bluuebunny/crossref_metadata_2025 huggingface dataset:
P067 A novel validated patient decision aid to enhance shared decision making for the management of actinic keratosis
Authors: Brent Geoffrey , Beardmore Caroline , Mayers Kate , Barea Alberto , Samarasinghe Venura , Pinder Vanessa , Soo Julia , Akhras Victoria , Jiyad Zainab
Published: June 2024

Actinic keratoses (AKs) are common premalignant lesions relating to chronic ultraviolet exposure. Several management options exist, including active surveillance, multiple topical therapies, cryotherapy, curettage and cautery, and photodynamic therapy, each with their own risks, benefits and efficacy. Best practice currently involves shared decision making between patient and clinician, particularly when there are numerous management options. Patient decision aids (PDAs) can be beneficial in the shared decision-making process. Between December 2022 and August 2023 we developed and validated a PDA for the management of AKs, in concordance with the International Patient Decision Aids Standards. A two-page leaflet was created with key information on the standard management options, such as what the treatment involves, side-effects and efficacy. Alpha testing of the draft PDA was conducted initially, with positive feedback from clinicians and patients. Beta testing was then undertaken, in which the PDA was used in consultations with 21 consecutive patients across three separate hospital trusts in dermatology clinics. Included patients were over 18 years of age and diagnosed clinically or histologically with one or more AKs. Patients were excluded if there was any suspicion of squamous cell carcinoma, or if they had tender or hypertrophic AKs. Two validated outcome measures, the Decisional Conflict Scale (DCS) and the nine-item Shared Decision Making Questionnaire (SDM-Q-9), were used for all patients. The majority of patients (75%) indicated a high level of decisional conflict prior to using the PDA, with a total mean DCS score of 53.0 (95% confidence interval 43.2–62.8), where a higher value corresponds with increasing decisional conflict. Following use of the PDA, the total mean DCS score improved to 13.0 (95% confidence interval 8.0–17.9). This represents a significant reduction in DCS score (P < 0.001), with the majority of responses as ‘strongly agree’ and ‘agree’ that the PDA facilitated their management decision. The total SDM-Q-9 score was 791/900 (87.9%), which indicates a high level of shared decision making following use of the PDA. As AKs can be managed in numerous ways, information given to patients can be overwhelming, making the decision more challenging for patients. A PDA given to the patient can reduce decisional conflict and improve the shared decision-making process. We suggest that this validated PDA can be used in various settings to facilitate informed care: during primary care consultations, in secondary care in both specialist nurse and doctor-led clinics, and also at the interface between primary and secondary care when responding to Advice and Guidance queries.
P068 A history of mycosis fungoides: from Alibert to mogamulizumab
Authors: Johnson Nicholas A , Venables Zoe C , Mistry Khaylen , Levell Nick J
Published: June 2024

In 1806, French physician Baron Jean-Louis Alibert treated a 56-year-old man with a desquamating rash and skin tumours. Alibert considered this to be a variant of yaws. In 1829 Alibert named the condition mycosis fungoides (MF), meaning ‘mushroom-like fungal disease’. Over 100 years later, French dermatologist Albert Sézary published papers from 1938 to 1949 detailing a mysterious disease that caused erythroderma and ‘cellules monstrueuses’, describing cutaneous ‘monster cells’. In 1961, these clinical findings were collated together into ‘Sézary syndrome’. There was widespread confusion between these conditions, i.e. fungal infections and yaws. In the 1870s English dermatologist William Tilbury Fox published a dermatology atlas detailing cases similar to what we know now as MF, with the name ‘fibroma fungoides’. The atlas described MF as a type of fungus, before giving a description of yaws and painting a clinical picture that differed from that of a lymphoma. In 1975, Pierre-Antoine-Ernest Bazin and associates suggested the classification system and term we now recognize as cutaneous T-cell lymphoma (CTCL). Neoplastic cells have been thought to arise from chronic activation of T cells via antigen-presenting cells, yet the antigen to trigger this response remains unknown. Several potential bacterial, viral, fungal and iatrogenic causes have been studied, but no reliable triggers have been discovered. In 2018, the World Health Organization and European Organisation for Research and Treatment of Cancer officially recognized four types of MF. These are the classic Alibert–Bazin type (representing 88.6% of cases) and its three subtypes; folliculotropic MF (11.4%), Pagetoid reticulosis, and granulomatous slack skin (both with a combined 1% prevalence). CTCL has an incidence of approximately 0.2–0.6 per 100 000 person-years, with MF being the most common subtype. MF is twice as common in male as in female patients. It is twice as common in those of Black ethnic background than in White and Asian ethnicities. Development of immunohistochemistry and polymerase chain reaction for the T-cell receptor gene in the 1980s improved the diagnosis of CTCL. However, diagnosis of MF remains challenging due to its heterogeneous presentation, often mimicking inflammatory dermatoses. Advanced diseases therapies have evolved from cytotoxic chemotherapy in the 1970s to novel monoclonal antibodies such as mogamulizumab, targeting proteins on T-cell lymphoma cells (CCR4). Reflection on the past two centuries from Alibert to mogamulizumab offers insight into the challenges that accompany the aetiology, diagnosis, classification and management of MF.
P071 Are Welsh primary schools sunproofed? Results of a national survey: sun protection practices in primary schools in Wales
Authors: Abbott Rachel , Tod Daniel , Lanyon Kirsty , Driscoll Timothy , Prathap Swetha , Watkins Alan , Peconi Julie
Published: June 2024

