bluuebunny/crossref_metadata_2025 huggingface dataset:
CD09 Prevalence of contact allergy in patients with vulval dermatoses: a 10-year retrospective review
Authors: Khan Wajeeha , Akhter Shaheen , Stone Natalie , Chowdhury Mahbub M U , Katugampola Ruwani
Published: June 2024

Allergic contact dermatitis (ACD) is an important diagnostic consideration in the evaluation of patients presenting with vulval dermatoses. Although ACD coexisting with vulval dermatoses is uncommon, identifying and avoiding the allergens can have a positive impact on the management and quality of life of patients. The aim of this retrospective review of patch test data was to identify relevant allergens in patients presenting with vulval dermatoses in two specialist centres. Relevant data were extracted from electronic database and patch test departmental records between 2013 to 2023 from two specialist cutaneous allergy centres. Patch tests were performed in accordance with the International Contact Dermatitis Research Group and European Society of Contact Dermatitis guidelines. Patch test readings were performed on day 2 and day 4, and positive reactions were recorded. In total, 155 female patients with a mean age of 53.4 years were referred for patch testing. Vulval pruritus (37.5%) and vulval eczema (29%) were the two most common presenting complaints for patch test referral. All patients were tested to the standard and anogenital series, and some to extra series including medicaments, cosmetic, plants, acrylates, hairdressing and own products, depending on clinical history. Multiple allergens were identified including metals, topical drugs, fragrances, preservatives, cosmetic constituents and rubber additives. The most common clinically relevant allergens were fragrances (27.4%), preservatives (18.5%), textile dyes (4.5%) and medicaments (2.5%). Interestingly, 9.6% of patients were tested to the acrylate series, but none had a positive reaction. Fragrance allergy was prevalent in patients with a history of vulval lichen planus and lichen sclerosus. Numerous products were implicated in causing the dermatosis, including sanitary pads, wipes, shower gels and topical medications. Overall, 76% of patients noticed improvement after avoidance of relevant allergens. Patients with chronic vulval dermatoses are at increased risk of ACD and should be assessed for possible contact dermatitis. Patch testing is required to identify relevant contact allergens, the most common of which from our cohort include fragrances, preservatives, textile dyes and medicaments. These results are comparable with previous results reported by Woodruff and Vandeweege (Woodruff CM, Trivedi MK, Botto N, Kornik R. Allergic contact dermatitis of the vulva. Dermatitis 2018; 29: 233–43; Vandeweege S, Debaena B, Lapeere H, Verstraelen H. A systematic review of allergic and irritant contact dermatitis of the vulva: the most important allergens/irritants and the role of patch testing. Contact Dermatitis 2023; 88: 249–62). Patient education and follow-up are essential in optimizing treatment and preventing recurrence of vulval ACD.
Poster presentationsCD10 Gunpowder dermatitis: is there such a thing?
Authors: Moledina Zahra , Singh Kiran , Tewari Angela
Published: June 2024

We report a case of a 17-year-old boy who developed a facial rash on three consecutive occasions after firing a rifle. Patch testing to the British Standard Series was positive to cobalt chloride. Our patient described a clear history of the gun smoking and then him developing an itchy facial rash 2 h later.  Over the next few hours, he developed worsening facial erythema and swelling. This was treated with antihistamines and topical steroids and resolved. A few months later, he developed a similar rash with facial oedema when firing his rifle. After just under 2 h there was facial erythema and oedema, and erythematous papules could be seen on the wrists. This was again treated in a similar manner and resolved. There was no oral or laryngeal involvement. Moreover, a third time, when he was cleaning his rifle, he developed a similar rash a few hours later. There have been no episodes of the rash occurring outside of relation to the rifle. It was felt that this could represent a contact allergy to the potassium nitrate found in gunpowder that would rebound back from the butt of the rifle to enable bullets to be fired from the cartridge. Our patient used blanks, which also contain gunpowder but without the firing bullets. The patient was tested to the European Standard Battery only. At day 4, the patient developed a 2++ reaction to cobalt only. Cobalt chloride is a common metal known to cause a delayed hypersensitivity reaction, affecting approximately 1–3% of the population (Midander K, Werner P, Isaksson M et al. Cobalt nanoparticles cause allergic contact dermatitis in humans. Br J Dermatol 2023; 188: 278–87). It is used to line the barrel of some rifles to reduce erosion and barrel wear (De Rosset WS, Montgomery JS. Cobalt-base alloy gun barrel study. Wear 2014; 316: 119–23). It is thought that our patient experienced immediate contact urticaria with a secondary id reaction to the cobalt. We have counselled him on other cobalt-containing products. There are currently no published reports of hypersensitivity reactions to cobalt through the use bullet-containing rifles.
CD11 Techniques for patch testing interpretation in patients with skin of colour: a systematic review of the literature and textbooks
Authors: Selvendran Subothini Sara , Goldsmith Portia
Published: June 2024

