bluuebunny/crossref_metadata_2025 huggingface dataset:
CPC08 Two fatal cases of fulminant, rapidly progressive interstitial lung disease secondary to MDA5 dermatomyositis
Authors: Shareef Narin , Natkunarajah Jana
Published: June 2024

Anti-MDA5 dermatomyositis (DM) is a rare systemic autoimmune condition associated with clinically amyopathic DM and rapidly progressive interstitial lung disease (RP-ILD). It is associated with unique skin features including cutaneous ulceration, eyelid oedema, palmar papules and mechanic’s hands. We present two challenging cases of anti-MDA5 DM with atypical skin manifestations, complicated by RP-ILD, which unfortunately resulted in death in both patients. The first case is a 47-year-old Egyptian woman who initially presented with erythema and burning sensation of the fingertips, thigh rash, arthralgia, joint swelling, dry cough and reduced exercise tolerance. She was diagnosed with undifferentiated inflammatory arthritis and possible amyopathic DM and started on methotrexate and systemic steroids. An autoimmune panel showed weakly positive rheumatoid factor but negative antinuclear antibodies, extractable nuclear antigen, dsDNA, antineutrophil cytoplasmic antibodies and anti-Jo1. Subsequently she presented to accident and emergency with worsening breathlessness and productive cough and was admitted to the intensive care unit, treated for pneumonia. A high-resolution computed tomography (CT) scan was reviewed at a tertiary multidisciplinary team, showing an RP-ILD picture, most likely due to MDA5 DM. She was started on pulsed intravenous methylprednisolone and transferred to a tertiary centre for extracorporeal membrane oxygenation (ECMO) and consideration of rituximab. Unfortunately, she died shortly after. She demonstrated positive anti-MDA5 serology. The second case is a 60-year-old Chinese woman who initially presented to ophthalmology with left-eye oedema and was diagnosed with preseptal cellulitis. Subsequently, she presented again to accident and emergency with fatigue, unintentional weight loss, and reduced mobility. She was cachectic with ulcerating skin lesions on her shoulders and hips. Initial CT of the chest–abdomen–pelvis showed patchy consolidation in both lungs, with nodularity and ground-glass changes. She developed pyrexia and mild hypoxia and was treated for bilateral pneumonia. During admission, fasciculations in her upper limbs and tongue prompted a neurology review. Nerve conduction studies demonstrated myopathic changes. Creatine kinase was elevated, and magnetic resonance imaging of the lower limbs confirmed diffuse oedema. Concurrently, she was noted to have mechanic’s hands and Gottron papules. She developed severe type 1 respiratory failure, requiring transfer to intensive care. Repeat CT imaging showed worsening bilateral consolidation and ground-glass changes, with pleural effusions. Her rapidly progressive respiratory failure in the context of likely DM prompted urgent referral to a tertiary centre for ECMO and aggressive immunosuppression. Unfortunately, she died 3 weeks later. Autoantibody testing confirmed positive anti-MDA5 and Ro52 antibodies.
P002 Inflammatory vitiligo with raised borders: a rare case of pseudolymphoma mimicking hypopigmented mycosis fungoides
Authors: Daruish Maged , Grossmith Cecilia , Taibjee Saleem
Published: June 2024

A 51-year-old woman was referred to our department with a mildly itchy persistent rash that had started 3 years earlier on the back of her thighs, leaving pale skin as it progressed. She noted worsening of the rash during winter months. There was a history of psychological stress preceding the onset of the rash. Clinical examination revealed bilateral symmetrical annular hypopigmented patches with erythematous and slightly scaly raised edges. Symmetrical patches of depigmentation were also seen on her forearms. An incisional biopsy from the left posterior thigh, including the hypopigmented centre and adjacent erythematous rim, revealed unremarkable epidermis corresponding to the hypopigmentation, while the advancing edge showed interface changes with a bandlike lymphohistiocytic infiltrate and prominent lymphocytic exocytosis. The lymphocytes were positive for pan T-cell markers (CD2, CD3, CD5, CD7), with relatively equal CD4 and CD8 populations. Melan-A indicated reduced density of melanocytes. There was no evidence of clonality on T-cell receptor (TCR) gene rearrangement studies. Punch biopsy from a depigmented patch on the right forearm was unremarkable on haematoxylin and eosin sections. However, melan-A indicated that the epidermis was completely devoid of melanocytes. The diagnosis of inflammatory vitiligo with raised borders (IVRB) was made. IVRB is a rare subtype of vitiligo that typically presents with a raised erythematous, scaly and pruritic edge surrounding depigmented patches. Differentiating IVRB from hypopigmented mycosis fungoides can be challenging, both clinically and histologically, due to the prominent lichenoid infiltrate with epidermotropism and the predominance of CD8+ lymphocytes that can be found in both. Helpful clues include the characteristic erythematous border, as well as lack of clonality on TCR gene rearrangement studies in IVRB (Gomez-Moyano E, Vera-Casaño A, Gamero AH et al. Inflammatory vitiligo or hypopigmented mycosis fungoides? J Pediatr Hematol Oncol 2010; 32: 338–9). Melanocytes and epidermal melanin are more likely to be preserved in hypopigmented mycosis fungoides [El-Darouti MA, Marzouk S, Azzam O et al. Vitiligo vs. hypopigmented mycosis fungoides (histopathological and immunohistochemical study, univariate analysis). Eur J Dermatol 2006; 16: 17–22]. Clinicopathological correlation is crucial to make the distinction.
P026 Teledermatology from the other side: a clinical photographers’ perspective
Authors: Uthayakumar Aarthy , Searle Tamara , Elshimy Noha
Published: June 2024