Skin cancer rates are on the rise globally. School sun safety programmes are recommended by the World Health Organization to reduce the risk of future skin cancer at the population level; however, these are encouraged but not mandated in Wales. Our study aimed to explore current sun protection practices and sun safety education in primary schools in Wales, and whether these are linked to the existence of a formal sun safety policy. To do this, we distributed an online survey to all 1241 Welsh primary schools asking about sun safety practices, education and formal policies. In total, 471 (38.0%) schools responded to our survey, with the characteristics of responding schools generally matching the profile of schools in Wales. A minority (22, 4.7%) of responding schools reported they had sufficient shade for most activities. In the spring and summer terms almost two-thirds of schools encourage hat wearing (304, 64.8% of available data) and suncream (296, 63.2%). While nearly all schools reported that parents were encouraged to apply suncream to students before school (449, 95.7%), there was wide variation in other suncream application practices. Less than one-third of schools (129, 29.0%) reported that they include sun protection education in the curriculum in every year group, with 11.7% (52) including this in certain years only. Schools with a formal sun safety policy were more likely to report more comprehensive sun protection practices, including having sufficient shade [odds ratio (OR) 1.51, 95% confidence interval (CI) 1.04–2.19; P = 0.03], having spare hats for pupils to wear (OR 1.59, 95% CI 1.07–2.37; P = 0.02), providing guidance for staff (OR 5.87, 95% CI 3.05–11.3; P < 0.001), encouraging them to model sun safe behaviours (OR 1.82, 95% CI 1.18–2.80; P = 0.007) and teaching sun protection education as part of the curriculum in every year group (OR 2.56, 95% CI 1.76–3.71; P < 0.001). The existence of a formal policy did not seem to affect a school’s practice with respect to suncream. While in most cases, the existence of a formal policy suggests more comprehensive sun protection practices and education in schools in Wales, sun protection measures and education need improvement across the primary school sector to reverse rising skin cancer rates.
P078 Establishing diagnostic criteria for vulval lichen sclerosus (SHELLS): an international electronic-Delphi consensus study
Authors: Simpson Rosalind , Birchall Mike , Daniels Jane , Gran Sonia , Kirtschig Gudula , Thomas Kim
Published: June 2024

Lichen sclerosus (LS) is a chronic inflammatory condition mainly affecting genital skin. It causes distressing symptoms that impact daily quality of life, results in progressive anatomical changes and has a potential risk of cancer. There is no defined set of diagnostic criteria for vulval LS. As a result, vulval LS is often misdiagnosed and improperly treated. The objectives of this study were to reach international expert consensus on clinical diagnostic criteria for vulval LS. Between March and May 2023, a four-stage electronic-Delphi consensus exercise was conducted. In the first three rounds, participants were asked to rate the importance of a list of clinical criteria. Responses from round one were summarized and presented in rounds two and three, along with additional criteria suggested by participants. Any items that met the definition of consensus as ‘very important/critical’ or ‘not important’ were not voted on again in subsequent rounds. In round four, items that met agreement for ‘important but not critical’ were ranked in order of their importance. Consensus was defined a priori, and all rounds were conducted anonymously. In total 47 participants from 14 countries completed round one, with 42 (89%) retained by round three when consensus was determined. Round four was completed by 36 (77%) participants. Participants completing all four rounds predominantly included healthcare professionals (78%, n = 28) and patient support group representatives (19%, n = 7). In round one, 21 diagnostic features were voted on. Participants suggested an additional 10 features that were subsequently added to the round two survey. After three rounds, consensus was achieved for five diagnostic features: whiteness, itch, changes in anatomy, burying of the clitoral area, and improvement in response to topical steroids. There were also 12 features voted as ‘important but not critical’, and participants subsequently ranked them in the fourth round. Experts have agreed on five critical diagnostic features for vulval LS in adults, and an additional 12 features that may also be important. Future research should assess these features for diagnostic validity through a multicentre diagnostic test accuracy study.
P091 Surgical management of hidradenitis suppurativa: a 12-month review from a tertiary referral centre on the long-term outcomes of surgical intervention for groin, gluteal, perianal and genital disease
Authors: Hughes Sam , Ferrari Linda , Rashid Ellie , Steyn Mia
Published: June 2024

