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Some of you may have seen Amanda Platell’s article in the Daily Mail on Tuesday about Photodynamic Therapy (PDT for short) and the treatment of skin cancers and skin pre-cancers.

In essence the article described the use of chemicals applied to the skin which then make rapidly growing skin cancer cells very susceptible to the damaging effects of particular light sources. Normal surrounding skin cells are unaffected so collateral damage is very limited. If you want to help your skin look younger, learn more about Renu ADVANCED. The technique can be used for other tumours in which case the photo-sensitising chemical is either swallowed or injected.

This technique does not involve the use of radiation – it just relies on the increased susceptibility of rapidly growing (jargon = hyperproliferative) skin cancer cells to take up the sensitising chemical and then become much more vulnerable to light.

The British Association of Dermatologists have produced a very good patient information leaflet on PhotoDynamic Therapy and also on Basal Cell Carcinoma’s.

The disadvantage of photodynamic therapy is primarily that it can only be used for certain types of skin cancer and pre-cancers and these have to be carefull assessed and pre-determined by taking a very fine biopsy sample for laboratory analysis. The treatable skin cancers are basal cell carcinomas, Bowen’s Disease and also actinic keratosis. Anatomical positioning is also important because although collateral damage to normal skin cells is most unlikely and unusual great care has to be used in areas such as the surrounds of the eye.

Malignant melanomas are currently definitely not amenable to treatment with routine photodynamic therapy or PDT at the moment.

What happens when using photodynamic therapy?

Well to begin, a skin biopsy, usually using a device called a punch biopsy is taken to make the diagnosis. This sounds rather horrid but there is no “punching” involved. Following application of a small amount of anaesthetic a tiny 2mm core of tissue is taken from the suspect target skin cancer.

The sample is sent for histology at our laboratory where the exact type of skin cancer or pre-cancer is determined and also very importantly the depth of the tumour. The depth is important because there are some sorts of basal cell skin cancers which do not respond to photodynamic therapy because they are too deep. These need to be surgically removed.

How does PDT – photodynamic therapy, work?

A specially prepared chemical cream called methyl aminolevulinate (MAL) is applied to the target area and then covered with a dressing which keeps out light. This remains on the skin for a variable period – usually a few hours and the patient is free to leave the clinic and return later.

The MAL will cause the production of porphorins in the rapidly growing and dividing cancer cells. By exposing the target area which had previously been covered by the MAL cream to a specific red or blue wavelength light, the porphrins will create oxygen free radicals within the cells which will then kill the cancer cells.

Typically two treatments are needed at a 7 day interval. During application of the cream and also the application of the red or blue light source there is usually no pain.

After the light exposure has finished there can be quite an intense discomfort localised to the target area which a few patients have likened to a hot “fizzing” sensation. This is generally anticipated and controlled by pain killers ahead of the use of the light treatment.

So in summary, the skin cancer is confirmed and identified by the biopsy specimen; the patient returns when the histology result is available; the first application of the cream is used and then three or so hours later the red or blue light is applied for a few minutes. The patient is then free to go home and rest and to return in 7 days for the second treatment.

Ongoing surveillance does need to be carried out over a lifetime. Patients with basal cell carcinoma’s tend to be either genetically susceptible eg with Celtic skin colouring and to have been heavily sun exposed and so usually the first basal cell carcinoma is just that – the first, and others can be expected.

The very definite advantage for basal cell cancers, Bowen’s Disease or actinic keratoses which fall into this treatment category is that the treatment avoids fairly substantial surgery. With Amanda Platell’s skin cancer she had a big surgical excision over her eyebrow with recurrence of the cancer some years later at the same site. Standard surgical treatment on the second time around would likely have resulted in her eyebrow being removed as part of the surgery. This would not be a desirable outcome for anyone.

Lee Garrett RN, BSc is a Specialist Cosmetic Medicine/ Non-Surgical Nurse working at Freedomhealth Limited London

Saturday GUM and STD / HIV clinics

In a paper in the Journal of STD and AIDS 2010; 21: 273-276, Challenor and Warwick assessed the acceptability and usage of weekend GUM and STD clinics in response to increasing demand and pressure to see mor epatients.

