bluuebunny/crossref_metadata_2025 huggingface dataset:
Historical H01 A published case of delusional parasitosis in an entomologist
Authors: Merchant Serena Altaf , Shah Syed Fazal Hussein
Published: June 2024

Delusional parasitosis describes an individual’s false yet firmly held belief that they are infested with parasites crawling or burrowing under their skin. This can result in self-inflicted dermatoses as patients attempt to remove the ‘parasites’. A notable case of delusional parasitosis is that of Jay R. Traver (1894–1974), an entomologist who published her personal account of living with a ‘mite infestation’ (Traver JR. Unusual scalp dermatitis in humans caused by the mite Dermatophagoides. Proc Entomol Soc Washington 1951; 53: 1–25). Traver’s account, written alternatingly in first and third person, describes her condition as beginning with pruritic red papules of the scalp that progressed to nocturnal sensations of ‘something biting, scratching and crawling from place to place’. Traver trialled numerous topical treatments, including mercuric iodide and sulfur ointments. Alongside topical agents, Traver also tried ‘digging out’ the ‘mites’ with her fingernails, without success. However, her condition spread downwards to involve her eyes, ears and nostrils. On one occasion, Traver describes her eyes becoming so swollen that she was unable to move her eyeballs and experienced ‘sharp pin-prick like sensations in one eye’. Desperate for relief, Traver consulted a dermatologist, who she recounts disdainfully as advising that her symptoms were ‘largely imaginary’. Following 3 days of ineffective in-hospital treatment, Traver was referred to a neurologist, who assessed for a ‘psychoneurotic condition’. However, she ‘succeeded in convincing [him] that she had no need of his services’. Traver also sought advice from a parasitologist, to whom she mailed samples of the ‘mites’ that she caught through skin scrapings and inspecting her pillowcases. Traver’s published article describes these organisms in taxonomic detail as belonging to a family of rare dust mites, and includes several hand-drawn figures of the mites. Despite concerted efforts to identify a cure, Traver’s condition persisted for 40 years until her death in 1974. Today, Traver is recognized as having had delusional parasitosis. Her article is considered a textbook case of the condition, describing characteristic features such as the use of home remedies and self-mutilation to remove offending ‘mites’, preserving skin scrapings in paper and/or small jars, consulting multiple physicians while rejecting the possibility of psychological or other explanations, and shared delusions among family members. Debate continues as to whether Traver’s publication warrants retraction due to conclusions being drawn from data that were unconsciously fabricated in the author’s mind.
H04 A historical journey of the structure, texture, and identity of afro-textured hair
Authors: Fabusiwa Kemi , Vyas Aparna , Dear Kate
Published: June 2024

‘Braids of strength, history’s embrace, afro crown, a legacy we trace. Braids hold secrets, whispers of pride, Afro hair, a heritage we can’t hide’ – Anonymous.

Understanding the history of afro-textured hair takes us on a journey, illuminating the complex structure of the hair follicle, its unique texture, and the various sociocultural and political implications it has carried throughout the centuries. The journey begins in the ancient African kingdoms and stretches into the contemporary era, exposing the shifting attitudes, practices and perceptions of afro-textured hair. It paves the way for an understanding of maladaptive hairstyling practices that can lead to hair conditions such as traction alopecia, central centrifugal cicatricial alopecia, and trichorrhexis nodosa, and it helps us to create a path for healthier hairstyling practices. The ancient African kingdoms, with their diverse cultures and traditions, held afro-textured hair in high esteem. The structure and texture of afro-textured hair, characterized by its tightly coiled strands and curved follicle, were not mere biological attributes but were integral to identity, status, and societal roles. Bantu knots from the Zulu tribe of South Africa were symbols of femininity and beauty. The braided crown, native to the Mangbetu people of Congo, were symbols of wealth and status, where beauty standards highlighted the elongation of the skull. And the Amasunzu style worn by the Hutu and Tzutzi population of Rwanda were worn in preparation for battle and therefore in preparation for death. Hairstyles were an art form, rich with symbolism, a canvas that depicted the individual’s life journey from birth to death. However, these hairstyles, handed down over centuries and once revered as symbols of status, strength and beauty, became a tool for racial segregation with the advent of slavery in the 1400s. Protective styles like braids were replaced with damaging hair-straightening practices including hot combs, flat irons and relaxing agents, to mimic European hair textures. These practices, often painful and damaging, were introduced in a bid to emulate European hair textures, reflecting the pervasive influence of racial hierarchies on self-perception and aesthetics. In conclusion, understanding the history of afro-textured hair provides a background that enables us to appreciate its natural structure and texture. It also underscores the importance of incorporating historical understanding into dermatological consultations and treatments, thereby ensuring culturally competent care. The history of afro-textured hair is more than a tale of evolving hairstyles; it is a reflection of the broader sociopolitical transformations experienced by ­people of African descent. Recognizing this historical context can change our attitudes, promote healthier hair practices, and encourage acceptance of afro-­textured hair in all its forms.
H06 The changing face of skin disease in warfare: from World War I to modern times
Authors: Shah Manu
Published: June 2024