Teledermatology has transformed the way we deliver our skin cancer service, with medical photographers playing a vital role in our trust. We sought to further streamline our existing teledermatology service and explore challenges faced by the photography team. Our teledermatology model involves patients directly attending the hospital for a professional photography appointment before consultant triage of the lesion(s). After observing teledermatology photography lists with detailed photographer feedback, 1 week of teledermatology clinics across all three sites of the trust were analysed. Referral type, discrepancies between the general practitioner (GP) referral and photos taken, and chaperone availability were explored, in addition to the referral pathway and patient information supplied. In total 122 teledermatology patients were included. Photographers highlighted difficulties with patients requesting lesions not specified on the GP referral to be photographed, and not having sufficient information prior to their teledermatology appointment, making it often difficult to manage expectations. Furthermore, due to minimal staffing, the availability of chaperones was often limited. In 19% of cases there was a discrepancy between the GP referred lesion and photograph taken, which was due to additional lesions being photographed (35%), patients having multiple moles (22%), and unlikely suitability for teledermatology and no GP referral being present (17%). Improvements have been implemented at different levels along the teledermatology pathway to further streamline the service and reduce some of the pressures faced by our clinical photographer colleagues. Modifications to the GP suspected skin cancer pathway referral make it clearer which patients are suitable for teledermatology, and request a mandatory lesion and locator photograph. The triage process has been altered to improve robustness, with an additional triage step to minimize patients inappropriate for teledermatology being booked in, such as those with more than three lesions, genital lesions and patients on stretchers. Patient information has been clearly displayed in the medical photography department, highlighting that only the referred lesion can be photographed, and a paper copy of the teledermatology patient information leaflet is provided to highlight the next steps to the patient. This minimizes questions directed at the photographers and aids management of patient expectations. Finally, a protocol for medical photographers has been implemented to standardize teledermatology images taken, with changes to include polarized and nonpolarized dermoscopy. With these changes we have minimized the challenges faced by our clinical photography colleagues, whose perspective and experience of a successful teledermatology service is critical, and we believe this should be explored in order to make meaningful improvements.
P051 The what, how and why of basal cell carcinoma: natural progression and surgical intervention
Authors: Lam Mun Wai , Wells Helena , Gibbs Heidi , Zhao Andrew , Tso Simon , Wernham Aaron
Published: June 2024

Basal cell carcinomas (BCCs) are slow-growing keratinocyte tumours. During the COVID-19 pandemic, the British Association of Dermatologists and British Society for Dermatological Surgery recommended deferment of surgical treatment for BCCs by 3–6 months unless they were causing significant symptoms or were at higher risk of growth. The deferment of surgical treatment for BCCs provided an unexpected opportunity to evaluate the natural history of BCC evolution given the paucity of evidence and conflicting outcomes of published literature. This study evaluated the natural progression of BCCs while awaiting surgical intervention, to better understand their natural growth and development. We also examined whether delays in surgery had implications on clinical outcomes. Patients with a suspected diagnosis of BCC, who had a surgical procedure planned between February and April 2023, were included in the data collection. Retrospective analysis was performed on the data, including waiting time for surgery, subtype of BCC, the size of the lesion, the location of the lesion, the planned and actual surgery performed and the patients’ symptomatology. Fifty-five patients, with a total of 70 lesions, were included in this analysis. Fifty lesions were found on the face and the others were on the trunk or limbs. The mean sum of BCC size was 91.7 mm2, while a larger mean size of BCCs of 119 mm2 was found on the trunk and limbs compared with the face (mean size 80.8 mm2). Twenty per cent of the cases had a larger procedure than originally planned at the time of booking. A regression ana­lysis showed 0.36 mm2 in growth on average (P < 0.002), and 0.0045% (P < 0.002) each day since presentation. Both values are statistically significant. A positive relationship between growth and time between presentation and surgical appointment (multiple R of 0.36) was demonstrated. The top three symptoms reported include itching (39%), crusting (36%) and bleeding (30%). In conclusion, our data reveal that while awaiting a surgical intervention, a BCC is likely to increase in size. Patients can therefore end up with larger and more complex procedures than originally planned. The symptoms experienced by patients should also be taken into consideration when planning surgery. Traditionally BCCs are not prioritized on a dermatology surgical list, compared with other skin cancers, but our findings demonstrate that a delay in surgical intervention can result in larger procedures being performed, and as a consequence increased morbidity to patients with greater impact on their quality of life.
P056 Reflectance confocal microscopy and basal cell carcinoma: is it time to embrace the new technology?
Authors: Nicholls Isabelle , Baloch Hina , Garioch Jennifer , Fadhil May
Published: June 2024

