Background: Stevens-Johnson Syndrome-Toxic Epidermal Necrolysis (SJS-TEN) overlap is a rare and unpredictable reaction to a medication in which there are sheet-like skin and mucosal loss. Taking a drug history and proper physical examination are crucial towards the clinical diagnosis as it is a serious medical emergency requiring immediate treatment.

Methods: This was a case of a patient who consulted at a primary care clinic in Singapore. Complementary information was collected by researching databases on this matter.

Results: A 79-year-old Chinese gentleman presented with one week history of worsening rash which spread from his bilateral upper limbs to the rest of his body. He had a past medical history of gout, diabetes mellitus, hypertension, hyperlipidemia, chronic kidney disease, benign prostate hyperplasia, osteoarthritis and anaemia. Besides the multiple target lesions, the patient also presented with oral ulcers. There was an increased dose of Allopurinol over the past few months, otherwise no other risk factors were found. Teledermatology service was activated for urgent consultation with a dermatologist. Although the initial differentials were atypical erythema multiforme and psoriasiform drug eruption, the patient was admitted and eventually diagnosed with Stevens-Johnson syndrome-Toxic Epidermal Necrolysis (SJS-TEN) overlap secondary to Allopurinol use.

Conclusion: Stevens-Johnson syndrome-Toxic Epidermal Necrolysis overlap is a potentially fatal multi-organ disease with a strong etiologic link to certain medications. Family doctors are often the first medical contact in the health ecosystem whom patients consult in an early stage. They must be vigilant and consider Stevens-Johnson syndrome as a potential complication of treatment when patients are on potential medications. Surviving patients must also be educated to avoid taking the causative drug in the future.

1. Stevens-Johnson syndrome is a potentially fatal multi-organ disease which is almost always caused by medications.
2. Family doctors, as a first line of medical contact, must be vigilant to such dermatological emergencies and refer patients to the emergency department for immediate treatment.
3. Surviving patients must also be educated by family doctors to avoid taking the causative drug.

Introduction
Plantar warts (Verruca plantaris) are contagious benign tumours caused by the human papillomavirus (HPV). Although very common, the management of plantar warts in general practice can be a challenging and time-consuming presentation owing to difficulties in their definitive removal and pain associated with some therapeutic modalities. Treatments encompass those which are chemically destructive, physically destructive, antiproliferative or immunostimulatory. These include cryotherapy, silver nitrate and topical agents such as podophyllotoxin, salicylic acid and imiquimod. This case will outline a novel therapeutic approach for the definitive treatment of plantar warts.

Clinical Case
A 46-year-old male presented with a 4-year history of multiple persistent plantar warts in the context of immunosuppression. He had a past history of Crohn’s and rheumatoid arthritis for which he was managed with infliximab and methotrexate. The location of the warts to his forefoot caused significant discomfort with walking. They had been unsuccessfully treated with numerous applications of cryotherapy, topical salicylic acid and imiquimod.

The plantar warts were successfully managed by being pared back and then painted with a compounded solution of cantharidin 1%, podophyllum 5% and salicylic acid 30%. The solution caused no discomfort at the time of application. An occlusive dressing was applied for 6 hours and then removed. He was seen and treated on two occasions, one month apart, with full resolution noted following the second application.

Clinical Lessons
This case highlights a novel way of treating intractable plantar warts within the general practice setting. Colloquially referred to as ‘Cantharidin Plus’, this compounded solution comprises cantharidin 1%, podophyllum 5% and salicylic acid 30%. Cantharidin is a substance derived from the blister beetle Cantharis vesicatoria which causes blistering to the epidermal layer. When the blister heals, the wart is lifted off the underlying dermal layer below, so that healing can occur.

At the conclusion of this presentation, attendees will take away:
1. Plantar warts (Verruca plantaris) are common contagious benign tumours caused by the human papillomavirus that can be difficult to treat.
2. An overview of therapeutic options, which encompass those which are chemically destructive, physically destructive, antiproliferative or immunostimulatory.
3. A novel therapeutic option that can be considered in difficult-to-treat plantar warts is compounded cantharidin 1%, podophyllum 5% and salicylic acid 30% solution applied topically after paring back.

Introduction:
The aim of this study is to identify the burden and the role of GPs in the management of skin diseases in the high-altitude region of Nepal. The pattern of skin diseases varies from one location to other. To provide a quality care in the high-altitude part of Nepal, there has been a subject of debate for policy makers.

Materials and Methods:
Mixed method of research design was applied. For quantitative analysis the retrospective data of skin diseases seen by GPs in the high-altitude part of Nepal was collected and analyzed using excel sheet version 16.59. We conducted zoom focus group discussion with 7 GPs using semi structured guidelines. Discussion was recorded and after transcribing the interview, qualitative analysis was done.

Results:
There were total 488 skin disease cases seen by GPs in a year. Infectious skin diseases conditions (40.5%) were the most common. The most common disease condition was scabies (22.13%) followed by dermatitis (19.05%). More than one fourth patients (28.48%) were 11-20 years. We found GPs were competent in diagnosing and treating common skin conditions. GPs used broad spectrum of strategies to diagnose, investigate, treat and refer the skin cases.