Skin disease has been always been associated with human conflict, causing considerable morbidity and removing soldiers from the battlefield. Records of skin disease in soldiers improved significantly from the early 20th century. Analysis of these quality data gives us an insight into the changing picture of skin disease across many theatres of war. In World War I, the most common skin conditions reported were bacterial infection (42%), scabies (28.5%), eczema/dermatitis (13%) and acne (5.4%). Interestingly, body lice were so common that cases were not routinely recorded, even though the association with typhus, which led to many deaths, was recognized. Trench foot, again common, was not routinely classified as a skin disease. By World War II, skin disease in combatants had changed considerably. Overall rates of skin disease varied by conflict zone from 25% (in temperate climates) to 75% (tropical climates). For example, the commonest skin conditions afflicting the British Army in India were fungal disease and scabies. The British Liberation Army found that their rates of skin disease doubled from July 1944 to March 1945, with high rates of eczema (42%) and bacterial infections (30.9%) and lower rates of fungal infections (5.1%) and scabies (7.4%). The dramatic difference between rates and types of skin disease reported in different climates is still seen today: 25.2% of medical consultations in the East Timor conflict (1999) were for skin disease, compared with 9.3% during the Gulf War (1990). Scabies became less important after World War II (apart from a small rise in the first Gulf War). In Vietnam (1965–70), dermatitis had become the most common skin problem (16.5%), with significant issues of fungal disease: mainly ‘jungle rot’ (a resurgence of the original trench foot, 13%), viral conditions including warts (11.5%) and acne (4.3%). Recent figures are similar for Afghanistan (2008–15), although cases of dermatitis had fallen (8.5%). The incidence of scabies in soldiers has hugely reduced since the World War I, probably due to effective treatments and improved military hygiene, as well as less prolonged, less intensive conflicts. Climate continues to play a major role in types and rates of skin disease. It is important to point out that skin disease, even in the modern age, continues to cause major morbidity among combatants, and soldiers need to be screened for pre-existing skin disease before being sent into combat zones.
H15 Inflammation of the hair follicle: multiple eponyms!
Authors: Yong Ji Fung , McFeely Orla , Griffin Laoise
Published: June 2024

Hidradenitis suppurativa (HS) had several different names in the past due to the bewildering history of conflicting bodies of knowledge and pathogenesis. In 1833, it was referred to as Velpeau disease, named after Alfred-Armand-Louis-Marie Velpeau, a French anatomist and surgeon, who was the first person who noted an unusual inflammatory process of the sebaceous follicle. He first described a ‘phlegmon tubériforme’ (tuberiform phlegmon) of the axilla, characterized by superficial abscess formation and often resulting in pain and suppuration. Velpeau then discovered painful induration and tumours, as a similar clinic aspect of HS, naming it ‘phlegmon érysipélateux’ (erysipelas phlegmon). In 1864, Verneuil renamed the disease to hidrosadénite phlegmoneuse, the French term for ‘hidradenitis suppurativa’, and defines it as a condition caused by inflammation of the sweat glands (hidradenitis) with pus collection (suppurativa). Later, Aristide Auguste Stanislas Verneuil, a French surgeon with special interest in skin and sudoral (sweat gland) tumours, found Velpeau’s discovery. He conducted the first clinical studies regarding this inflammatory condition from 1854 to 1865 and recognized that it was a disorder of sweat glands, earning it the name of Verneuil disease. In 1891, ‘acnitis’ and ‘folliclis’ were new terms introduced to describe HS as part of folliculitis, by French physician Barthélémy. However, these were soon rejected by French dermatologist William Auguste Dubreuilh, in favour of ‘hydrosadenitis’. In 1956, Pillsbury came up with the term ‘follicular occlusion triad’ as a group disorder consisting of HS, acne conglobata and dissecting cellulitis of the scalp. This decision was made on common features of follicular hyperkeratinization, with keratin retention complicated with bacterial infection in these conditions. Nineteen years later in 1975, Plewig and Kligman added pilonidal sinus to the follicular occlusion triad and introduced the new term ‘acne tetrad’. Histopathologically, all four entities are identical, with evidence of follicular occlusion causing inflammation of sweat glands. Given the inverse localizations of HS compared with the acne tetrad, Plewig suggested the term ‘acne inversa’ instead in 1989. In 2005, American dermatologists Sellheyer and Krahl observed histopathological evidence of hair follicle occlusion and noted clinical and therapeutic similarities to acne. They insisted on abandoning the name ‘HS’, replacing it with ‘acne inversa’. However, adversaries of the name ‘acne inversa’ contended that more research should be conducted, as histology alone does not define dermatology. HS is currently the recognized name of this disease, as agreement on its terminology has yet to be reached, despite centuries of research.
H16 Fake or bake…the history of tanning in the worlds of medicine and fashion
Authors: Ashraf Sana , Goh Alicia , Surgenor Laura , McKenna Kevin
Published: June 2024