In perhaps an unsurprising finding they discovered that the Saturday GUM clinics were popular and more so than Sunday clinics. This is in keeping with our experience with Saturday GUM Clinics at our London Freedomhealth Clinic. Freedomhealth opens every Saturday between 10.30 am and 3.30 pm and the clinics typically are booked in advance with many “walk-in’s” – ie patients without prior booked appointments. Reasons offered are that many of our patients find it difficult to get away from work in the week; attending NHS clinics tends to result in the waste of a good part of the day and patients are able to choose which of our doctors they can see.

Challoner and Warwick’s review showed that around 30% of patientswere likley or very likley to use a Saturday NHS GUM Clinic service. They also found that Saturday patients are more likely to attend with symptoms of a http://www.freedomhealth.co.uk/sexual-health/std-sti-test-and-testing-clinic-london/175/. Interestingly many patients attending the Saturday GUM NHS clinic were too embarrassed to reveal to admin staff that they had symptoms.

Our patients on the other hand tend to be very informative about their symptoms and conditions before they arrive at our private GUM clinic.

Should gay men be screened for anal cancer?

Cases of anal cancer among gay men who are HIV positive have been on the rise since the advent of antiretroviral treatment for those living with the virus.

Consequently questions are now being asked about whether men who have sex with men should be routinely screened for anal cancer using anal cytology (taking cell samples from the area) and high resolution anoscopy (a tube used to see the lining of the anus).

In an article published in Wolters Kluwer Health journal Dr Paul Fox examines the current evidence and opinion on routine anal cancer screening. Dr Fox is a Consultant Physician at the ChelseFreedomhealth Clinic in London a and Westminster Hospital and also where he runs a private High Resolution Anoscopy Clinic for anal cancer screening.

Current UK guidelines do not recommend routine anal cancer screening and guidelines from outside the UK vary. For example in New York routine anal cytology is recommend for gay men, whereas leading groups in other states including Texas and California say that there is not yet enough research to form any guidelines.

There are a number of reasons why routine anal screening programmes have not been rolled out. The cost, both of setting up and maintaining the programme, is just one of the factors. Balancing the need for screening with any patient anxiety is another factor as well as concerns over the efficacy of screening.

The sensitivity of anal cytology is regarded as poor and so is used in conjunction with high resolution anoscopy, where medical professionals will look for the precursor lesion to anal cancer known as a high grade squamos intraepithelial lesion (HSIL).

A number of studies have been carried out to try and assess how great the risk of anal cancer is to gay men in a bid to identify groups that could benefit from routine anal cancer screening.

Dr Fox makes some criticism of the small number of studies for the way in which patients were recruited; many were not randomly selected meaning there was a potential selection bias.

However Dr Fox highlighted two recent studies which he was sure eliminated selection bias, one by randomly selecting patients and another by using the entire population of an HIV clinic.

The first study screened the 516 patients of an HIV clinic in Paris. It was found that 473 had HSIL, and that men who had sex with men were more than twice as likely to have HPV lesions – which can be potentially cancerous – than heterosexual men or women.

A second study looked at HIV patients on antiretroviral treatment from different demographic groups, evenly divided between MSM, heterosexual men and women. It found what Dr Fox described as “surprisingly little difference” between the groups in terms of the number of patients with HSIL. Around 5% of people in each group had an HSIL – the anal cancer precursor lesion.

The figure matched data from the days before antiretrovirals were available, leading Dr Fox to conclude that there was a possibility that the rising incidence of anal cancer in HIV-positive patients treated with anti-retroviral therapy is due to patients living longer, which gives greater rise to the cancers occurring.

Dr Fox also concluded that patients on antiretroviral treatment must therefore be at greater risk of their HSIL making a malignant transformation into anal cancer.

There were also concerns that treatment was less effective for HIV patients compared to HIV negative people. Dr Fox looked at a number of studies carried out on the treatment of HSIL and anal cancer.

A study by Goldstone et al showed that 65% of HIV positive men who received infrared coagulation treatment treatment for HSIL had new or persistent lesions after a 10 month follow-up, compared to 50% of patients who were HIV negative. A further study, which differed in its methodology by performing a repeat biopsy of the treatment site at 6 months post-treatment found only 10% of HIV positive patients were disease free.