Despite numerous pharmacological advances in the management of hidradenitis suppurativa (HS), achieving adequate disease control remains challenging. This has led to an increased need for surgical intervention. Representing a tertiary referral centre, run in conjunction with a dedicated colorectal surgery team, we aim to highlight our experience of running a multidisciplinary service and the long-term outcomes achieved with surgical management, in conjunction with traditional medical management. Between October 2022 and October 2023, 28 patients underwent surgical debridement for groin, gluteal, perianal or genital disease. A retrospective cross-sectional analysis was then conducted, comparing their Hidradenitis Suppurativa Physician Global Assessment (HSPGA) scores both pre- and postoperatively. We evaluated the role of patient factors such as body mass index (BMI), smoking status, age at disease onset, number of sites involved and associated inflammatory bowel disease (IBD). Moreover, we assessed whether cotherapy with adalimumab, acitretin or dapsone affected the overall outcome. Within the evaluated 12-month timeframe, 28 patients underwent surgical debridement of groin, gluteal, perianal or genital disease. Most were men (68%), most currently or formerly smoked (75%), the mean BMI was 28.5 kg m−2 and an average of 3 individual body sites were affected. Six patients had associated IBD. At the time of surgery, all patients had an HSPGA score of 3 or above, with 86% having Hurley stage 3 disease. In regard to concomitant medical therapies, 13 were taking adalimumab and seven were taking acitretin. Notably, none of our patients had been prescribed long-term antibiotics. Operatively, all patients underwent debridement of complex fistula (two with the addition of a seton suture). In all cases, wounds healed by secondary intention and no skin grafts were performed. At the 4-month postoperative review, 59% of patients had a reduction in their HSPGA severity score (35% by 1 point and 24% by 2 points). There were no hospital readmissions, no documented postoperative complications and no evidence of disease recurrence. Our collaborative approach with colorectal surgery resulted in a significant reduction in disease severity, emphasizing the impactful role of surgical intervention alongside traditional medical management. This underscores the efficacy of our multidisciplinary service in achieving long-term positive outcomes for patients with complex disease.
P095 Ten cases of scabies successfully treated with topical ivermectin
Authors: Oldham Jaimie , Sahota Anshoo , O’Toole Edel , Cunningham Malvina
Published: June 2024

Scabies is an increasing problem in the UK with a surge in cases reported by dermatologists and the media. It is intensely itchy and caused by the highly contagious mite Sarcoptes scabiei. There are many theories regarding the increased prevalence, including hypotheses related to global warming, increased poverty, reduced treatment availability and resistance. The standard treatments in the UK include topical malathion, topical permethrin and oral ivermectin. All have had significant supply issues as reported by the British Association of Dermatologists. There have also been concerns of permethrin resistance. Oral ivermectin is expensive, with four tablets listed at £116.84 in the British National Formulary (BNF). Finally, oral ivermectin is not licensed in children weighing < 15 kg (although data seem to suggest this is safe). One option that is less used but reported is topical ivermectin. This was in the 2018 Cochrane review that assessed the efficacy of topical permethrin, and oral and topical (as 1% lotion) ivermectin. This showed no difference in efficacy and few or mild adverse events. These findings are also replicated in recent studies and there are case reports of topical ivermectin to treat neonatal scabies that seems resistant to permethrin. In our centre, we have used topical ivermectin (as the 10 mg g−1 cream Soolantra) to treat 10 patients, with great success. The first was a 14-month-old child who weighed 9.2 kg. She had previously had three courses of permethrin and two courses of malathion with ongoing signs and symptoms of scabies, including burrows. The entire family had been treated every time and the entire family (except this patient) was treated with oral ivermectin during the final treatment before topical ivermectin. The patient was treated top to toe with two applications of topical ivermectin cream 1 week apart, with resolution after one application. Subsequently we have had success using the same protocol to treat a 21-year-old man (with no response to four courses of permethrin) and his 53-year-old mother (with no response to three courses of permethrin). We have also treated a 31-year-old man, a 48-year-old man and his partner (all of whom had not responded to one course of permethrin), and a 68-year-old man and his family who had no previous treatment. Our patients have not experienced any adverse effects and there have been no treatment failures. We report on 10 patients who we treated successfully with topical ivermectin. Topical ivermectin provides an exciting option for treatment and, of note, one tube is listed at £27.43 in the BNF, making it significantly cheaper than the oral alternative.
P110 Comparative efficacy of low-dose oral minoxidil, topical minoxidil, and platelet-rich plasma with topical minoxidil in androgenetic alopecia: a randomized controlled trial
Authors: Janaani P , Kumaran Sendhil , Vinay K , Mehta Hitaishi , Sharma Vinod Kumar
Published: June 2024