By 2031, approximately 15% of the UK population will comprise individuals with skin of colour. Allergic contact dermatitis can result in significant morbidity, and patch testing is the gold standard to detect triggers. Under-representation of those with skin of colour in educational materials may contribute to false negative patch testing and underdiagnosis of contact dermatitis in this population. Our aim was to investigate the extent to which images of positive patch tests in individuals with skin of colour are represented in the literature. A systematic search of the PubMed database and the Royal Society of Medicine (RSM) electronic library from conception to date was conducted. This revealed 903 articles and 2034 resources, respectively. Screening titles and abstracts revealed that six articles on PubMed and one paragraph in an electronic book on the RSM database commented on patch testing in those with skin of colour. Of these, only one article on PubMed included images of positive patch test results in individuals with skin of colour. In our department, 60% of patients have skin of colour. We describe our techniques for patch test readings and present an example of how positive reactions can be missed. We recommend using a tangential light at a 45° to 90° angle to reveal any areas of skin that are papular. The skin under all the areas where patches have been applied should be gently palpated by running an index finger over the skin to assess whether they are raised or infiltrated. A 61-year-old Afro-Caribbean woman underwent patch testing. Positive patch test reactions to fragrance mix I, fragrance mix II, geraniol, citral, limonene and thiuram were observed. These were demonstrated through a cluster of vesicles and papules that were skin coloured rather than erythematous. The use of tangential lighting enabled visualization of the results and mitigated glare. In summary, our literature review has shown that there is an omission in textbooks and papers on the challenges of how to read patch tests in patients with skin of colour. There is a need to increase the awareness of the pitfalls of looking for skin erythema and how to use simple techniques such as tangential lighting and palpation to help detect positive patch test reactions. This information coupled with images should be in educational materials to prevent underdiagnosing contact dermatitis and healthcare inequalities for people with skin of colour.
CD14 Efficacy of narrowband ultraviolet B phototherapy vs. low-dose oral ciclosporin as second-line management in antihistamine-refractory chronic spontaneous urticaria: a noninferiority, randomized study
Authors: Roshini N , Mehta Hitaishi , Bishnoi Anuradha , Parsad Davinder , Kumaran Sendhil
Published: June 2024

Literature regarding the role of narrowband ultraviolet B (NB-UVB) phototherapy in the treatment of antihistamine-resistant chronic spontaneous urticaria (CSU) is scarce, and ciclosporin has established its role in management. We aimed to study the efficacy of NB-UVB phototherapy vs. low-dose oral ciclosporin in the management of chronic refractory urticaria (CRU), terms of change in Urticaria Activity Score (UAS), Urticaria Control Test (UCT), Chronic Urticaria Quality of Life (CU-QoL) and Angioedema Activity Score (AAS). In this randomized prospective noninferiority study, 50 patients were recruited who fulfilled the criteria of oral antihistamine-refractory CSU, namely 6 months of spontaneous urticaria with no response from three consecutive months of antihistamines, and steroid dependence. The patients were randomized to receive NB-UVB (group A) or ciclosporin 3 mg kg−1 (group B) for 90 days, with post-treatment follow-up of 90 more days. Patients were assessed fortnightly. The mean (SD) UAS7 decreased from baseline scores of 24.8 (8.2) and 27.1 (8.2) to 0.82 (1.47) and 0.28 (1.4) in group A and group B, respectively at the end of the 90-day treatment (P < 0.001). These increased to 1.55 (1.74) and 4.13 (4.85) at day 180 in groups A and B, respectively (P = 0.01 and P = 0.002). The mean (SD) UCT scores increased from baseline 8.52 (2.8) and 8.24 (2.67) to 15.0 (1.7) and 15.9 (0.4) at day 90 (P < 0.001), which decreased to 14.9 (1.0) and 14.1 (2.0) at day 180 in groups A and B, respectively (P = 0.03 and P = 0.001). The mean (SD) CU-QoL decreased from baseline scores of 26.8 (14.9) and 30.0 (14.9) to 3.4 (6.3) and 0.48 (2.0) at day 90 (P < 0.001 and P = 0.002), which increased to 2.1 (2.3) and 4.9 (5.2) at day 180 in groups A and B, respectively (P = 0.09 and P = 0.001). The mean (SD) AAS7 scores decreased from baseline 2.0 (4.7) and 4.9 (8.2) to 0 (0) and 0 (0) at day 90 in both groups (P = 0.04 and P = 0.007). AAS7 scores remained at 0 through follow-up. Ciclosporin performed as a crisis buster, giving early and better control of CRU during the treatment period; however, disease relapsed promptly on stopping ciclosporin. On the other hand NB-UVB had more sustained suppression of CRU even during follow-up. Thus NB-UVB is an effective, safe, affordable therapeutic modality for steroid-dependent CRU. Our study had a small sample size and the results may not be representative of a bigger population.
CD16 Medical-grade manuka honey and a sugar-free manuka honey extract inhibit allergic IgE-induced mast-cell degranulation: potential role as an topical anti-inflammatory agent in atopic dermatitis
Authors: Abdelwahab Omar , Lwaleed Bashir
Published: June 2024