Over the years, the perception of health, beauty and status has been associated with skin colour. Influential figures over the ages, from Queen Elizabeth I to Kim Kardashian, have dictated social standards of beauty including the ‘ideal’ skin colour. In parallel, advancements in medicine and science have led to the use of light therapy as a treatment for many medical conditions. The history of tanning and the basis for society’s obsession are important to understand. During the Elizabethan era, Queen Elizabeth I used heavy layers of ‘Venetian ceruse’, a deadly concoction of white lead and vinegar, to achieve the porcelain skin that was desirable at the time. Members of high society followed suit, as tanned skin was associated with outdoor manual labour. During the Industrial Revolution, social perception turned on its head as the rural poor moved to work in mills and factories in the 18th century. Working in sunlight-depleted environments resulted in pallor being associated with low social status. In the 1920s, the French designer and fashion icon Coco Chanel famously returned from the French Riviera with a suntan and announced in Vogue magazine that, ‘the 1929 girl must be tanned…a golden tan is the index of chic’, leading to her accreditation for beginning the fashionable trend of a suntan in modern history and the present day. From ‘Malibu Barbie’ dolls in the 1970s to Kim Kardashian showing off her office sunbed in 2024, the Western beauty ideal of tanned skin is continually perpetuated. Parallel to the beauty world, the novel idea of phototherapy and its successful treatment of lupus vulgaris resulted in Niels Finsen receiving the Nobel Prize for Medicine in 1903. Further development of indoor tanning devices in the 1920s led to their promotion as treatment for diverse conditions from rickets to pneumonia. In the 1970s, the first commercial sunbed was invented by European scientist Friedrich Wolff, culminating in 1977 with the world’s first tanning salon in Berlin. By the 1980s the association of sunbed use and skin cancer was observed. As a result, nonultraviolet tanning methods were popularized, from teabags in the 1950s to the revolutionary discovery of dihydroxyacetone in the 1960s, resulting in ‘fake tan’ as we know it today and allowing for safer methods of attaining the desired glow. Ultimately, tanned skin rose from a hallmark of low socioeconomic status in history, to now reflect the opposite: wealth, health and beauty.
H18 Scabies: can we repurpose treatments from the past?
Authors: Shakeel Musfira , Price William , Shah Manu
Published: June 2024

The UK is currently in the grip of a scabies epidemic. Current treatments seem to be either unavailable or ineffective, with multiple cases of permethrin resistance being reported. The British Association of Dermatologists has highlighted the shortage of scabies treatments and the lack of national tracking of cases. Scabies is not new, so can we learn from experiences and treatments of the past to help us in the present and the future? Scabies has irritated mankind for hundreds of thousands of years. The first treatments were based on sulfur and have been used for at least 5000 years. Sulfur is an irritant; it is unpleasant to use but can be effective. Lindane, created in 1825 but not used commercially until the 20th century is rarely used now due to its neurotoxicity and possible carcinogenic nature. It is still available but is banned in many countries. More treatments became available in the early 20th century due to the explosion of scabies cases associated with World War I. Benzyl benzoate, balsam of Peru and beta-naphthol were all successfully used to treat thousands of afflicted infantrymen. All have their limitations: benzyl benzoate and balsam of Peru commonly cause allergic reactions, and beta-naphthol may cause death. A reformulation of benzyl benzoate may be possible (its cure rate is a remarkable 86%), but overuse can lead to neurotoxicity. Dermatologists in World War II experimented with their own recipes. John Ingram reported in 1942 that a benzyl benzoate lotion of ‘equal parts soft soap and spirit’ gave ‘excellent results and caused no skin irritation’. New uses of old medicines may be one way forward. Tea tree oil has scabicide properties and is undergoing investigations for possible topical use. Oral ivermectin (discovered in 1975), although currently not licensed for scabies in humans, will probably be used in thousands of patients if the current surge of cases continues. There is the possibility that the topical form of ivermectin could be equally effective, and further studies are needed. Better formulation of old drugs may be possible to make them less irritant and cause fewer allergic reactions. Our current reliance on a tiny range of ‘safe’ topical therapies for treating scabies is clearly not working as the incidence of cases continues to rise. While work on developing new treatments and ways of dealing with this timeless problem continue, we also need to explore old treatments and reformulate irritant therapies.
H19 Not only a finder of ‘solutions’: Max Jessner, Holocaust survivor and discoverer of Jessner–Kanof lymphocytic infiltrate
Authors: McAllister Lucy , Hiranput Siwaporn , Yesudian Paul Devakar
Published: June 2024

Max Jessner’s name is renowned for his codiscovery of Jessner–Kanof disease and his eponymous peel. However, unknown to many, Jessner faced many uncertainties in his lifetime and lived in a frequent state of movement. Max Jessner read medicine at the universities of Munich and Königsberg (now Kaliningrad). After graduation, he trained in dermatology clinics under Albert Neisser in Breslau (now Wroclaw) before moving to Bern, Switzerland to become assistant to Joseph Jadassohn from 1912 to 1914. Like his father, dermatologist Samuel Jessner, Max Jessner initially developed his specialism in the studies of syphilis, namely through an expedition to Buryat-Mongolia, to study the effect of salvarsan, an antisyphilitic agent. On his return in 1920, he moved to the University of Breslau, where he continued to work alongside Jadassohn as head of the dermatology department. Due to growing anti-Semitism in Europe, Jessner’s resignation was forced just 4 years later. He was permitted to emigrate to Switzerland but ultimately evaded persecution by leaving Europe and continuing a career in New York, like many other European dermatologists of Jewish descent facing oppression during the Third Reich. In the USA, Jessner lived in a tight-knit community socializing with other dermatologists including Hans Biberstein. Arguably Jessner’s greatest accomplishment was achieved in 1953 while working at the New York Skin and Cancer unit, with the description of Jessner–Kanof lymphocytic infiltrate, a photosensitive lymphocytic disorder now believed to be on the same disease spectrum as lupus tumidus. In the same decade, Jessner published his seminal paper on his self-named solution, an augmented formula of a well-known peel containing lactic acid, salicylic acid and resorcinol. The modified form is a tolerable and effective agent for hyperkeratotic disorders and remains popular in the treatment of acne scarring, pigmentation and rhytides. Max Jessner was born on 2 November 1887, in Slupsk, Poland. In 1971 he returned to Europe, where he spent much of his retirement. Jessner died in Switzerland at age 91. Max Jessner was survived by his wife Marianne, and children Peter and Sabine Jessner. His only sibling, Fritz Jessner, was a theatre director in Boston. Jessner’s esteemed career, his contribution to the field of dermatology and his resilience to continue in his profession despite many major obstacles will be remembered for years to come.
H21 These Barbies were dermatologists
Authors: Quigley Claire
Published: June 2024