Androgenetic alopecia (AGA) is conventionally managed with topical minoxidil, while platelet-rich plasma (PRP) and oral minoxidil present alternative options. Head-to-head trials are scarce, necessitating a comparative study. This randomized controlled trial aimed to compare the efficacy of low-dose oral minoxidil (2.5 mg once daily), topical minoxidil (5% twice daily), and PRP (four sessions, conducted every 4 weeks) combined with topical minoxidil 5% twice daily in individuals with AGA. Natural regulatory T cells (Tregs; CD4+ CD25high FOXP3+) reside within hair follicles, fostering the proliferation of hair follicular stem cells through the NOTCH signalling pathway by elevating Jagged1 ligand expression. Additionally, the study explored the impact of these treatments on Treg cell populations – inducible Treg cells (CD4+ CD25low FOXP3+) and natural Treg cells (CD4+ CD25high FOXP3+) – and signalling molecules including cytotoxic T-lymphocyte-associated protein (CTLA)4, NOTCH and Jagged1. In total 66 male participants were randomly assigned to three groups of 22 patients each: oral minoxidil (Group 1), topical minoxidil (Group 2) and PRP with topical minoxidil (Group 3). Clinical and videodermoscopic assessments were conducted every 8 weeks, over 32 weeks. Treg cell populations and signalling molecules were analysed in skin biopsies (n = 5 from each group) obtained at baseline and 32 weeks. At 32 weeks, six (27%) patients each in Group 1 and Group 3, and three (14%) patients in Group 2 showed improvement in the grade of AGA. At 32 weeks, Group 3 significantly surpassed Groups 1 and 2 in increasing terminal hair density (P = 0.03 and P = 0.02, respectively). Group 1 had notably decreased vellus hairs compared with Group 3 (P = 0.02), and no significant difference was seen between Groups 2 and 3 (P = 0.2). Reduction in hair diameter diversity was observed with all three modalities, with earlier responses in Groups 1 and 3 (P < 0.01). A proportionate significant increase in natural Treg cells and a decrease in inducible Treg cells was observed at week 32 compared with baseline, without significant modality-specific differences: Group 1, mean 36.2 (SD 15); Group 2, mean 22 (SD 3.4); Group 3, mean 33.7 (SD 10); P = 0.31. A mean decrease in CTLA4 level and an increase in NOTCH and Jagged1 levels with a weakly negative nonsignificant correlation was observed in all three groups at week 32, with no modality-specific differences. Combining PRP with topical minoxidil achieved superior terminal hair density, while oral minoxidil exhibited an advantage in reducing vellus hair density. The study endorses low-dose oral minoxidil as an alternative to topical use and indicates the benefits of combining oral or topical minoxidil with PRP.
P112 The British Hair and Nail Society present a review of our national grand round of challenging nail conditions and the benefits to the wider British Association of Dermatologists membership
Authors: Sharma Sonia , Fonia Athina , Mowbray Megan , Takwale Anita , Asfour Leila , Laheru Dhruvkumar
Published: June 2024

The British Hair and Nail Society (BHNS) was formed in 2011. We currently have 133 members and invite them to submit challenging cases of nail disorders to our grand round (with relevant history, histopathology and photo- graphs) for review by our expert nail panel. This comprises consultants with nail expertise from around the UK, and together we aim to address the referrers’ queries relating to diagnosis, treatment or both. We appreciate the com- plexity of nail conditions and the limited number of special- ists around the country with an interest in nail conditions. Therefore, we have recently offered the opportunity for all British Association of Dermatologists (BAD) members to submit cases once a year. The aim of our review is to pres- ent the type of complex nail conditions and queries that have been referred to our dedicated national nail conditions grand round and to showcase some of the most educational cases. The nail conditions grand round began in 2018, and since then a total of 21 nail cases (three children and 18 adults) have been submitted from various regions. The main aims of referral included diagnostic expertise (n = 7), aid with treatment plans (n = 3) or both (n = 9). Two cases were referred for help with the need for diagnostic nail biopsy. The median age of patients was 45 years (range 12−77). The cases involved 14 female and 7 male patients. The regions of referral include Gloucestershire, Reading, Cambridge and Scotland. The diagnosis was altered in nine cases (43%). The most common nail condition was psoriasis with nail involvement (n = 4), with the possibility of concurrent condi- tions such as chronic paronychia and subungual keratosis. In one of these cases where the extent of psoriatic nail disease was causing huge psychological burden for the patient, but their Psoriasis Area and Severity Index score was < 10, we supported the application of an individual funding request for biologic therapy. Examples of some of our rare diagnoses include nailbed seborrhoeic keratosis presenting as leucox- anthonychia, and a nailbed myxoid cyst following osteoar- thritic degeneration in distal interphalangeal joints. We hope our presentation showcases to the wider BAD membership the value of our national nail conditions grand round in supporting complex diagnostic and therapeutic decisions, as well as offering support for clinicians in the form of independent funding request submissions or trialling novel therapies, which may have limited evidence. We welcome any future submissions.
BC03 Assessment of atrophic and hypertrophic photoageing in patients with basal cell carcinoma
Authors: Kelly Aine , Mathew Libin , Stefanato Catherine , Ali Faisal , Ayer Jean , Craythorne Emma
Published: June 2024