Reflectance confocal microscopy (RCM) is a noninvasive technique for in vivo examination of the skin. In vivo RCM can be used to diagnose basal cell carcinoma (BCC) noninvasively. Previous studies have demonstrated that RCM is an accurate technique for the diagnosis of BCC. RCM has the advantage that it is noninvasive and provides the diagnosis within a few minutes. By contrast, the current standard of care requires an invasive biopsy, taking several days before the result is available, and is costly and can result in sampling errors. We provide a snapshot of how we have integrated RCM into our service, and how it has reduced the number of biopsies, resulting in significant cost savings and shortening patients’ pathways. Sixty-three patients with suspected BCC of the head and neck were referred to our RCM clinic in January, February and March 2023. A diagnosis of BCC was made by RCM in real time in 89% of cases (56 of 63). Confirmation of the diagnosis of BCC in clinic facilitated discussion with the patient at the same outpatient attendance with regards to treatment, without the need for an additional outpatient visit. Overall, 11% of patients (seven of 63) suspected of having a BCC, whose diagnosis could not be confirmed by RCM, required a biopsy that confirmed the diagnosis of BCC. The median turnaround time for the biopsy result was 12 days. The cost of a punch biopsy in our hospital is £330 per patient, of which £176 is attributable to histopathology costs. Following the diagnosis of BCC, 73% (46 of 63) were referred directly for Mohs surgery, 12% (eight of 63) had conventional excision, 5% (three of 63) were referred for radiotherapy, and 10% (six of 63) were managed conservatively. We have shown that integrating RCM into our dermatology service has negated the need for biopsy in 89% of head and neck BCCs referred to the RCM clinic. RCM has resulted in shortening of patients’ pathways, it has reduced the pressure on our histopathology service, it has lessened the risk of false negative biopsies due to sampling errors, and it has produced significant cost savings. The diagnosis of BCC by RCM is a simple skill to acquire and allows the clinician to make the diagnosis with a few minutes. For patients, it is a more acceptable method of diagnosing BCC without recourse to biopsy. For the wider NHS, it has the potential for significant cost savings.
British Hair and Nail SocietyOral presentationsBH01 (P087) The British Hair and Nail Society present a review of our national grand round of challenging hair disorders and the benefits to the wider British Association of Dermatologists membership
Authors: Sharma Sonia , Bryden Alyson , Clayton Nicola , Farrant Paul , Mowbray Megan , Holmes Susan , Therianou Anastasia , Al-Nuaimi Yusur , Meah Nekma , Asfour Leila , Takwale Anita
Published: June 2024

The British Hair and Nail Society was formed in 2011. We currently have 133 members and invite them to submit challenging cases of hair disorders to our grand round (with relevant history, histopathology and photographs) for review by our expert hair panel. This comprises consultants with hair expertise from around the UK, and together we aim to address the referrers’ queries relating to diagnosis, treatment or both. We appreciate the complexity of hair disorders and the limited number of specialist hair clinics around the country, and 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 present the types of complex hair disorders that have been referred to our dedicated national hair-­related grand round and showcase some of the most educational cases. The hair disorders grand round began in 2018 and since then a total of 26 hair cases (10 children and 16 adults) have been submitted from various regions. The main aims of referral include diagnostic expertise (n = 4), aid with treatment plans (n = 8) or both (n = 14). The median age of patients was 33 years (range 4–75). There were 14 female and 12 male cases. The regions of referral include Oxford, Brighton, Manchester and Scotland. There were equal numbers of scarring alopecia (n = 13) and nonscarring (n = 13) cases. The most common nonscarring hair condition was alopecia areata (n = 6), with the possibility of other concurrent hair conditions (n = 1) or an underlying genetic disorder (n = 3). The most common diagnosis of scarring alopecia was folliculitis decalvans (n = 6). The diagnosis was altered in 10 cases (38%). Examples of some of our rare diagnoses include keratosis follicularis spinulosa decalvans, genetic hypotrichosis and scalp dermatomyositis. We reviewed cases of recalcitrant disease such as folliculitis decalvans, and novel therapeutics were suggested such as the use of naltrexone, utilizing photodynamic therapy after removing crusts, and even the use of manuka honey and cannabinoid oil. Our grand round has recommended independent funding requests in three cases and supports applications from clinicians for their patients with complex conditions. We hope our presentation showcases to the wider BAD members the value of our national hair disorders grand round in supporting complex diagnostic and therapeutic decisions, as well as offering support for clinicians in the form of individual funding request submissions or trialling novel therapies, which may have limited evidence. We welcome any future submissions.
BH14 Bald-faced lies: a qualitative review of misinformation on alopecia
Authors: Finnegan Paula , O’Connor Cathal , Murphy Michelle
Published: June 2024

Hair loss, or alopecia, is a major issue worldwide, and can be associated with negative psychological effects. Patients often use the internet and social media to research health-related issues. Health misinformation can confuse patients and have a negative impact on decision making, leading patients to search for illogical ‘causes’ and seek groundless ‘cures’. A PubMed literature search was performed, using the terms ‘alopecia’ AND ‘misinformation’ OR ‘disinformation’ OR ‘conspiracy theory’, alongside a Google search using combinations of these terms. Further searches were also performed on social media platforms including Instagram, TikTok, X (formerly Twitter) and Facebook. Four papers were deemed to be appropriate for inclusion. Common myths highlighted on social media included false causes of hair loss, criticism of conventional hair loss treatments, recommendation of alternative hair loss treatments (including for chemotherapy-induced hair loss) and unhelpful haircare practices. False causes of hair loss included hat wearing, sun exposure, excess washing or brushing, use of gelatin-containing hair products, excess testosterone, and sexual intercourse. Many posts criticized conventional alopecia treatments, including minoxidil, topical steroids, finasteride and Janus kinase inhibitors. Several alternative treatments were promoted online, often as ‘natural’ supplements, such as zinc, iron, biotin, and various oils and extracts. Certain common haircare practices were discouraged or recommended online, such as hair brushing and hair straightening. All healthcare professionals, including dermatologists, are responsible for actively combatting health misinformation.
DS04 A transcontinental qualitative comparison study of two Mohs external quality assurance programmes
Authors: Aslam Arif
Published: June 2024