Greta Gerwig’s 2023 Barbie blockbuster provided an infectious reminder that women are capable of the success of their male counterparts, as well as emphasizing the impressiveness of female empowerment and leadership. Luckily, in dermatology, we have had this leadership from the beginning. According to the 2022 UK consensus of consultant physicians, women make up 51% of higher specialty trainees, and there have been more women than men in training since 2013. However, despite this, only 41% of the consultant physician workforce are women while 59% are men (Royal College of Physicians of Edinburgh. Focus on Physicians. Census of Consultant Physicians and Higher Specialty Trainees in the UK 2016–17. Edinburgh: Royal College of Physicians, 2017). However, dermatology stands out as a female-predominant area of specialization. In the UK in 2016, 57% of consultants and 75% of higher specialty trainees in dermatology were women [Royal College of Physicians. The UK 2022 census of consultant physicians. Available at: https://www.rcplondon.ac.uk/projects/outputs/uk-2022-census-consultant-physicians (last accessed 29 February 2024)]. There is likely a multitude of reasons contributing to this, but the historical influence of prominent female leaders in the specialty cannot be ignored. Presented here are a select group of pioneering female dermatologists whose careers and contributions to the field of dermatology paved the way for the development of one of the few female-dominated medical specialties. Helen Ollendorff-Curth was a female pioneer of genodermatology and is commemorated with four eponyms: the Ollendorff probe sign, the Curth criteria, Buschke–Ollendorff syndrome, and ichthyosis hystrix, Curth–Macklin type (IHCM). Loretta Joy Cummins was the first woman to pass the Dermatology Board examination in the USA and the first to be president of the New England Dermatological Society. Cummins founded a fund for Massachusetts General Hospital and a scholarship fund for women at Tufts Medical School. Agnes Blackadder was the first female consultant dermatologist in the UK, when she was appointed consultant dermatologist at St John’s Hospital, London in 1907. Daisy Maude Orleman Robinson’s achievements include becoming the first female dermatologist in the USA in 1905, as well as being the first female dermatologist to present a case at a dermatological meeting, to publish a scholarly paper in dermatology, and to present a case at an international dermatology meeting. These influential women were catalysts for creating and cultivating a specialty that promotes female leadership in the world of dermatology, medicine and science.
PS02 Efficacy of antipsychotics in delusional infestation
Authors: Tang Paul K , Lepping Peter , Lepping Sophie G , Noorthoorn Eric O , Squire Stephen B , Mohandas Padma , Bewley Anthony
Published: June 2024

The 2022 British Association of Dermatologists’ (BAD) guidelines suggest the use of low doses of second-generation antipsychotics as the first-line pharmacological treatment option for adults with delusional infestation (DI). We evaluated the treatment responses associated with different antipsychotics in patients with DI. We undertook a multicentre, retrospective observational study using anonymized electronic patient records from two hospitals in the UK from 1 January 2011 to 1 January 2023. Eligible participants were adults (≥ 18 years) diagnosed with DI treated with an antipsychotic, and had both an assigned baseline and follow-up Clinical Global Impression Scale (CGI-S) score. Participants were excluded if they had known limited or nonadherence to an antipsychotic, or if no CGI-S scores were present at follow-up. First clinic visits before the initiation of an antipsychotic were assigned as the baseline CGI-S score. The last available CGI-S score before the patient either changed antipsychotic or left the clinic for any reason was used to assign the follow-up CGI-S score. The primary outcome was the response to each individual antipsychotic treatment, measured by the difference in the baseline and last available follow-up CGI-S scores. Differences in CGI-S changes between antipsychotic episodes were tested by Anova. In total, 414 patient records were analysed, and data were extracted. The mean age was 61.8 years (SD 14.1). Overall, 170 (41%) of the 414 patients were men and 244 (59%) were women. In total, 156 (38%) of 414 patients were eligible, yielding a total of 315 antipsychotic prescribing episodes. The Anova, ranking in order of treatment response, showed that the highest mean scores (expressing highest treatment response) were observed for amisulpride and risperidone, followed by some distance by quetiapine, aripiprazole and olanzapine (Table). In conclusion, amisulpride and risperidone were associated with a higher treatment response than quetiapine, aripiprazole and olanzapine, and should therefore be considered the first-line treatment options in patients with DI. We thank the BAD for sponsoring this study.TableDifferences in CGI-S scores between baseline and follow-up; data presented as n (%)Risperidone (n = 167)Aripiprazole (n = 46)Amisulpride (n = 46)Olanzapine (n = 28)Quetiapine (n = 25)Chlorpromazine (n = 1)Total (n = 313)+12 (1.2)5 (11)1 (2)1 (4)3 (12%)012 (3.8)   070 (41.9)28 (61)14 (9)20 (71)13 (52)1 (100%)136 (44.9)−161 (36.5)9 (20)10 (22)3 (11)6 (24)089 (28.4)−214 (8.4)4 (9)9 (20)2 (7)1 (4)030 (9.6)−314 (8.4)09 (20)2 (7)2 (8)027 (8.9)−46 (3.6)03 (7)0009 (2.9)−50000000
PS10 A novel framework for the diagnosis, management and terminology of ‘dermatitis artefacta’
Authors: Nancarrow-Lei Rhiannon , Baron Susannah , Ali Rukshana , McPherson Tess
Published: June 2024