Two contrasting forms of clinically evident photoageing have been described – hypertrophic and atrophic. Recent studies postulate that hypertrophic photoageing, described as a leathery appearance with coarse wrinkles, may be protective and mitigate skin cancer. Conversely, atrophic skin ageing is described as translucent skin with telangiectasia and skin thinning and is thought to be associated with actinic damage and an increased incidence of skin cancer. Full-face photographs of 102 patients who underwent Mohs surgery for basal cell carcinomas of the cheek during 2018–2023 were selected, and their hypertrophic and atrophic photodamage scored by two dermatologists and a nonmedic independently (score of 0–8, in increasing severity). All histopathology from 102 patients was reviewed. Two of the 102 patients were omitted due to poor-quality slides. Solar elastosis was scored based on the percentage of dermis affected (grade 1 < 50%, grade 2 50–90%, grade 3 100%). Epidermal thickness was measured from an inter-rete ridge region halfway along each specimen. In total, 53% of patients were female and 47% were male; 49% had Fitzpatrick skin type I, 49% type II, and 2% type III. Overall, 89% of patients did not smoke, 9% currently smoked and 2% formerly smoked. Only 3% of patients were immunosuppressed. Five patients (5%) had an atrophic score of 2, 29% of 4, 49% of 6, and 17% of 8. Overall, 22% of patients had a hypertrophic score of 0, 58% of 2, 18% of 4, and 1% of 6. Eighty-eight patients (88%) had a solar elastosis score of 3. Of the patients with severe solar elastosis 70% had an atrophic photoageing score graded as severe (6 or 8). There was no association between sex and atrophic photoageing score. There was an association between solar elastosis grade and atrophic photoageing score. The mean epidermal thickness was lower in patients with a higher atrophic photoageing score (sum of squares 43.6, P = 0.002). The mean epidermal thickness was lower in patients with higher hypertrophic photoageing scores; however, this result was not statistically significant. There was a discrepancy between atrophic scoring and a concordance for hypertrophic scoring between the dermatologist and nonmedical personnel. Epidermal thickness was reduced regardless of sex in both atrophic and hypertrophic photodamaged skin. Most patients in our study had significant solar elastosis in their dermis, although this appeared to be more severe in those with higher atrophic photoageing scores. We postulate that photoageing changes are complex but can be depicted clinically. It is unclear whether dividing patients into atrophic and hypertrophic categories can distinguish histological changes and overall skin cancer risk.
BH08 Evaluating quality-of-life measures for alopecia: a comparative analysis of Dermatology Life Quality Index and Hospital Anxiety and Depression Scale correlations with disease severity
Authors: Lim Chris Puo Nen , Holmes Susan
Published: June 2024

Assessing quality of life (QoL) is crucial in managing patients with alopecia areata (AA), but the optimal health-related quality-of-life (HRQoL) measures remain debated. This uncertainty has been highlighted by recent clinical trials of Janus kinase inhibitors for severe AA, which employed various tools to evaluate the impact of AA and treatment effects on patient QoL. Measures used included generic scores [e.g. Hospital Anxiety and Depression Scale (HADS) and EuroQol (EQ)-5D-5L] and AA-specific scores (e.g. Alopecia Areata Symptom Impact Scale and Skindex-16-AA). Despite the well-recognized psychological impact of severe AA, EQ-5D-5L-based cost-effectiveness models failed to demonstrate significant improvement post-treatment. The current study aimed to evaluate the usefulness of QoL scores [Dermatology Life Quality Index (DLQI) and HADS] routinely collected from patients attending a specialist alopecia clinic. As there is no gold-standard QoL measure for alopecia, we analysed whether there was a correlation between DLQI and HADS, and with clinician-rated disease severity. The influence of psychiatric history and patient age was also assessed. Quantitative data were evaluated using SPSS (version 29.0.1.0; IBM, Armonk, NY, USA) for descriptive and parametric analyses. In total, 179 patients were assessed (17 male, 162 female; age 15–78 years). The results showed moderate positive correlations between DLQI and HADS-D (depression; P < 0.001), DLQI and HADS-A (anxiety; P < 0.001), and DLQI and total HADS (P < 0.001). DLQI correlated positively with clinician-rated disease severity (P = 0.003); however, no association was observed between HADS and clinician-rated disease severity scores. Patients with a pre-existing psychiatric history had higher DLQI (P = 0.03), HADS-D (P < 0.001) and HADS-A scores (P < 0.001). Patients with scarring alopecia tended to have lower DLQI scores, while patients with nonscarring alopecia had higher scores (P < 0.006). There was a statistically significant relationship between DLQI and patients’ ages, with younger patients more likely to have ‘moderate’ or ‘very large’ DLQI (P < 0.004). On the basis of these results, DLQI and HADS correlate moderately; however, only DLQI correlates with clinician-assessed disease severity. Patients with a psychiatric history and nonscarring alopecia tended to have higher scores, and younger patients tended to score more highly using DLQI. The impact of alopecia on patients is often severe; however, the best measure(s) of assessment is unclear. Although it has limitations, DLQI seems to be a reasonable QoL measure for patients with alopecia and correlates with clinician assessment of disease extent. However, further research is required to identify the most useful QoL tools for patients with alopecia, and disease registries will facilitate this work.
BH10 Unequal National Health Service wig provision: toupée or no toupée, that is the question?
Authors: de Brito Marianne , Johnson Amy , Schilling Sue , Asfour Leila , Levell Nick J
Published: June 2024