Discussion:
Infectious skin conditions were most common skin disease in rural high-altitude part of Nepal. When Policy makers have challenge to give quality of care through respective consultants, GPs are there to diagnose and treat wide range of skin conditions. Periodic training and courses should be offered to GPs in rural set up.

1. The pattern of skin diseases in the rural populations
2. Role of GPs in skin disease management
3. Advocacy of GPs in the resource scarce setting and globally

Background: Acne is a common disease among youths and young adults, mainly treated by general practitioners (GPs). Isotretinoin prescription is not restricted to dermatologists in Norway, unlike most comparable countries.

Objectives: To describe acne-treatment in Norway from 2012 to 2019, with focus on prescription-
patterns, type of treatment, and the role of the GPs.

Methods: This observational study was performed by linking individual-level data from nationwide
healthcare registries (The Norwegian Prescription Database (NorPD), Statistics Norway (SSB), Control and Payment of Reimbursement to Health Service Provider’s database (KUHR), and The Regular General Practitioner (RGP) registry) in Norway from 2012 to 2019. We included patients from 12 to 39 years of age who either had an acne diagnosis or a relevant medication (topical treatment,
tetracyclines 50 DDDs or more, or isotretinoin) registered before the age of 40. We compared yearly prescription rates and adherence to recommendations comparing GPs and dermatologists.

Results: 302,273 patients were included, 63 % females. 280,922 patients received acne-treatment, where 80, 36 and 20 % received topical treatment, tetracyclines and isotretinoin, respectively. Comparing patterns of acne treatment shows that the use of isotretinoin increased by 118% from 2012-2019, tetracyclines by 10 % and topical treatment by 8 %, as measured in defined daily doses (DDDs). Hence, overall prescribing of isotretinoin increased dramatically over the study period and more GPs initiated this type of treatment. Still only 26 % of GPs ever initiated isotretinoin. Adherence to the recommendation to always use systemic antibiotics together with topical treatment was low (26 % among GPs and 44 % among dermatologists).
Conclusions: Isotretinoin treatment prescription increased among GPs. A large proportion of tetracycline treatment were prescribed without co-occurring topical treatment. Whether or not GPs initiating isotretinoin treatment is correlated with more adverse events or adherence to recommended patient surveillance, remains to be investigated.

1. GPs in Norway prescribe isotretinoin in an increasing matter
2. Adherence to the recommendation of always using topical treatment together with systemic antibiotics is inadequate, more so among GPs.

Research conducted by MotherSafe, an organisation that provides evidence-based advice to consumers and healthcare providers about medication and exposures in pregnancy and breastfeeding, suggests that retinoid exposure in pregnancy is an ongoing concern. Oral isotretinoin is a well known teratogen, and since 2000 MotherSafe has received hundreds of calls regarding potential exposures in pregnancy. Currently only specialist dermatologists in Australia are authorised to initiate and prescribe oral isotretinoin. Primary care practitioners would be well placed to assist in this field, as contraception is an essential part of the retinoid prescription consult, and sexual health and reproductive medicine are core elements of GP training. This research highlights ongoing challenges regarding appropriate contraceptive counselling to women of reproductive age within the existing model of retinoid prescribing, and makes a case for general practitioners to be able to provide wrap around care, not only providing the prescription, but providing contraceptive options and appropriate followup as well.

1. The risk of retinoid use as a teratogen
2. Retinoid prescribing and the importance of contraceptive counselling and followup
3. Evidence-based counselling services after exposure to teratogens in pregnancy or breastfeeding

Aims:
Cairns and Hinterland hospital and Health Service (CHHHS) serves Far North Queensland with a catchment population of about 289,000 (including Torres and Cape Hospital and Health Service population). Geography, demographics, and climatic conditions presents peculiar challenges in provision of dermatological services in this region. Higher prevalence of Melanomas, non-melanoma skin cancers and other dermatological conditions along with paucity of specialist services can impact on timely diagnosis and management of these conditions. CHHHS allocated GP with special interest in Dermatology (GPSI or GPwSI) to Cairns hospital dermatology department in 2018. We discuss implementation and service delivery of this alternative care model, analysing its impacts on the dermatology service at Cairns Hospital.

Methods:
Literature review of related articles and annual reports of organisations (public hospitals where relevant model of service care was implemented) was conducted to ascertain and compare the effectiveness of the GPSI model in Australia.

Results:
This model augments the workforce and efficiency of the department, therefore reducing waiting times for patients. This provides training registrar on rotation opportunity to focus on diverse dermatological conditions in addition to skin cancer. It enhances the capacity of supervising specialist to spare dedicated teaching time. Given GPSI positions can be retained for 12 to 24 months, this model provides continuity of care for skin cancer surveillance. The clinic provides significant upskilling for GPs working to then provide services in community and upskill their colleagues.

Conclusions:
GPSI service model supported by specialists can be integrated in large regional dermatology services within the hospitals. This can be further extended in communities as an outreach service supported by a dedicated tele-dermatology service. Formalisation and standardisation of GPSI training in collaboration between respective training institutions is recommended.

1.General practitioners with special interest can play a key role in plugging gaps for rural workforce shortage .
2.Innovative models of care like telehealth can be instrumental in achieving goals of health equity.
3.Formalisation and standardisation of GPSI training in collaboration between respective training institutions is recommended.