‘Dermatitis artefacta’ (DA), or ‘factitious skin disorder’, was first documented in 1909 by Spanish dermatologist Juan de Azúa, known for confronting and challenging his patients {Heras-Mendaza F. [Dermatitis artefacta 100 years ago]. Actas Dermosifiliogr 2009; 100: 657–60 (in Spanish)}. This condition is recognized as challenging, and patients can present a significant burden on health services (Mohandas P, Ravenscroft JC, Bewley A. Dermatitis artefacta in childhood and adolescence: a spectrum of disease. G Ital Dermatol Venereol 2018; 153: 525–34). Although current practice emphasizes understanding ‘why not how’, communications with patients, families and health professionals expose problematic inconsistencies not only across different specialities but also among dermatology colleagues. Specifically, the terms ‘DA’, ‘artefactual’, ‘factious’ and ‘malingering’ carry negative connotations of secrecy, dismissal and judgement. They serve to medicalize the condition, excluding the patient and thereby hindering open and honest communication. It further misrepresents the condition as intentional ‘self-harm’, failing to recognize the hidden underlying psychological distress – a perspective that warrants reconsideration. We present a case series of 10 presentations in children and young people, which highlights specific themes to aid a positive diagnosis and demonstrates a novel way to communicate with successful outcomes. We advocate for a comprehensive rebranding of this condition. It should be considered a functional illness – a physical response to emotional distress and deeper psychological need that may not be readily apparent. The field of psychiatry has witnessed a shift towards less stigmatizing terminology, illustrated by the adoption of ‘dissociative seizures’ in lieu of ‘pseudoseizures’. Particularly within the paediatric patient group, a dissociative phenomenon is likely at play, leading to genuine distress observed when new lesions emerge. The method by which these lesions appear may remain a mystery to both the patient and their families. A positive diagnosis should be made, and communication should prioritize openness, honesty and a patient-centred approach. We propose the term ‘external skin lesions (ESLs)’. ‘ESL’ is more readily accepted and understood by patients and their families than ‘DA’. Rather than focusing on investigating ‘ESL’ methods, attention should be directed towards exploring the underlying psychological causes – triggers, stressors, anxiety, and aspects of home and school life. Reassurance is crucial, providing clarity that this recognized condition arises from external damage, frequently occurring unconsciously as an expression of anxiety, stress or upset. The reassurance should extend to the understanding that there is no concern regarding skin healing, and improvement is likely through collaborative efforts involving family, school, and healthcare teams.
PS11 Assessment of willingness to pay for acne cure across different income groups, age groups, genders and disease severities in a UK secondary-care cohort
Authors: Latt Moe , Salari Yalda , Layton Alison
Published: June 2024

Willingness to pay (WTP) is often used as a marker for burden of disease and health-related quality of life. To date, there are no other large UK studies available investigating WTP for a cure (WTP-cure) of patients with acne in secondary care. This study aims to review whether there are differences in acne WTP-cure across different groups in terms of income, age, gender and severity of disease, in patients presenting to secondary care. This was a single-centre, descriptive study of retrospective data collected from patients with acne referred to a National Health Service dermatology department (n = 1593). Consenting patients provided demographic data and completed a questionnaire quantifying WTP-cure for acne, as well as assessment of monthly income. Acne severity was assessed according to site using the Leeds revised acne grading system (O’Brien S, Lewis J, Cunliffe W. The Leeds revised acne grading system. J Dermatolog Treat 1998; 9: 215–20). Data were analysed using SPSS (IBM, Armonk, NY, USA. Anova and t-tests were used to calculate P-values (critical level 0.05). Lower-income groups demonstrated higher WTP-cure than higher-income groups (up to 128.2 times the monthly post-tax income in the lowest-income group of £10–20 per month, vs. up to 1.2 times in highest-income group of > £3500 per month; P < 0.05). People in younger age groups had higher frequencies of more severe acne at all sites, and lower incomes (P < 0.05). Controlling for income, patients in younger age groups had higher WTP-cure scores than those in the older age groups: 23.2 times the monthly post-tax income in the youngest age group of 10–13 years, vs. 1.7 times in the oldest group of ≥ 31 years. There was no correlation between WTP-cure and acne severity on the face or chest, but more severe acne on the back correlated with lower WTP-cure (P = 0.01). There was no significant difference in WTP between male and female patients [P(T ≤ t) two tail = 0.34]. There were significant differences in WTP-cure scores for acne across age groups, income groups and acne severities. There were no differences found for gender, or face or chest severity. It would be of benefit for further research studies to assess psychometric scores against WTP-cure.
SG02 First report of ABCA12 mutations causing isolated palmoplantar keratoderma and a review of mild phenotypes associated with ABCA12
Authors: Song Deyu , Wang Sheng
Published: June 2024