The psychological impact of alopecia on patients’ quality of life can be significant. Patients may experience loss of confidence, discrimination, social anxiety and other mental health disorders as a result. In the absence of effective and well-tolerated treatments available in the National Health Service (NHS) to treat the underlying cause of the alopecia, wigs can provide an opportunity for patients to live confidently, free of stigma and visible differences. The Alopecia UK Charter for Best Practice for Wigs Provision aimed to support fair and equitable wig provision across the UK, work that was supported by NHS England and NHS Improvement. We investigated wig provision across nonprivate patients in the UK via an online survey. We circulated a three-question, 1-minute survey to dermatology doctors and healthcare professionals seeing nonprivate patients within NHS trusts (England), health boards (Wales and Scotland) or health and social care trusts (Northern Ireland). This was via the Alopecia UK stand at the British Association of Dermatologists (BAD) Annual Meeting 2023, to the circulation of the British Hair and Nail Society membership and events, and via the BAD newsletter. We received 73 responses. Overall, for nonprivate patients with severe alopecia, most reported that wig provision would be straightforward (52%), but a large minority reported variable difficulty, due to patient or other factors (33%), and 5% reported it would be impossible. The remaining 10% did not know. There were respondents from all regions of the UK, with most from England: 59 (Northern Ireland: 2, Scotland: 3, Wales: 7, not stated: 2). The best-represented regions in England were the Midlands (14), the North West (14), North East and Yorkshire (10) and London (9), but there were responses from all regions. There was widespread variation in access to wig provision by different regions. All respondents from Scotland (3 of 3) and the South West (2 of 2) reported wig provision was straightforward, while all respondents from Northern Ireland (2 of 2) reported variable difficulty. At least 50% of the respondents from the East of England, London, Midlands, South East and North West reported wig provision was not straightforward. The findings of this survey reveal widespread variation in ease of access to wig provision throughout different regions of the UK. This demonstrates a lack of equality between patients with alopecia in different regions of the UK and impacts on patient choice. This goes against the Alopecia UK Charter for Best Practice for Wigs Provision. We hope that these findings will have implications at health policy level to improve and standardize access for all patients with alopecia who want and need a wig.
BH13 Current wig prescribing practices and financial evaluation in a National Health Service foundation trust: lessons learnt and future challenges
Authors: Ross Hannah , Ong Xian Hue , Harries Matthew , Asfour Leila
Published: June 2024

Alopecia is classified into nonscarring, such as alopecia areata, and scarring variants, including lichen planopilaris and frontal fibrosing alopecia. Treatment options are limited and there are restrictions on what is available on the National Health Service (NHS). Therefore, many patients require wigs or hairpieces as the mainstay of their management. Significant psychological burden has been associated with alopecia, and the use of wigs can have a positive impact on patients’ wellbeing. Montgomery et al. highlighted the unequal NHS wig provision (Montgomery K, White C, Thompson A. A mixed methods survey of social anxiety, anxiety, depression and wig use in alopecia. BMJ Open 2017; 7: e015468). This has led to the recommended ‘Charter for best practice for NHS wig provision’ by Alopecia UK and the British Association of Dermatologists and British Hair and Nail Society published in June 2022. They propose that all patients with alopecia should be able to access a wig via NHS prescription that is appropriate for their skin and hair colour, age and preference. Despite this, discrepancies exist in how wigs are funded in different regions and trusts. All our wig prescriptions are incurred by each department. Due to inflation these costs are rising. This has led to our department’s review of budgets and current prescribing practices. Our hospital’s overall gross cost of wig orders was £193 403 in 1 year. Our aim was to establish the wig prescribing practices in a single centre, which also provides a specialist hair clinic service, and the costs associated with current practices. We reviewed all wig prescriptions throughout our hospital over 12 months. We collected the following parameters: prescribing department, age, sex, diagnosis, number and type of wigs per year, cost per prescription and patient’s address. Patients who were seen in our hair clinic also had psychology-related scores reviewed. In total 324 prescriptions were issued to 200 patients with a median age of 52 years (range 4–87). There was a female predominance (97.5%). Nonscarring alopecia accounted for 57.7%. Overall, 60.5% of the prescriptions issued were for acrylic wigs, with the remainder prescribed human hair wigs. Prescriptions for out-of-area patients accounted for 69.1%. Psychological assessment using validated questionnaires including Dermatology Life Quality Index, Patient Health Questionnaire-9 and General Anxiety Disorder-7 were collected from patients’ initial consultations compared with their current scores. Wigs are an essential treatment for all patients with alopecia. Our results demonstrate the level of demand, the variety in diagnoses and a vast age range. Targeted treatments for alopecia areata are currently unavailable on the NHS; therefore, access to wigs remains vital in its management. Further work is required to ensure equitable NHS wig prescribing; we support Getting it Right First Time’s ongoing review of this.
BH15 The burden of alopecia areata: examining baseline health-related quality of life and clinical assessment tools
Authors: Boyle Aoife , Wall Dmitri , McDonald Ian
Published: June 2024

