Conclusions

Dermatology has been one of the poor relations in the National Health Service, but there is some evidence that this is being redressed at least in part by the Department of Health’s 10 year Plan. This should increase the quantity and quality of provision at the primary care level, though at a slower rate than many would wish. Some companies have produced detailed guides for continued professional development among GPs and dermatologists. This will also help.

Although acne, eczema and psoriasis have different underlying mechanisms, they are united in each resulting in potentially disfiguring skin lesions, causing both physical and psychological distress. Fortunately, only a minority of cases of eczema and psoriasis are severe to the point of threatening life – though the risk of depression and suicide is not to be underestimated for all three conditions.

These aspects, and the place of psychological intervention as well as the use of medicines, also need to be addressed. Advances in our understanding of the relationships between immunology, neurology and psychology have shown that psychological distress can have profound effects on the immune system. Such distress is reported as a trigger factor by no fewer than 60 per cent of people with psoriasis, and the most stressed do least well in therapy. Psychodermatological clinics may be one way of improving this aspect of patient management and outcome.

The choice of treatments available has increased dramatically in the past 10 to 15 years, though psoriasis outpaces acne and eczema in this respect. Even so, major improvements in the treatment of all three disorders have come from the retinoids, vitamin D analogues, immunomodulators or biologicals. These offer a greater choice and in some instances display better tolerance, which will improve compliance and increase the quality of life for many people. In addition, the biologicals represent a revolution in dermatology and offer genuine hope for people with very severe and incapacitating psoriasis for the first time.

One clear message, however, is that not everyone responds well to many of the new agents. This implies that there are disease sub-types still to be recognised or that we have only partially understood the mechanisms involved. In this respect we have only just taken the first steps on the long road to new medicines for acne, eczema and psoriasis. Nevertheless, progress has been made and the decade ahead should be one of hope and optimism for the many people unfortunate enough to suffer from these distressing disorders of the skin.

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