This report presents a case of isolated palmoplantar keratoderma (PPK) resulting from mutations in the C-terminus of ABCA12, and reviews the reported mild cases associated with ABCA12 mutations. A 31-year-old female patient presented with progressive thickening of the palms and soles since the age of 7 years, with no obvious conscious symptoms. No rashes of ichthyosis were noted on other areas of the body, and no abnormalities of the nails, hair and teeth were identified. Genetic analysis identified a novel compound heterozygous ABCA12 gene mutation in the patient. This included a mutation c.7659_7662dupGAGT (p.Q2555Efs*20) in exon 52 and c.7386G>C (p.M2462I) in exon 50, inherited from her mother and father, respectively. The diagnosis of isolated PPK associated with ABCA12 variants was considered. Pathogenic variants in ABCA12 are important causative genetic defects for autosomal recessive congenital ichthyoses, encompassing conditions such as congenital ichthyosiform erythroderma (CIE; MIM #601277), harlequin ichthyosis (#242500) and lamellar ichthyosis, often accompanied by PPK. Occasionally, specific ABCA12 mutations have been linked to milder phenotypes, including erythrokeratodermia variabilis et progressiva (EKVP) and pityriasis rubra pilaris (PRP) (Table) (Sun Q, Burgren NM, Cheraghlou S et al. The genomic and phenotypic landscape of ichthyosis: an analysis of 1000 kindreds. JAMA Dermatol 2022; 158: 16–25; Takeichi T, Hamada T, Yamamoto M et al. Patients with keratinization disorders due to ABCA12 variants showing pityriasis rubra pilaris phenotypes. J Dermatol 2024; 51: 101–5). In our study, PPK without lesions of generalized ichthyosis was noted. The identified causal mutations, located in exons 50 and 52, indicate a potential mild loss of protein function in the C-terminus of ABCA12, offering a plausible explanation for the observed mild phenotype. Our study expands the phenotypic spectrum associated with ABCA12 variants and underscores the genetic heterogeneity of isolated PPK.TableABCA12-associated mild keratinization disordersClinical phenotypeGenetic basisEKVPCompound heterozygous: p.N678Rfs*10; c.2866–8T>ACompound heterozygous: p.D844G;p.P1938SCompound heterozygous: p.Y1929*; p.E2284DCompound heterozygous: H1471R; T1534PRPHomozygous: p.T1534MHomozygous: p.R2426WNaevoid form of CIERecessive mosaicism: p.l1257Nfs*4; p.E1227KMild CIE with periodic exacerbationCompound heterozygous: p.N2184I; p.I2307Rfs*14Isolated PPKCompound heterozygous: p.Q2555Efs*20; p.M2462I
SG12 ‘There’s something fishy going on’: a case of trimethylaminuria
Authors: Quigley Claire , Loftus Clodagh , Clowry Julianne , Irvine Alan D
Published: June 2024

Trimethylaminuria (TMAU) is a rare metabolic disorder resulting in the accumulation of trimethylamine (TMA), which is a foul-smelling metabolite that is excreted in bodily fluids and exudes a characteristic odour of rotting fish. Although the condition is not life-threatening, the psychological and social consequence can be devastating. Herein, we present the case of a 35-year-old woman with a diagnosis of TMAU. This case outlines the methods by which a diagnosis of TMAU can be made, while also magnifying the negative psychosocial impact of this rare diagnosis. It also reflects real-world experience with the currently available therapeutic options. TMA is produced in the gastrointestinal tract from dietary precursors such as choline (present in eggs, liver and poultry), trimethylamine N-oxide (TMAO; found in marine fish) and carnitine (found in meat). Primary trimethylaminuria is due to a mutation in the FMO3 gene, leading to the inability to oxidize this amine to the nonodorous metabolite (TMAO) (Antoñanzas J, Querol-Cisneros E, Alkorta-Aranburu G et al. Primary trimethylaminuria syndrome: more than an unpleasant odor. Int J Dermatol 2023; 62: e176–8). At present, over 40 variants in FMO3 associated with TMAU have been identified. Secondary or acquired TMAU is the result of a combination of factors including increased consumption of dietary precursors, gut dysbiosis, hepatic impairment and hormonal fluctuations resulting in an accumulation of TMA. Treatment regimens involve limiting precursors intake, using acidic soaps to reduce the volatility of excreted TMA, targeting gut microbiota, and the use of oral sequestering agents (Schmidt AC, Leroux JC. Treatments of trimethylaminuria: where we are and where we might be heading. Drug Discov Today 2020; 25: 1710–17). However, current treatment options have had limited therapeutic effect. Referral to metabolic specialists for correct nutritional support and referral to psychiatry is paramount for these patients. As evident from our patient’s viewpoint, this diagnosis can have a lifelong impact on social engagement and psychological health.
Teledermatology & Digital Dermatology SymposiumOral presentationsBT01 Developing a national artificial intelligence-assisted skin cancer pathway
Authors: Morton Colin , Chin Gillian X M , Carse Jacob , McKenna Stephen , Matin Rubeta , Fleming Colin
Published: June 2024