Alopecia areata (AA) is an autoimmune-mediated, nonscarring hair loss that affects 2% of the population. Patients with AA experience significant impairment in health-related quality of life (HRQoL), particularly mental health (Senna M, Ko J, Glashofer M et al. Predictors of QOL in patients with alopecia areata. J Invest Dermatol 2022; 142: 2646–50). The Severity of Alopecia Tool (SALT) is a physician-derived, semiobjective measure, frequently used in clinical practice, that calculates the extent of scalp hair loss. Nonscalp hair or quality of life is not incorporated and may explain why SALT can underestimate the overall impact of AA (Senna et al.; Wall D, Rees H, Bokhari L et al. Signposts to the promised land in alopecia areata. J Invest Dermatol 2023; 143: 9–10). The Dermatology Life Quality Index (DLQI) and Hospital Anxiety and Depression Scale (HADS) are common HRQoL assessments. Emerging disease-specific tools, which examine both hair loss extent and quality-of-life impact, include the Alopecia Areata Patient Priority Outcomes (AAPPO) and the Alopecia Areata Symptom Impact Scale (AASIS). This study aimed to determine the baseline HRQoL burden among adult patients with AA in a newly developed hair research clinic. A secondary aim was to examine how HRQoL assessments compared with SALT vs. newer compound measures, AAPPO and AASIS. A retrospective chart review identified 20 patients with complete data. The mean SALT score was 61.2. The mean DLQI score was 11.05, indicating a very large impact on QoL as measured by DLQI bands. Overall, 15% of patients experienced no effect, 25% a small effect, 10% a moderate effect, 30% a very large effect and 20% an extremely large effect. The mean HADS-D (depression) score was 8, indicating a borderline score. In total, 47% had normal scores, 21% had borderline scores and 32% had abnormal scores. Similarly, the mean HADS-A (anxiety) score was borderline at 9.9; 26% had normal scores, 21% borderline scores and 53% abnormal scores. The mean total AAPPO score was 16.8 out of 44. The highest mean subscore was the emotional symptoms subscore of 9.9 out of 16, followed by a hair loss subscore of 9 out of 16 and an activity limitations subscore of 3.9 out of 12. The mean total AASIS score was 118 out of 170. The highest mean subscore was the symptoms subscore of 36.9 out of 70, followed by the feelings subscore of 17.5 out of 40 and daily functioning subscore of 24.1 out of 60. SALT had a nonsignificant positive association with HRQoL. AAPPO and AASIS had significant positive associations with HRQoL. In conclusion, our study has demonstrated a significant impact on HRQoL among patients with AA, irrespectively of the degree of hair loss. Our study has also shown that the emerging disease-specific tools, AAPPO and AASIS, are superior in determining the overall impact of AA compared with SALT.
British Photodermatology GroupOral presentationsPD01 Accelerated oral psoralen–ultraviolet A therapy in the management of polymorphic skin eruption: real-world data from a specialist centre
Authors: Campbell Fiona , Montgomery Rachel , Goulden Victoria
Published: June 2024

Polymorphic light eruption (PLE) is a common, debilitating disease. First-line management includes photoprotective measures, which are restrictive, and ineffective for severe cases. Many patients notice increased tolerance (hardening) to sunlight as summer progresses. This phenomenon can be induced by exposure to artificial sources of ultraviolet. Many studies have demonstrated the efficacy of both narrowband ultraviolet B radiation (NB-UVB) and psoralen–ultraviolet A therapy (PUVA) in reducing PLE flares (Ling TC, Clayton TH, Crawley J et al. British Association of Dermatologists and British Photodermatology Group guidelines for the safe and effective use of psoralen–ultraviolet A therapy 2015. Br J Dermatol 2016; 174: 24–55). NB-UVB is generally used first line due to simplicity of treatment and long-term safety. PUVA is second-line phototherapy and, as PUVA is associated with a dose-dependent risk of skin cancer, shorter treatment courses are desirable. A study by Palmer and Friedmann showed that six PUVA treatments provided as much protection as 12 in patients with PLE (Palmer RA, Friedmann PS. A comparison of six and 12 PUVA treatments in the prophylaxis of polymorphic light eruption. Clin Exp Dermatol 2004; 29: 141–3). We have retrospectively reviewed our patients with PLE who did not gain benefit with NB-UVB hardening and were treated with ‘accelerated’ PUVA. In the early spring, patients were treated on exposed sites with four UVA exposures after taking oral psoralen. The initial irradiation dose was 70% of the minimal phototoxic dose. Doses were then escalated by 1 J cm−2 each visit for a total of four exposures only. To prevent a significant flare of PLE during treatment, patients were prescribed oral prednisolone 20 mg once daily, commencing on the day of the first exposure and continued for the 2-week course of treatment. Fourteen patients (12 female, two male) with severe PLE and poor response to narrowband NB-UVB were treated. The age range was 25–67 years. Thirteen patients experienced a significant reduction in severity of their PLE flares. Only one patient (male, 39 years) found the treatment unsuccessful. Half of the patients went on to have further courses of accelerated PUVA. No patient experienced significant adverse effects. Our experience has demonstrated that only four exposures of oral PUVA can induce significant skin hardening, preventing PLE flares. This has the significant advantage of a short course of treatment and reduction in cumulative exposure for patients who frequently require repeated courses of treatment. Oral steroid cover is necessary to suppress reactions during treatment but was well tolerated in all cases.
PD11 Simultaneous development of photosensitivity in a father and daughter: de novo or exposure induced?
Authors: Ross Hannah , Parkin Donna , Ayer Jean
Published: June 2024