A study on the outcome of two different types of treatment for HIV positive men with HSIL has provisionally shown little difference. It looked at patients who were given a single infrared coagulation treatment and those who applied trichloroacetic acid once monthly for four months. There was an individual clearance of 68% with individual lesions with IRC and 87% in the group treated with trichloroacetic acid.

A further study involved a placebo controlled study of 53 HIV patients using a self-applied imiquimod cream. In the patients using the cream the response rate was 39% compared to those using the placebo cream.

In a further study where participants were offered open-label imiquimod the response rate was 40% with half of those patients having a complete and sustained resolution of their lesions.

It was noted that the benefit of these treatments is that the lesions disappear and although some recur in different locations it is thought that lesions that have not been static for some years will carry only a low risk of malignant transformation.
According to the article it is therefore reasonable to suppose that treatment of HSIL will reduce the likelihood of anal cancer, but this has not yet been proven.

Dr Fox also concluded that anal cytology is a validated means of detecting anal cancer but is best restricted to selected patients.

He recommends that clinics carry out physical, digital examination of the anus to look for abnormalities and that this becomes the standard at HIV clinics.

A study in San Francisco highlights the important of digital examination. The cases of 21 patients who had developed anal cancer were examined and it was found that 19 had presented with palpable mass, an induration or ulcer. The implication was that physical examination could have picked up these lesions at an early stage.

Patients should also be encouraged to self-examine with Dr Fox saying it may be “just as effective as a cytology based approach”.

He says the clinics must play an important role in encouraging patients to self-examine and helping them learn how to carry it out properly. The report suggests clinicians carry out the initial examination to prevent patients becoming concerned by lumps that are either benign or part of their normal anatomy.

Cost concerns over shingles vaccine

Earlier this year government advisors recommended that a safe detox centers against shingles be given to Brits aged between 70 and 79, but raised concerns over its cost. Now, as research shows just 10% of eligible patients in America have received the vaccine because of its high price, is there really a hope for Britain’s elderly?

Shingles is the common name for herpes zoster which is caused by the reactivation of the virus which causes chicken pox and then lies dormant in our body.
The virus is called the varicella-zoster virus and is reactivated in around a third of people who have had chicken pox, causing shingles – which is a localised rash commonly with blisters. Unlike chicken pox, shingles is not contagious.

People of any age can develop shingles but it commonly occurs in people aged over 50, this is because of the decline in immunity as people age. For this reason people with suppressed immune systems are also susceptible to shingles, according to Kimberlin and Whitley writing in the New England Journal of Medicine.

They report that a patient over 60 years old is 8 to 10 more times more likely to develop shingles than a younger patient and that shingles will have developed in up to half of people who are 85 years old.

One of the most serious complications of shingles is a condition known as postherpetic neuralgia, a persistent pain which remains in the area of the rash after the rash has gone. It is caused by the virus damaging a nerve and can lead to pain, itchiness, numbness which can last for months or years.

Estimates suggest that around 250,000 people in the UK get shingles every year, and almost 100,000 of them develop postherpetic neuralgia. Patient.co.uk reports that 1 in 4 of those with shingles develops postherpetic neuralgia that lasts more than 30 days.

As Nigel Scott from the Shingles Support Society told the BBC,: “Shingles and postherpetic pain, can make people’s final years a complete misery’.
So you would think there would be widespread relief about the Joint Committee on Vaccination and Immunisation recommending to the British government this January that a vaccine against shingles be given to those aged between 70 and 79.
The vaccine works as a preventative measure given before the reactivation of the varicella-zoster virus. It has been used in America for over four years, where it is available for everybody over 60 years of age.

Just one dose of the vaccine is needed. The vaccine contains the live varicella virus which enables the body to develop enough immunity against it, giving the patient a new ‘immunologic threshold’ above that at which the patient is at risk for shingles.

Kimberlin and Whitley report a study found that the vaccine reduced the likelihood of developing shingles by over 50%. The evaluation was based upon two groups totally around 40,000 people, one who had received the vaccine and another who had received a placebo. The study also found that the incidence of postherpetic neuralgia was 67% lower among those who had received the vaccine.