The AI Skin Cancer Consortium seeks to progress integration of artificial intelligence (AI) into the skin cancer referral pathway to promote rapid diagnosis of skin cancer and reassurance with benign lesions. In contrast to other fields of medicine, such as radiology, dermatology has lacked standardization in data acquisition, which is required for high-quality, reproducible and interoperable AI algorithm performance. Beginning in 2021, the consortium has made substantial progress towards defining a national pathway, technology architecture and data flows. We describe a standardized approach to acquisition of macroscopic and dermoscopic images, and technical and clinical metadata in a DICOM (Digital Imaging and Communications in Medicine) format, currently acquired in outpatient imaging centres and in general practice. In order to develop a transparent competitive environment for testing of this standardized National Health Service (NHS) pipeline, the consortium created a Small Business Research Initiative funded via a government agency. Three companies were awarded funding for this two-phase programme, from 15 applicants. These industry partners tested the pipeline within a trusted research environment (TRE), using real-world data. All industry partners were able to evaluate skin lesion images in combination with interoperable clinical metadata and run existing algorithms in the TRE. We report progress on this competition and also on the process of creating a national database, to permit competitive testing performance of different algorithms with specific clinical use cases. To assess the cost-effectiveness of introducing AI into the skin cancer pathway, we have also collaborated with the York Health Economics Consortium to produce a model to permit estimation of the impact of an AI triage tool to assist clinician triage. The recent vision statement from the British Association of Dermatologists encourages AI solutions intended to address a clinical unmet need and that integrates into patient pathways to enhance the service provided by healthcare professionals [https://www.bad.org.uk/clinical-services/artificial-intelligence/vision-statement-on-artificial-intelligence-ai-interventions/ (last accessed 19 March 2024)]. If the UK is to be at the forefront of skin AI, then it is imperative that the market is stimulated through use of meticulously standardized interoperable data standards with platforms that allow for transparent testing of multiple algorithms. We have successfully introduced a pipeline for safely generating standardized, high-quality images that are suitable for AI, identifying where we can achieve the greatest potential value for introducing AI into the NHS skin cancer referral pathway.
BT03 A picture paints a thousand words: simple solutions for optimizing the flow of urgent skin cancer referrals
Authors: Felton Jessie
Published: June 2024

In the face of increasing urgent skin cancer (USC) referrals from primary care, innovative solutions are needed. We present a low-cost, low-burden solution. Alternative pathways such as ‘rapid access lesion clinics’ build up waiting lists. In some areas photos are not assessed for 4 months (unpublished data) and the pathway is redundant. USC referrals are traditionally not triaged by a consultant, but non-USC referral are. We use consultant triage of some USC referrals, to support the USC teledermatology service. This ensures patients are appropriate, and correct numbers of patient are seen via teledermatology each week to avoid build-up of a waiting list. We present data from a 1-week snapshot survey of 66 USC referrals from primary care to a National Health Service hospital. We recorded the following: (i) whether a photo of any type accompanied the referral; (ii) whether the patient was suitable for teledermatology; this was established using criteria agreed by our local network with exclusions (e.g. immunosuppressed) and (iii) whether the consultant undertaking triage was confident to either downgrade off the USC pathway or discharge the patient based on the information provided in the USC referral. The results showed that 35 of 66 (53%) were suitable for teledermatology, and 31 of 66 (47%) were for face-to-face review. Ten of 66 referrals (15%) had a photograph but no dermoscopic images provided. Six of 66 (9%) were considered suitable for removal from the USC pathway or for discharge to the general practitioner (GP). Of these patients, five of six (83%) had a photograph attached to the referral. This indicates that use of USC consultant triage has the potential to reduce the number of patients entering the USC pathway. A macroscopic picture can be sufficient. This is a low-cost change that can be implemented quickly in most services. One clear referral pathway for the GP is used, USC referral, but patients are diverted at an early stage. USC triage also ensures that appropriate patients enter into the teledermatology pathway, avoiding duplication. The number of patients triaged to teledermatology matches the image-taking capacity, to eliminate waiting lists. USC triage allows for low-risk patients to be sent for artificial intelligence (AI) analysis, but can select out high-risk patients and unusual tumours. Many AI skin cancer services do not use metadata in their process and are not sufficiently trained on rare tumours. USC triage places additional burden on dermatology consultants but this is balanced against USC breaches and unrestricted numbers of patients entering the USC pathway.
BT05 Comparing the number-needed-to-biopsy ratio for melanoma diagnosis between teledermatology, an artificial intelligence device with teledermatology, and face-to-face models of care
Authors: Bali Radhika , Chung Jenny , Thomas Lucy , Hussain Khawar , Fearfield Louise
Published: June 2024