Chronic actinic dermatitis and photoaggravated eczema are rare photosensitivity disorders that, while considered to be immunologically mediated, usually develop de novo. A 4-year-old White British girl and her 33-year-old White British father presented to a tertiary photobiology clinic with similar photodistributed eruptions that occurred acutely following exposure to an airborne glyphosate organophosphate-containing weedkiller. The eruptions persisted thereafter on exposure to sunlight. Approximately 15 min of sun exposure is sufficient to provoke a red, scaly and blistering eruption around 6–12 h later. The eruption affects only photoexposed sites, including the posterior neck, elbows, dorsal hands and cheeks, and episodes persist for several days. The father underwent monochromated light testing to narrowband widths of ultraviolet (UV)B, UVA and visible radiation and demonstrated exquisite photosensitivity. Provocation testing to broadband UVA and a solar simulator were abandoned after the first exposure due to a significant erythemal and oedematous response. The daughter underwent modified monochromator testing due to her age, but similarly demonstrated significant photosensitivity with reduced thresholds from 300 to 370 nm. Reduced-dose provocation with broadband UVA and a solar simulator resulted in a mild, blotchy, papular erythema. Several months later, both father and daughter reported worsening of their photosensitivity. Repeat photoinvestigation carried out 15 months following the initial exposure to the glyphosate, suspected to be the precipitant, showed an objective deterioration in photosensitivity in both patients, resulting in formal diagnoses of chronic actinic dermatitis. Reports of phototoxicity after contact with glyphosate formulations are exceedingly rare. However, there is a report of the preservative coformulant benzothiazolinone (BIT), found in glyphosate formulations, that was confirmed to be phototoxic through exposure of the skin for 24 h followed by UVA exposure (Hindson C, Diffey B. Phototoxicity of glyphosate in a weedkiller. Contact Dermatitis 1984; 10: 51–2.) The reported papulovesicular eruption that followed BIT and UVA exposure is in keeping with the eruption seen in our patients. However, photopatch testing to BIT was negative in both patients. There are no other reports in the literature of photosensitization following organophosphate exposure with prolonged and worsening effects 15 months after exposure. Therefore could it be possible that two de novo cases have occurred in one family at exactly the same time, or could the initial phototoxic reaction have triggered an immune response that has subsequently caused the development of chronic actinic dermatitis?
Poster presentationsDS12 A rare ophthalmological consequence of cutaneous malignant melanoma
Authors: Mahendiran Thushika , Orpin Stephen , Patil Ajay
Published: June 2024

A 66-year-old man was referred urgently to dermatology from ophthalmology with a short history of developing multiple pigmented lesions on the trunk and in the axillae, the concern being that he had developed a malignant melanoma. He had been under their care for almost a year with a history of a subacute decline in vision in both eyes leading to ‘tunnel vision’. His medical history was complex and included acute myeloid leukaemia secondary to myelodysplastic syndrome treated with fludarabine, melphalan and alemtuzumab (FMA) reduced-intensity sibling allograft. Following bone marrow transplant and chemotherapy, he had post-transplant complications including cytomegalovirus reactivation, cytopenia secondary to splenomegaly, and possible graft-versus-host disease (bronchiolitis obliterans and brachial plexitis). He had presented to ophthalmology with his vision at 6/12 and 6/9 in the right and left eye, respectively. On examination, there were poorly reactive pupils with normal pupil reflexes and normal colour vision in both eyes. The visual field to confrontation was significantly constricted. Optical coherence tomography scans demonstrated outer retinal loss in the parafoveal region with macular oedema in both eyes. An autoimmune retinopathy was suspected due to these findings. Electrodiagnostic tests were consistent with this. A secondary survey was undertaken, and a positron emission tomography scan showed no evidence of active acute myeloid leukaemia or other malignancy. Neuroimaging demonstrated generalized cortical atrophy with no acute intracranial abnormalities. He was treated for a presumed nonparaneoplastic autoimmune retinopathy. He was commenced on dexamethasone intravitreal implants and mycophenolate mofetil 1 g twice a day. At review, as well as him having multiple seborrhoeic keratoses, there was an atypical melanocytic lesion on the back, which was excised urgently. This proved to be a malignant melanoma in situ with extensive regression; subsequent re-excision revealed no residual tumour. Therefore, he was diagnosed with presumed melanoma-associated retinopathy (MAR) and commenced on monthly intravenous immunoglobulin 1.5g kg−1. On subsequent visits he subjectively felt his vision had remained stable with no further deterioration. MAR is a rare paraneoplastic ocular condition. This is an autoimmune retinopathy, where a molecular mimicry occurs between the neuroectodermally derived melanocytes and the retinal proteins. MAR can precede the diagnosis of malignant melanoma, with other initial investigations being negative. This case highlights the importance of referring patients for a thorough dermatology examination for an individual presenting with an autoimmune retinopathy. With early detection and treatment, irreversible immune-related retinal damage and associated visual loss can be mitigated.