Mohs micrographic surgery (MMS) has been shown to be an effective treatment for nonmelanoma skin cancer. It provides distinct advantages over traditional excisional surgery and its success rate is dependent on the accurate microscopic evaluation of carefully mapped specimens. The Mohs surgeon must be able to translate abnormal findings on the tissue map into appropriate sequential tumour removal. A critical component of this technique is the surgeon’s skill in interpreting histological specimens. Some studies have investigated the concordance of Mohs surgeons’ interpretation of frozen sections with that of dermatopathologists. The American College of Mohs Surgeons has successfully run an annual diagnostic quality control virtual exam. The Australasian College of Dermatologists (ACD) has a well-established external and independent quality assurance programme in conjunction with the Royal College of Pathologists Australia Quality Assurance Program. The British Society for Dermatological Surgery launched its own external quality assessment programme in 2022. This study compares the quality control programmes of both Australia and the UK and highlights key differences and lessons from both.
DS11 Buffering of lidocaine, time for a British Society for Dermatological Surgery position statement?
Authors: Nguyen Uyen , Habaluyas Katrina , Oliphant Thomas
Published: June 2024

Patients often experience pain or discomfort during local anaesthetic administration in Mohs surgery. Buffering local anaesthetics with sodium bicarbonate has been proven as a potential means to mitigate this pain in various research. However, despite the evidence, there are no standardized guidelines in the UK outlining the application of sodium bicarbonate buffering, which results in its limited application in practice and potential to improve patient comfort and quality of healthcare. This study investigates the usage of sodium bicarbonate-buffered Xylocaine solution in Mohs micrographic surgery as a simple, effective technique to reduce discomfort associated with the injection of local anaesthetic at a tertiary centre in the UK. Sodium bicarbonate (2 mL of 8.4% w/v) was mixed with 20 mL of Xylocaine 1% (lidocaine 1% with adrenaline 1 : 200 000) in a ratio of 1 : 10 to create a buffered solution. This buffered mixture was used for anaesthesia during Mohs surgery procedures on the head and neck. Pain assessment was conducted using a numerical rating scale ranging from 0 to 10, with 10 representing the worst pain. Pain scores were collected for each lesion injected in all patients receiving unbuffered Xylocaine and buffered Xylocaine. Unpaired t-tests were used for statistical analysis to compare the average pain score per lesion in both groups. The study included 62 patients, 28 receiving unbuffered Xylocaine and 34 receiving buffered Xylocaine. In total, 37 lesions were injected with buffered Xylocaine, and 47 lesions were injected with unbuffered Xylocaine. The average pain score for each lesion in the buffered Xylocaine group was lower than for the unbuffered Xylocaine group: 0.94 and 1.76, respectively (P = 0.03). For patients receiving injections to the nose (n = 16), 11 received buffered Xylocaine for 12 nose lesions, and five received unbuffered Xylocaine group for six nose lesions. The average pain score per nose lesion in the buffered Xylocaine group (0.75) was notably lower than that in the plain Xylocaine group (3.8) (P = 0.002). Additionally, 17 patients were surveyed regarding their previous experiences with unbuffered Xylocaine injections at the same anatomical location. Out of these, 16 patients reported that buffered Xylocaine injections were less painful, while only one patient perceived no difference in pain. No adverse effects related to sodium bicarbonate were reported. The study demonstrates that buffering Xylocaine 1% with sodium bicarbonate 8.4% is a simple and effective technique to reduce discomfort associated with the injection of local anaesthetic among patients undergoing Mohs micrographic surgery, potentially improving overall patient satisfaction. This highlights the need for comprehensive guidelines to guide its integration into practice with the goal of optimizing patient care.
DP08 Striking post COVID-19 vaccine aseptic pustular folliculitis, a follicular variant of acute generalized exanthematous pustulosis
Authors: Patel Nikesh , King-Stokes Natalie , Carter Jonathan , Carr Richard
Published: June 2024