The study found that around 17 people would need to be vaccinated to prevent one case of shingles and 31 would need to be vaccinated to prevent one case of postherpetic neuralgia.

Side effects appear to be minimal with rashes at the injection site and skin redness being reported. However, the study was carried out less than a year after the shingles vaccine became available to Americans and so it was difficult to study the potential risk of rare adverse effects.

The biggest side effect seems to be the cost. Writing for the New York Times in June this year, Pauline Chen reports that in the two years since the shingles vaccine became available, fewer than 10 percent of all eligible patients have received it.
This is because the shingles vaccine typically costs between $160 and $195 dollars, around 10 times more than other commonly prescribed adult vaccines. Chen reports that even patients with health insurance plans are not having the vaccine because of complicated reimbursement methods relating to it.

The article also describes how American doctors have tried to help patients obtain their vaccines more cheaply. Some have sent their patients to cheap pharmacies to buy the vaccine and then return to the surgery to be injected, or to go to pharmacies which offer immunisations to have the vaccine administered there.
However, Chen reports that the hassles of these methods put patients off.
Now it looks like the cost of the vaccine may prove to be a hurdle with the roll-out of the vaccination programme by the NHS in the UK.

Vaccination against shingles would just be available to people in the UK between the ages of 70 and 79, according to the BBC. This is despite the aforementioned study finding that the vaccine was more effective in preventing shingles among persons aged 60 to 69, than those aged 70 or over.

It also contrasts with the situation in the US, where all over 60s are recommended to be vaccinated against shingles.In January the Department of Health told the BBC the programme was dependent on a “fair price” but that they was confident this could be achieved, given that four million doses would be required.

They also revealed that the programme should start before the end of the year to achieve maximum effectiveness.

Genital Herpes (HSV2) and HIV disease: Why does it matter?

There is good evidence from population studies of people infected with both HIV1 and also HSV2 that infection with Herpes Simplex 2 virus will both increase the amount of HIV1 which is shed in gental secretions and also it increases the rate at which HIV 1 is transmitted.

Treatment designed to suppress Herpes simplex 2 (HSV2) is established to reduce the amount of HIV1 RNA in blood and also genital secretions such as semen and vaginal secretions.

The impact of co-infection (having infection with HIV and HSV2) of HIV1 and HSV2 is very significant indeed with HSV2 and HIV1 co-infected individuals having very much more HIV1 RNA (ie the infectiouness of the individual is increased)

This obviously means that their potential for spreading HIV either through asymptomatic HSV shedding or symptomatic HSV2 lesions is greatly increased. In addition, treatment for the HSV2 part of the co-infection has no effect on the HIV1 directly but does reduce the HIV1 viral load.
HIV viral load increases are associated with an accelerated course towards the development of AIDS defining diagnoses (AIDS is not the same as being HIV positive). The way anti HSV2 medications reduce HIV1 viral load is thought to be through partly interupting the “HIV inducing effect” of HSV2.

Unfortunately, we also know that people with HSV2 genital lesions are much more likely to acquire HIV1 from an HIV infected individual – by a factor of up to six times more likely.

Up to 60% of people living in the “West” with HIV have Herpes Simplex 2 (HSV2) infections whereas in Sub-Saharan Africa the figure is thought to be up to 90%.
A study by Nagot and others published in the NEJM (Nagot N, Ouedraogo A, Foulongne V, et al. Reduction of HIV-1 RNA levels with therapy to suppress herpes simplex virus.

According to https://www.stdaware.com/stds/treatment, many STDs are asymptomatic (show no signs or symptoms), and it’s still possible to pass the infection to others. The absence of symptoms for many people is why regular STD testing is so important. In most cases, if symptoms will become present with a new STD infection, they will present themselves within a few days of initial exposure (sexual activity).

N Engl J Med 2007;356:790-9) looked at HIV1 and HSV2 co-infected populations in Sub-Saharan Africa and treated trial subjects with valaciclovir, an anti-HSV2 drug.

HIV1 is shed from HSV2 lesions and most of the shedding (85%) occurs without the actual physical appearance of HSV2 genital ulcers.

The effects were to markedly reduce the re-occurence of HSV2 lesions, and to markedly reduce the amount of HIV1 in both blood and also genital secretions.

