for Allergies?
Dr Nasser: Yes. We have just completed
guidelines which are due to be published soon. I should also add
that Clive Grattan on my left is the lead person on the urticaria
guidelines for the British Association of Dermatology, so there
is a little bit of urticaria expertise here.
Q587 Chairman: Are those guidelines
being written in parallel and in conjunction to make sure that
they are completely compatible?
Dr Nasser: We have certainly had some
input from Clive and I know that Clive has written the editorial
for the guidelines.
Q588 Baroness Platt of Writtle: May
we ask when they are going to be published. Are they going to
be published before our report or after?
Dr Nasser: Before, I am sure.
Q589 Chairman: Would you make sure
that we have a copy of those as they will be helpful.
Dr Grattan: The British Association of
Dermatologists' guidelines were published in 2001 but a revision
is currently under way and will be published soon.
Q590 Chairman: Mrs Cox, in relation
to the question about the main forms of allergic dermatological
diseases, is there anything that you would like to add?
Mrs Cox: Only one thing, which will I
think be a consistent theme for me, and that is that, for the
patient, one of the main challenges in this area is in fact knowing
what you have.
Q591 Chairman: It has been suggested
to us as a committee that there is perhaps less credence given
to allergy in relation to urticaria and atopic dermatitis or eczema
in this country than happens in other parts of Europe where these
patients are principally seen by dermatologists. I wonder if you
have any comments on that. Perhaps you would like to begin, Mrs
Cox.
Mrs Cox: I do not think that on an evidence
base I could say whether it is right or wrong that the UK is more
or less inclined to see these diseases in dermatology than allergy,
although my personal perception specifically by reference to communications,
for example, with my opposite numbers in the US equivalent group
is that such is indeed the case. My perception again as far as
a patient is concerned is that there is a tendency to get either
into one track, be it the allergy track, or into another track,
be it the dermatology track, and that possibly in some cases what
we are lacking is an overlap in the middle.
Q592 Chairman: Do you feel that there
is sufficient credence given by dermatology in the UK to the allergic
nature of some skin diseases?
Mrs Cox: I think that it is becoming
increasingly accepted by the dermatology community, particularly
perhaps those who are working with children in paediatrics, that
there are cases where allergy or allergy-related issues are if
not the whole story at least part of it.
Chairman: Would you clarify for us the
difference between atopic dermatitis, contact dermatitis, atopic
eczema, urticaria and angio-oedema.
Q593 Lord Colwyn: And may I ask on
top of that, is a differential diagnosis easy or is it difficult?
It sounds impossible to me.
Professor Gawkrodger: Usually I would
say that it is really quite straightforward to diagnose atopic
dermatitis when it presents in children. If a child develops eczema
affecting the skin folds of the elbow, behind the knees, on the
neck or on the face, it is usually quite obvious that it is atopic
dermatitis. It can be a little more difficult in adults who present
for the first time with eczema. I think that diagnosing and sorting
out dermatitis in adults, say hand dermatitis or facial dermatitis
or foot dermatitis, is quite a complicated business and that is
where consideration of different allergic-based phenomena may
come in because you may need to consider contact allergy in addition
to a background of atopy which is a type of endogenous or internal
eczema, and other factors as well including external environmental
factors.
Q594 Chairman: Dr Grattan, do you
wish to add to that?
Dr Grattan: In relationship to urticaria,
which has not been covered by Professor Gawkrodger, the diagnosis
is often relatively straightforward to the public, the primary
care physicians and the specialists, but the exact type of urticaria
and therefore its cause and treatment may be elusive and this
is where there is a need for a specialist with insight.
Q595 Lord Rea: If you look at atopic
eczema, is there always a trigger factor or do you suppose that
there is one even if you cannot discover it, or does it sometimes
come out of the blue for no particular reasons?