This case report documents the unique presentation of a 46-year-old woman who developed a widespread follicular pustular rash, prominently affecting her face, neck, upper chest and back, merely 4 days after receiving the Pfizer–BioNTech COVID-19 vaccine. Laboratory investigations revealed an elevated neutrophil count of 10.6 × 109 L−1 and an increased C-reactive protein level of 96 mg L−1. A skin biopsy showed a striking neutrophilic pustular folliculitis, characterized by the absence of viral inclusions and the presence of neutrophil exocytosis in the adjacent epidermis. A diagnosis of a follicular pustular variant of acute generalized exanthematous pustulosis was proposed. In response to the diagnosis, the patient was initiated on a therapeutic regimen, including prednisolone at 30 mg and topical applications of clobetasol propionate for her body and fusidic acid–betamethasone valerate for her face. The treatment approach aimed at alleviating the inflammatory response associated with the neutrophilic infiltration observed in the skin biopsy. The patient exhibited a slow yet progressive improvement in her rash, which transitioned from a pustular to a nonpustular presentation. This case contributes to the growing body of evidence regarding cutaneous manifestations following COVID-19 vaccination. The association between the patient’s symptoms and the Pfizer–BioNTech vaccine suggests a potential link, emphasizing the importance of vigilance in monitoring adverse events postvaccination. While the specific mechanisms underlying such reactions remain unclear, the prompt initiation of corticosteroid therapy, as demonstrated in this case, appears effective in managing the inflammatory cutaneous manifestations. The patient’s positive response to treatment underscores the clinical significance of recognizing and promptly addressing these rare dermatological side-effects associated with COVID-19 vaccination. In conclusion, this case report sheds light on a distinctive presentation of neutrophilic pustular folliculitis following COVID-19 vaccination, highlighting the importance of dermatological vigilance in the ongoing global vaccination efforts. Further research is warranted to elucidate the underlying pathophysiological mechanisms and establish optimal management strategies for these rare cutaneous reactions.
DP23 Stage presentation of melanomas arising in the back: a 20-year retrospective study of site-specific distribution and review of the literature
Authors: Kubba Faris , Hawkins Joanna , Alaani Haya
Published: June 2024

This is a study over 20 years to assess the pathological stage of presentation for melanomas arising in the back. We have reviewed studies for presentation of body-site-specific melanoma to compare against our findings and to see whether there has been any significant improvement in the rate of early detection. We extracted and analysed data from archived histopathology reports on the WinPath system by running a SNOMED code search on all melanomas reported from 2001 to 2011 and selected those affecting the back. The age of presentation varied from 29 to 94 years (mean 58.7). Twenty patients were male and seven female (male-to-female ratio 2.9 : 1). Most cases presented as American Joint Committee on Cancer 8th Edition stage pT1 (11 were 1a, 2 were 1b), pT2 (n = 2), pT3 (n = 4) and pT4 (n = 2). Six were in situ melanomas, mostly lentigo maligna or arising from severely dysplastic naevi. Breslow depth ranged from 0.1 to 6.5 mm (mean 1.6 mm). The cases were mostly from the upper back (n = 10). The melanoma types were superficial spreading (n = 14), nodular (n = 2), lentigo maligna (n = 3) and melanoma in situ from dysplastic naevi (n = 3). On reviewing the literature, we found one study suggesting that melanomas in visible areas present earlier. Another concluded that a melanoma is more often self-detected in female patients, explained by the high proportion of lesions in men presenting on the back. Further research suggests that older patients recognize melanomas at a lower rate than younger patients. Older men frequently have lesions in difficult-to-see areas such as the scalp and the back, and therefore also may be limited to self-notice new or changing lesions. The role of family members is as important in early detection as that of trained health professionals. As a delay in diagnosis may be responsible for the thicker melanomas in hidden areas, preventive and screening programmes should stress the importance of not neglecting these locations in self-examination. Special attention should be given to educating older men. To conclude, we have presented a laboratory-based study on the presenting pathological stage of melanoma of the back in patients aged > 20 years. Half of our patients presented as stage pT1, while the other half of the tumours included in situ melanoma to stage pT4. Men predominated over women (ratio 2.9 : 1). There is no screening programme for melanoma, and providing education that raises awareness of the early signs and patient self-examination with opportunistic screening is the current standard. As the back area is not routinely inspected by patients, we believe that late presentation should be avoidable by recommending whole-body examination in general practice and dermatology clinics to ensure early detection and better prognosis of melanomas arising in the back and other hidden anatomical sites.
BG03 A case of nasal tip necrosis secondary to giant cell arteritis and a review of the cutaneous manifestations reported in large-vessel vasculitis
Authors: Binns Hannah , Steuer Alan , Zacharias Hannah
Published: June 2024

A 90-year-old woman presented to the emergency department with a 6-week history of a nasal tip lesion associated with left-sided headache, and scalp and facial tenderness. Visual symptoms, jaw claudication and systemic upset were absent. On physical examination, an 8 × 8-mm annular ulcerated and necrotic lesion was present on the nasal tip. Pain was elicited on palpation of the left superficial temporal artery. At presentation inflammatory markers were elevated, with C-reactive protein (CRP) 310 mg L−1 and erythrocyte sedimentation rate (ESR) 131 mm h−1. The white cell count was 13.6 × 109 L−1 and platelets were 410 × 109 L−1 and estimated glomerular filtration rate 31 mL min−1 1.73 m−2. Computed tomography of the head showed no acute abnormality. A subsequent ultrasound doppler scan of the left superficial temporal artery demonstrated changes typical of giant cell arteritis (GCA). Prednisolone (40 mg once daily) was initiated. Two weeks later the patient reported complete resolution of the headache, the necrotic area of nasal tip skin was healing, and the temporal arteries were pulsatile and nontender. CRP and ESR had reduced to 13 mg L−1 and 57 mm h−1, respectively. While GCA commonly affects the branches of the external carotid artery, any artery can be affected. Necrosis in this case was thought to be a direct result of inflammation of the distal branches of the facial artery, a branch of the external carotid artery that supplies superficial facial structures. The nasal tip area is supplied predominantly by the superior labial and angular vessels. The diagnosis of GCA was established due to the classical presentation of acute-onset headache, scalp tenderness and raised inflammatory markers, combined with the left temporal artery ultrasound Doppler findings and in association with rapid response to steroid therapy. Temporal artery biopsy was not performed. Cutaneous manifestations of GCA and other large-vessel vasculitides are rare, and as a presenting complaint are exceptional. Necrosis of the scalp and tongue is a well-recognized ischaemic complication of GCC. However, nonischaemic manifestations such as panniculitis-like lesions and acute inflammatory nodules have also been reported in the context of GCA and Takayasu arteritis. GCA presenting with necrosis of the nasal tip has rarely been reported. An older person with such a lesion could forcibly present to a 2-week-wait dermatology clinic and clinicians should consider GCA as a differential, if other suggestive features are present. Older people are more likely to be referred with suspected skin cancers, and given that GCA is the most common vasculitis among this population group, dermatologists should have a good working knowledge of the disease’s clinical features, namely headache, scalp tenderness, visual manifestations and claudication of the tongue and jaw.
BG07 Once in a blue moon?
Authors: Madhwapathi Vidya , Tso Simon
Published: June 2024