The significance of this is that reducing the HIV1 viral load in the genital tract by treating the additional HSV2 infection may reduce the transmissibility of HIV1 infections (and probably HIV2 although this was not within the studied populations).

A further possible scenario is that people with HSV2 but not HIV will be at theoretically reduced risk of HIV acquisition if they suppress the appearance of HSV2 lesions by long term suppressive treatments such as aciclovir or valaciclovir, now that you know all this information make sure to look for genital herpes testing near me so that they you can get tested to make sure your sexual health is going well. Aciclovir has the great advantage of being very cheap and very well tolerated.

Selected STD’s and STI’s testing

Herpes Simplex Virus Type 1 and 2 by PCR

Testing for the virus directly from the skin is useful if genital signs or symptoms are present at the time of examination. A viral (green) or PCR swab need to be taken from a lesion or sore for detection of herpes simplex virus.

PCR tests are the most accurate tests for herpes. PCR techniques make many copies of the viral genetic material (DNA) in a short time so that even tiny amounts of virus are sufficient for a positive test. Positive samples are confirmed as positive for either HSV I or HSV II. Herpes PCR DNA swabs can be ordered directly from Freedomhealth for personal sampling in the convenience of your own home. We would prefer you to have a telephone consultation with us prior to sampling to make sure you need the test, understand the limitations of the test, understand how best to perform the test and we will help you understand the results with a free follow up telephone call. To book a telephone consultation with us please call 02076371600 Monday to Friday bewteen 8.30 am to 6.30 pm.

Trichomonas vaginalis

One of the most common sexually transmitted protozoal infections, T. vaginalis, is associated with signs and symptoms of urethritis, an odorous vaginal discharge and dyspareunia. Pregnant women infected with T. vaginalis are more likely than uninfected women to deliver preterm, or to have a low birth weight infant.

Complications in men include prostatitis, epididymitis, urethral stricture disease, and infertility. T. vaginalis infection is highly associated with the presence of other STDs. I bet you must have a check up at Advanced Fertility of Chicago to see if you are capable of carrying a child.

Mycoplasma genitalium

Sexually transmitted pathogen, M. genitalium, is identified in acute and chronic non-gonococcal, non-chlamydial urethritis in men, and urethritis, cervicitis, and pelvic inflammatory disease in women. A high concordance rate is found among sexual partners of M. genitalium infected patients, indicating that the infection is sexually transmitted.

Results of studies have shown that in male patients presenting with persistent or recurrent non chlamydial, non-gonococcal urethritis after treatment with antibiotics, nearly half were infected with M. genitalium. It is an organism that continues to be of interest to clinicians and pathologists. It exceedingly difficult to culture, and accurate detection is dependent on specific PCR assays. Data indicating that M. genitalium is a potential cause of non-gonococcal urethritis have only recently been demonstrated by the use of PCR.

HPV 20 DNA subtypes

More than 100 different types of HPV exist, most of which are harmless. Around 40 types are thought to be spread through sexual contact and are classified as either low risk or high risk. High-risk types of HPV may cause abnormal Pap smear results and could lead to cancers of the cervix, vulva, vagina, anus, or penis. Some types of HPV cause genital warts and are considered low risk types (the most common of which are 6 and 11). Genital warts are contagious. About two-thirds of people who have sexual contact with a partner with genital warts will develop warts, usually within 3 months of contact. Men can unknowingly transmit HPV to their female sex partners. Compared to heterosexual men, women are at higher risk of developing disease from HPV – most notably, cervical cancer. Cervical cancer in women is much more common than anal or penile cancer in men. Anal cancer rates are high in men who have sex with men, women who have already had cervical cancer or cervical cancer pre-changes. HIV positive people have a particularly high risk of anal cancers and pre-cancers.

Persistent High Risk HPV infection is a necessary cause of cervical cancer. Although it has been widely accepted that HPV is sexually transmitted there is limited insight available about the clinical manifestations of HPV infection in men and their contribution to viral spread. Initial studies looking to further the understanding of HPV infection (relevant subtypes, mixed-type, and persistence of infection) in men are taking place with the aim of developing programmes effective for both men and women.