Professor Gawkrodger: Atopic eczema is
one of those conditions which can be very easy to diagnose or
quite difficult. There are many, many different things which feed
into it and partly there are strong constitutional or genetic
factors, so inheritance is often a strong thing. It is associated
with other disorders such as asthma or hay fever rhinitis and
some people do have a previous history of these things. If somebody
develops an eczema in adulthood, they may have a past history
of eczema as a child which cleared up and then something comes
along, say they develop hand dermatitis, and, in those sort of
instances, it would be important to look for some triggering factor
which may be occupational, so they may be exposed to some environmental
factors that have brought their eczema out and that could be wet
work or exposure to a cold or hot climate and there can be other
things such as stress and allergy for example contact dermatitis,
but there may be some internal factors as well and it is quite
well recognised that, for example, in students who are undertaking
examinations, their eczema may get worse at the time of their
exams because of stress and stress makes them rub their skin which
brings out the eczema. Having said that, even despite looking
for triggering factors and investigating for allergic problems
which may include patch testing and also blood tests for immunoglobulin
E levels and specific immunoglobulin E levels, you do not always
find the triggering factor in every case.
Q596 Chairman: How often do these
conditions coexist in patients?
Professor Gawkrodger: Do you mean asthma,
hay fever and eczema?
Q597 Chairman: I was thinking of
the different skin manifestations such as urticaria and eczema.
Professor Gawkrodger: I think I will
let Clive answer the one about urticaria.
Dr Grattan: Usually, urticaria is a stand-alone
disease but, in children with atopic eczema, it is possible for
them to react with urticaria to allergens including foods and
maybe animals or plants, so there is overlap. Most patients who
present to hospital clinics with chronic urticaria—and this
implies continuous disease for at least six weeks—have a
stand-alone disease.
Q598 Chairman: How often do children
with eczema have other manifestations of allergy?
Dr Grattan: I will ask Dr Nasser to supplement
what I am going to say, if I may. My own experience is that it
is quite a small number. I see a number of children with eczema
every week and the parents are often concerned that allergy is
driving the condition and that allergy is causing specific problems
over and above the eczema. I think that the number of times I
can confirm that is probably no more than 10 per cent, but that
is a personal view and remember that this is a population of patients
referred to a dermatologist rather than an allergist.
Dr Nasser: The first thing that I would
like to say on this issue is that eczema should really be regarded
as a symptom rather than a disease with many underlying causes
of which allergy is one. So, you can have patients with eczema
who are completely non-allergic and do not have any allergenic
triggers and others in whom allergy does play an important role,
and it is important to try to tease out that group because if
you can get them to avoid certain allergenic foods or aeroallergens,
then you can improve their symptoms. In terms of overlap, we know
that one of the first manifestations of allergic disease (and
by that I mean food allergy, asthma and hay fever) is in fact
eczema and I regard the surface of the skin as a portal of entry
for allergic sensitisation. So, it is not just the forerunner,
it is actually an important underlying factor leading to food
allergic sensitisation and also asthma and hay fever. So, there
is a large overlap and certainly patients presenting to an allergy
clinic are much more likely to have these overlap diseases.
Q599 Lord Taverne: Coming back to
an earlier question regarding how treatment and diagnosis of dermatitis
compares with other countries, Mrs Cox said that she had some
comparison that she could make with the United States. Can any
of you throw any light on how we compare with the continent?
Professor Gawkrodger: One problem that
we have in the UK is that we have far fewer specialists—that
is not just for dermatology; there are far, far fewer specialists
in allergy for example—than most of the countries in Europe.
Germany has several thousand dermatologists and the same in France
and Italy. We only have 500 consultants in dermatology and far
fewer consultants in allergy. In Germany, for example, a number
of dermatologists have more than one qualification, so they have
a qualification in dermatology and they are also qualified in
allergy as well. I think that the combination of these two things,
the fact that they are more widely qualified in Germany and there
are many more of them, perhaps 7,000 dermatologists in Germany
compared to just 500 in this country, perhaps means that they
are more prone to investigate patients with some eczema and urticaria
than the average dermatologist might do in this country. Having
said that, I think that it might also be true to say that British
dermatologists might have something to learn from their continental
counterparts in perhaps taking a wider interest in IgE-mediated
allergy than they presently do.
| 