An 80-year-old woman with a background of Hodgkin disease, hypertension and arthritis was diagnosed with bullous pemphigoid (BP) following skin biopsy. She was managed as a dermatology outpatient with skin-directed therapies (clobetasol propionate ointment and emollients) and doxycycline 100 mg once daily (due to renal function). Following a flare of BP, the accident and emergency department added oral prednisolone 40 mg once daily with proton pump inhibitor cover, which was gradually weaned down, but disease control remained suboptimal at prednisolone 20 mg once daily. She was later admitted as an inpatient due to new-onset delirium and acute chronic renal impairment attributable to hyponatraemia and steroid-induced delirium. Despite supervised weaning of oral prednisolone (with cortisol monitored to avoid Addisonian crisis) and commencement of oral dapsone 50 mg once daily (on a background of normal glucose-6-phosphate dehydrogenase level and baseline methaemoglobin level), the delirium persisted. Full-body computed tomography was performed, showing small-vessel ischaemia. A methaemoglobin level performed after dermatology review showed an increased level of 14.2%. Methylene blue was commenced and dapsone stopped. The patient continued to deteriorate despite ward-based care. She was discharged for palliation and passed away a few weeks later. Dapsone is a drug with immunosuppressive properties, used in a wide variety of dermatological conditions including BP, pyoderma gangrenosum and vasculitis. Methaemoglobinaemia is a well-known, but uncommon side-effect. Attributing causation for this patient’s symptoms to prednisolone alone is difficult, as her symptoms started 4 weeks after, at a dose of 20 mg. Fully attributing them to dapsone is also difficult, as the symptoms had started before its initiation. However, it is likely multifactorial. BP itself, addition of immunosuppressive BP treatment, polypharmacy and subsequent methaemoglobinaemia tipped the delicate balance in a patient of advancing age, with known small-vessel ischaemia and other comorbidities. This difficult case highlights the challenges and complexities of managing dermatological conditions and the use of immunosuppression in an increasingly older population. The number of people aged ≥ 85 years in the UK was estimated to be 1.7 million in 2020 (2.5% of the UK population) and this is projected to almost double to 3.1 million by 2045 (4.3% of the UK population). The issues arising in this case will become more commonplace for dermatologists. This case emphasizes the need for working closely with colleagues caring for older patients, and for consideration of rare side-effects of medications as a contributor to delirium.
BG08 Boosting the cutaneous chronicle of the COVID-19 vaccine: it’s not over yet
Authors: Moon Emily , Peng Chenjing , Abdullah Anthony
Published: June 2024

The initial UK rollout of the SARS-CoV-2 COVID-19 vaccine in 2020 sparked concerns regarding vaccine-related adverse reactions. Cutaneous pustular eruptions subsequent to COVID-19 vaccination have primarily manifested after the first to third doses, with the second dose being the norm [Karampinis E, Gravani A, Gidarokosta P et al. Pustular eruption following COVID-19 vaccination: a narrative case-based review. Vaccines (Basel) 2023; 11: 1298]. We report a distinctive case of new-onset generalized pustular psoriasis (GPP) following the sixth dose of a COVID-19 vaccine in a 77-year-old woman. Our patient presented with a widespread pustular eruption affecting 80% of her body, 3 days after receiving her COVID-19 VidPrevtyn Beta monovalent B.1.351 vaccine (Sanofi). This marked her sixth dose of a COVID-19 vaccine since 2021, with no history of allergy or reactions. Her vaccination history revealed exposure to five different types of vaccines from four different pharmaceutical companies. Notably, this was her first encounter with VidPrevtyn by Sanofi. A clinical diagnosis of GPP secondary to the COVID-19 booster was made, which was supported by histological findings on a punch biopsy. She was commenced on acitretin (10 mg daily) and intravenous piperacillin–tazobactam to cover for skin impetiginization. Initial skin improvement was slow, but antibiotic-induced pancytopenia and renal impairment precluded a switch to ciclosporin. Full-skin clearance was eventually achieved after a few months of acitretin 20 mg, but discontinuation resulted in a recurrence of symptoms. Consequently, the patient continues acitretin 10 mg daily, which is proving effective for control and is well tolerated. The patient was advised against future COVID-19 vaccination and to consider early antiviral treatment for COVID-19 infection if indicated. This case serves as a poignant reminder that despite a cumulative vaccination history, significant cutaneous adverse reactions following the COVID-19 vaccine persist. The Joint Committee on Vaccination and Immunisation advocates for 6-monthly COVID-19 booster vaccines in adults aged ≥ 75 years, with a seasonal booster recommended for those aged ≥ 65 years [UK Health Security Agency. COVID-19: the green book, chapter 14a. Available at: https://www.gov.uk/government/publications/covid-19-the-green-book-­chapter-14a (last accessed 19 April 2024)]. As the landscape evolves with new variants and booster vaccines, there is an escalating potential for reactions, particularly after the first or second dose of the new booster vaccine. Furthermore, our case demonstrated a notable achievement in the effective management of vaccine-induced GPP with acitretin. It is imperative for clinicians to remain vigilant, recognizing that COVID-19 vaccination, while increasingly common, should not falsely reassure based on a negative history of numerous COVID vaccines in the past. Thoroughly assessing vaccination history is essential in clinical practice.
PA06 A cross-sectional study to evaluate the clinical and allergenic differences between intrinsic and extrinsic forms of atopic dermatitis
Authors: Garg Divya , Mahajan Rahul , Sharma Vinod Kumar , De Dipankar , Handa Sanjeev
Published: June 2024