Traditional face-to-face (FTF) models of care are shifting towards use of hybrid FTF–teledermatology (TD) models, with certain UK centres adopting the additional use of artificial intelligence (AI) medical devices in suspected 2-week-wait (2WW) skin cancer referrals. The number-needed-to-biopsy (NNB) ratio is calculated by dividing the total number of biopsies by the number of biopsied (excised) skin cancers. NNB is increasingly used as a metric for diagnostic accuracy of malignant melanoma (MM) detection, with low ratios suggesting high specificity and vice versa. Our TD service has incorporated AI technology (DERM) using a marked class IIA medical device from April 2022. We therefore aimed to compare the NNB ratio for MM detection assessed via TD before and after introduction of the AI tool with FTF models of care. Retrospective analysis was performed on 50 consecutive patients in each group with suspected MM, assessed by consultant dermatologists. In the pre-AI group (31 female, 19 male; median age 51 years, range 23–94), six patients had confirmed MM (NNB 8.3). Subtypes included 4 of 6 superficial spreading melanoma (SSM), 1 of 6 nodular, and 1 of 6 in situ melanoma. The median Breslow thickness (BT) was 0.6 mm (range 0.6–7.5). Comparatively, in the post-AI cohort (36 female, 14 male; median age 53.5 years, range 22–97), seven lesions were confirmed as MM (NNB 7.1). Four of 7 were SSM, 1 of 7 lentiginous, 1 of 7 regressed and 1 of 7 in situ melanoma, with median BT 0.7 mm (range 0.4–17.1). Concordance between AI and reviewer diagnosis was 70% (35 of 50) in total and 86% (6 of 7) for confirmed MM. The accuracy of the AI compared with the histological diagnosis was 28% (14 of 50) overall, with a tendency to overdiagnose benign lesions as malignant, and 86% (6 of 7) for the MM cohort. FTF analysis (25 female, 25 male; median age 50.5 years, range 21–87) revealed six confirmed MM (NNB 8.3). Two of 6 were SSM, 2 of 6 nodular and 2 of 6 in situ melanoma, with median BT 2.8 mm (range 1–15). Our results show similar NNB ratios in both the pre-AI (8.3) and post-AI (7.1) TD cohorts, and the FTF group (8.3), which is reassuring and comparable with an NNB of 9.6, reported from a meta-analysis of 26 studies worldwide (Petty AJ, Ackerson B, Garza R et al. Meta-analysis of number needed to treat for diagnosis of melanoma by clinical setting. J Am Acad Dermatol 2020; 82: 1158–65). Decreased median BT was observed in the TD cohorts compared with FTF analysis, signalling possible earlier detection of MM. While TD, in conjunction with AI tools, may offer innovative and practical approaches to manage high volumes of 2WW referrals through extraction of benign lesions, specificity may initially be compromised. Ultimately, larger real-world datasets are required to further validate the performance of AI to assess superiority in diagnostic accuracy.
BT06 (P034) Using artificial intelligence to bridge the technical gap in dermatology: the role of large language models in creating an interactive Fitzpatrick skin phototype assessment
Authors: Zeina Mohamad , Zeina Bassam , Nachev Parashkev
Published: June 2024

Patient engagement is evolving with the advent of digital tools such as interactive websites and artificial intelligence (AI), yet significant barriers remain in the technical expertise required to create tools that benefit patients. We explore how large language models (LLMs), a type of AI that can facilitate and accelerate programming tasks, can enable clinicians and researchers to create interactive web-based patient engagement tools without the need for a dedicated web developer. We explore this possibility by developing, with the help of an LLM, an interactive skin self-assessment web tool. We used GPT4, a state-of-the-art LLM, as a web development assistant, and created an interactive JavaScript web page that guides patients through the Fitzpatrick skin phototype questionnaire. This involved building a minimal version first, and iteratively improving it. This web page initially asked the user the first two questions of the assessment, calculated a score, and returned this to the user. Once the code written by GPT4 was tested and shown to work, the tool was gradually improved to include all questions in the Fitzpatrick scale, and the result was modified to provide not only the total score, but also the result category. GPT4 allowed us, with no experience writing interactive JavaScript web pages, to develop and launch a web page that guides patients through a Fitzpatrick scale assessment. When GPT4 was asked to expand the questionnaire from two questions to the whole test, it gladly did so; however, the questions were not accurate. It then had to be given the specific wording of the questions and answers for the test, which it incorporated into functioning JavaScript code. This had to be performed in stages, adding two questions at a time, due to context limitations at the time. When this introduced issues, such as the code breaking or the website style looking inconsistent, GPT4 was able to fix these issues when they were described to it. Since the web page’s launch in March 2023, the web page has been viewed 1875 times by 1419 unique users. This study demonstrates one way in which LLMs can be used to enhance patient engagement in dermatology, by facilitating the creation of interactive skin assessments with utility in many dermatology settings. Hallucination remains a problem, and any created tools must be thoroughly verified for factuality. Although no authors had any experience writing interactive JavaScript, they have coding experience elsewhere, and future work should assess whether similar results can be achieved by a broader user base. Two authors received funding from a commercial organization for this work (A & Z Dermatology Clinic Ltd).