The graph at the top shows he four subtypes being immunised against with the Gardasil HPV vaccine are 6,11 (low risk) and 16, 18 (high risk). HPV20 reports each DNA subtype individually as positive or negative. There is another vaccine, Cervarix, which is active against both the very high risk subtypes 16 and 18.

Freedomhealth is launching a brand new STD/STI and HIV / Hepatitis B and Hepatitis C testing service across Europe. Patients can text the code for the STD or HIV test of their choice to a dedicated number and an HIV / Hepatitis B / Hepatitis C /STD /STI testing kit will be sent to them by post (arriving the next working day if ordered by 5.00 pm).

Each test is performed by the Doctors Laboratory. the biggest private laboratory in the UK and part of the Sonic Group which is a global provider of diagnostic services. The Doctors Laboratory is a major and sophisticated testing facility.

Freedomhealth works closely with The Doctors Laboratory and also in partnership with ChemistDirect to provide a comprehensive range of Health Solutions.

Freedomhealth is registered with the Care Quality Commission, has a permanent staff of dedicated, very experienced and well trained doctors and also operates a walk-in or appointment service from very comfortable, smart and clean premises at 60 Harley Street London W1G 7HA. If you’d rather visit us then please call us on +44 (0)20 6371600.

We also offer telephone consultations for one to one discussion of your individual circumstances.

This innovative new system is simple and very easy to use.

Decide which test seems the most appropriate for you and then text the special code to 88020 if you live in the UK or +447950080232 if you live in Western Europe.

You will then receive a set of very simple questions and some instructions. The test results will be returned to Freedomhealth Limited and all results will be individually checked by one of our doctors.

The tests currently available are as follows:-

FHPATH1 – this is a very sophisticated combined urine test which will correctly identify genital infection with chlamydia, gonorrhoea, herpes 1 and 2, mycoplasma, ureaplasma, trichomonas, and gardnerella all in one simple test. The test costs £180 and the fee is payable only when you return the testing kit to our laboratory in the pre-paid envelope supplied. To obtain this test kit text FHPATH1 to 88020.

FHPATH2 – an important urine test for chlamydia alone. The test costs £70 and the fee is payable only when you return the testing kit to our laboratory in the pre-paid envelope supplied. To obtain this test kit text FHPATH2 to 88020

FHPATH3 – this is a combined test looking for chlamydia and gonorrhoea. The test costs £85 and is payable only when you return the testing kit to our laboratory in the pre-paid envelope supplied. To obtain this test kit text FHPATH3 to 88020.

FHPATH4 – this is a state of the art HIV DUO BLOOD test kit. The HIV DUO test combines a test looking for HIV 1 and 2 antibodies and also p24 antigen which allows for very early detection of HIV infection. This is an excellent test and very accurate indeed after just 28 days after possible exposure. The test costs £75 and is payable only when you return the testing kit to our laboratory in the pre-paid envelope supplied. To obtain this test kit text FHPATH4 to 88020

FHPATH5 – a superb Early Detection Screen for very early HIV 1 and HIV 2, Hepatitis B and Hepatitis C – testing from as early as 7 days post possible exposure to HIV. This test is superior to the HIV DUO and can be done much earlier. In terms of HIV it detects RNA which is the key viral structure. The test costs £192 and this is payable only when you return the testing kit to our laboratory in the pre-paid envelope supplied. The test takes 5 working days to be processed from the date of receipt. To obtain this test kit text FHPATH5 to 88020

All of these tests are available by simply texting the test code number to the 88020 (or +447950080232 if you live in Western Europe and outside the UK) and answering the simple questions.

You have the option if you live within the London M25 area of requesting a nurse to visit you to collect the blood from you. You can do this by calling us on 020 7637 1600 Monday to Friday 8.30 am to 6.30 pm or Saturday 10.30 am to 3.30 pm and asking for the Freedomhealth Visiting Nurse service. This service will cost a further flat fee of £85 which covers the cost of dispatching the nurse to you, collecting the blood and returning to the laboratory with your samples.

Telephone consultations are available with one of our doctors through the week and into Saturday’s. However, doctors are people too. They must rest, especially they have families to look for. To all of you doctors, rocketparkmusic can help you when it comes to this. They are pre-paid at the time of booking and we charge £55 for a twenty minute consultation.