Atopic dermatitis (AD) is now recognized as a condition comprising various endotypes, rather than being a homogeneous disease. One of these distinctions lies in the intrinsic and extrinsic forms of AD, which are pathogenetically different but exhibit subtle clinical differences. Limited knowledge is available regarding the comparison of clinical features between the two endotypes in paediatric populations and individuals with skin of colour. The aim of this study was to compare the frequency of occurrence of different demographic parameters and clinical features of AD between intrinsic and extrinsic AD. Consecutive children with AD, all under the age of 18 years, were enrolled. A comprehensive examination of their medical history and clinical assessment was conducted. Serum IgE levels were utilized to distinguish between extrinsic AD (characterized by high IgE) and intrinsic AD (associated with normal IgE levels). Additionally, assessments for food-allergen-specific IgE (with seven food allergens) and skin prick tests were performed. Out of the 200 children who were recruited, 181 (90.5%) had high IgE levels. The group with extrinsic AD showed a positive association with a personal history of atopy (P = 0.005), involvement of the dorsum of the hands and feet (P = 0.01), orbital darkening (P = 0.01), and prurigo-like lesions (P = 0.02). Conversely, the group with intrinsic AD exhibited a significant association with the presence of ichthyosis (P = 0.01). A moderate correlation (correlation coefficient, r = 0.48) between Scoring Atopic Dermatitis and IgE was observed, which was statistically significant (P < 0.001). According to the radioallergosorbent test, the most common food allergen was wheat (46.4%), followed by peanut (39.7%). In skin prick tests, the most common allergens were house dust mites, specifically Dermatophagoides pteronyssinus (52.4%) and Dermatophagoides farina (38.1%), followed by wheat dust (23.8%), whole egg (19%) and Blomia mites (19%). However, no significant association was found between either endotype and allergen testing. The findings highlight the clinical differences, disease course and associated factors between these subtypes, which can aid in accurate diagnosis, management, and personalized care for individuals with AD.
PA17 Multiple lesions in a child mimicking juvenile xanthogranulomas
Authors: Hiranput Siwaporn , Raweily Essam , Alsaadi Dalia Saidely
Published: June 2024

An 11-year-old White girl presented with a lesion on her left arm, present since she was a toddler. The lesion had increased in size over the past year with associated discomfort. Two further lesions appeared over a 12-month period. She was born at full term, and had no developmental delay and no past medical history. On examination, a 15 × 20-mm firm yellow–orange plaque was noted on her left upper arm without epidermal changes, and two smaller lesions with similar appearance were present on her right upper arm and right posterior thigh. There was no palpable lymphadenopathy or hepatosplenomegaly. She did not have dysmorphic facial features or short stature. The clinical impression was that of juvenile xanthogranulomas. As the arm lesion was symptomatic, it was excised with a narrow margin. Excisional biopsy showed cells with abundant eosinophilic granular cytoplasm, bland chromatin and nuclei. There was no lymphovascular or perineural invasion, mitotic figures, necrosis or apoptotic cells. Features were consistent with granular cell tumour (GCT). Subsequently, a biopsy of the thigh lesion confirmed GCT. GCT is a rare soft-tissue tumour, thought to originate from Schwann cells. The expression of S100 proteins in GCT supports its neural cell origin. There is a predilection for women in their fourth to sixth decades. Half of cases are found on the head, neck and oral cavity; although any body site can be affected, including internal organs. GCTs are usually solitary, but multiple lesions have been described in up to 25% of cases. Multiple GCTs in paediatric populations have been reported to be associated with genetic syndromes including Leopard syndrome, Noonan syndrome and neurofibromatosis type 1. Most cases of GCTs are benign; however, 1–2% can be malignant. The latter may be suspected when specific clinical and histological features are present. High-risk clinical features include lesions more than 4 cm in size, rapid growth, ulceration, necrosis and lymph node involvement. High-risk histological features are high mitotic activity, necrosis, high nuclear-to-cytoplasmic ratio, spindle cells, vesicular or large nuclei, and pleomorphism. The recommended treatment for benign and malignant GCTs is complete surgical excision to prevent recurrence. Our patient was reviewed by genetics, who felt that further genetic testing was not indicated given her normal physical examination. There was no sign of disease recurrence at 1 year. She remained under our regular follow-up. In conclusion, we report an unusual case of multiple cutaneous GCTs arising in the extremities in a paediatric patient. Although the presentation is rare, our case highlights that GCTs should be considered in the differential diagnosis of cutaneous tumours in the paediatric population.
PA26 Severe pyoderma gangrenosum in a child and the response to adalimumab
Authors: Zwain Ahmed , Crawford Alexander , Belgi Avinash , Morgan Caroline , August Suzannah
Published: June 2024

Pyoderma gangrenosum (PG) is an uncommon ulcerating skin condition that can be associated with underlying problems such as inflammatory bowel disease, rheumatic or haematological diseases and malignancy. The peak incidence is between age 20 and 50 years, and it is rare in children (Graham JA, Hansen KK, Rabinowitz LG, Esterly NB. Pyoderma gangrenosum in infants and children. Pediatr Dermatol 1994; 11: 10–17). A 7-year-old boy presented with multiple erythematous and ulcerated plaques affecting the lower back and abdomen. He had recovered from chickenpox 3 weeks previously. He had been admitted under the paediatric team but had not responded to intravenous antibiotics. A skin biopsy was carried out under general anaesthesia, which showed dense dermal neutrophilic inflammation on histology. Investigations showed no evidence of inflammatory bowel disease, atypical viral infection, granulomatous disease, connective tissue disease or lymphoma. The ulcers became increasingly extensive and painful. A diagnosis of PG was made, and intravenous methylprednisolone was given followed by oral and topical cortico­steroids. There was an initial improvement, but the ulcers flared on reduction of the corticosteroid dose. Ciclosporin was therefore added but there was no improvement after 2 months of therapy, with the ulceration progressing to involve a large proportion of the abdominal skin. Adalimumab was then commenced and there was a marked improvement in the ulceration within 3–4 weeks of starting treatment. It has been shown that adalimumab is effective in children with PG (Kechichian E, Haber R, Mourad N et al. Pediatric pyoderma gangrenosum: a systematic review and update. Int J Dermatol 2017; 56: 486–95). Our patient showed a dramatic response to adalimumab with complete healing of large areas of ulceration after 2 months of therapy, enabling complete cessation of ciclosporin and oral corticosteroids. PG is a rare condition in childhood but can lead to devastating cutaneous ulceration. Adalimumab is a well-tolerated and effective treatment in this patient group.
BI07 (P063) Understanding the landscape of Kaposi sarcoma hospitalizations in the USA: demographic associations stratified by AIDS/HIV status
Authors: Mendoza Roy , Espinoza Norma , Saoub Jessica , Kieron Leslie , Ge Shaokui
Published: June 2024

Kaposi sarcoma (KS), a low-grade vascular tumour associated with human herpesvirus 8 (KSHV/HHV-8), has demonstrated a notable increase among Black men despite an overall decreasing trend in the USA. Given the lack of information regarding the national rates of KS in the USA, this study aims to characterize the national inpatient burden of individuals affected by KS, exploring demographic disparities on a broader scale. We queried the National Inpatient Sample (NIS), a subset of the Healthcare Cost and Utilization Project database containing US hospital discharge data, from 2016 to 2019, to identify all patients aged ≥ 18 years with a diagnosis of KS. We used the data to estimate the national representation and KS-relevant hospital admissions compared with the national civilian population. Stratifying by HIV/AIDS status (AIDS-related KS vs. non-AIDS-related KS), we examined the demographic associations of inpatients with KS using a Wald χ2-test. We determined the incidence rate ratios of admission for KS-related concerns using a Poisson regression model. All statistical analyses were performed with SAS 9.4 (SAS Institute Inc., Cary, NC, USA). In total, 12 246 patients with KS were estimated from the NIS. Overall, the inpatients with KS were predominantly male (91.1%), Black (41.4%) and in the 18–44-year age group (47.7%). AIDS-related KS constituted the majority of patients with KS (10 065, 82.2%), predominantly affecting Black individuals (45.7%) compared with patients classified as White, Hispanic and other (30.2%, 17.6% and 6.5%, respectively). Male patients were more often affected, at a 16 : 1 male-to-female ratio, the largest recorded thus far. Black patients with AIDS had a significantly higher risk of hospitalization. Non-AIDS-related KS comprised 17.8% of cases, primarily among White (51.4%) and male (77.5%) patients, and those aged 65–84 years (49.3%). Despite the differences by KS type, Black patients and those aged ≥ 85 years with non-AIDS-related KS still faced a heightened risk of hospitalization. This study underscores the distinct demographic patterns of inpatients with KS by HIV/AIDS status. For AIDS-related KS, focused efforts are required for Black individuals – addressing their elevated risk, initiating early therapeutic intervention, and promoting adherence to antiretroviral therapy. In cases of non-AIDS-related KS, attention must be given to the older age groups, especially those with a history of immunosuppression. These findings advocate for specialized dermatological strategies considering demographic nuances, contributing to more effective and targeted care for patients with KS.