Mast-cell numbers and activity are both increased in atopic dermatitis (AD) lesions. AD is characterized by allergen–IgE–FcεRI-induced mast-cell activation, associated with allergic responses to specific types of foods or allergens. Medihoney® (MH) is a medical-grade manuka honey with strong antimicrobial properties. Recent reports also suggest it has anti-inflammatory properties via inhibition of histamine release by mast cells. In the present study, we investigated the anti-inflammatory effect of MH and a sugar-free manuka honey extract (EX) against allergic inflammation by studying its effect on mast-cell degranulation induced by IgE. LAD-2 human mast cells were preincubated overnight with 100 ng mL−1 of human myeloma IgE, then activated by 1% antihuman IgE for 40 min with or without 20-min preincubation with 4%, 2% and 1% of MH or EX. Degranulation was assessed by measuring release of the lysosomal enzyme β-hexosaminidase. Both MH and EX induced significant dose-dependent inhibition of IgE-induced mast-cell degranulation, culminating at 85% and 100% inhibition, respectively, at 4% concentration. In conclusion, MH and EX potentially inhibit allergic IgE-induced mast-cell degranulation. Aqueous preparations of MH and EX (applied topically) could potentially be useful as anti-inflammatory agents directed against the allergic inflammation involved in the pathophysiology of AD.
DS13 Pregnancy-associated melanoma: a UK-wide service evaluation
Authors: Lawlor Kate , Hadjieconomou Sofia , Katugampola Ruwani , Mills Caroline , Li Vincent , Rajan Suchitra
Published: June 2024

There are currently no guidelines in the UK regarding management of pregnancy-associated melanoma (PAM). It is estimated that one-third of women diagnosed with melanoma are of childbearing age and numbers are rising (Still R, Brennecke S. Melanoma in pregnancy. Obstet Med 2017; 10: 107–12). Melanoma can metastasize to the placenta. Therefore, a diagnosis of PAM complicates decisions regarding staging and treatment (Carter TJ, George C, Harwood C, Nathan P. Melanoma in pregnancy: diagnosis and management in early-stage and advanced disease. Eur J Cancer 2022; 166: 240–53). A UK-wide survey distributed to members of the British Society for Dermatological Surgery (BSDS) has shown 23 cases of PAM and we await data of up to 26 additional identified cases. The data collected on these cases demonstrate an average age of 33.2 years at the time of diagnosis, with a range from 22 to 46 years. The stage of pregnancy at the time of diagnosis ranged from 2/40 gestation to 11 months postpartum. The diagnosis was primary melanoma in 18 patients, with metastatic disease in five patients. Breslow thickness ranged from in situ melanoma to > 4 mm. Fifteen patients underwent narrow and subsequent wide local excision during pregnancy. Two patients delayed their wide local excision until after pregnancy. Two patients underwent sentinel lymph node biopsy during pregnancy, one of whom also underwent an axillary lymph node dissection during pregnancy. Three patients had immunotherapy for stage 4 disease postpartum. One of these patients delivered at term, having being diagnosed with metastatic melanoma at 32 weeks. She is currently having palliative treatment for advancing metastatic disease. Another of these patients underwent an elective caesarean section at 35 weeks’ gestation in order to commence immunotherapy and is likely to need further adjuvant treatment after a relapse. The details of the obstetric outcome for the third patient are awaited, but it is known that the patient has died from complications of metastatic melanoma. The placenta was sent for histological examination for only one of the patients and it did not show any evidence of metastases. The baby had a full-skin examination after birth in four cases (in three patients on one occasion only), with none showing any abnormalities secondary to melanoma. Four of the patients have successfully completed follow-up. Fifteen patients are currently undergoing follow-up, including one who is having palliative treatment and one who is due to recommence on immunotherapy. Four patients have died from complications of melanoma. We await data on up to 26 additional cases of PAM to include in this study.
DS16 Incidence and management of pregnancy-associated melanoma in a district general hospital in the Southeast of England
Authors: Pearson Nicholas , O’Kelly Sara , Birnie Andrew
Published: June 2024

Melanoma is the most common malignancy during pregnancy (Driscoll MS, Martires K, Bieber AK et al. Pregnancy and melanoma. J Am Acad Dermatol 2016; 75: 669–78). Pregnancy-associated melanoma (PAM) is defined as any melanoma diagnosed during pregnancy or up to 1 year postpartum. PAM appears to have poorer outcomes than other melanomas (Byrom L, Olsen C, Knight L et al. Increased mortality for pregnancy-associated melanoma: systemic review and meta-analysis. J Eur Acad Dermatol Venereol 2015; 29: 1457–66). The pathophysiology of why this could be is incompletely understood. There are currently no guidelines on the management of PAM in the UK. This is part of a project to collect data nationally to identify features of PAM, and to determine potential diagnostic challenges due to pregnancy. Patients were identified from the paper notes of the skin cancer multidisciplinary meetings from a district general hospital in the south-east of England. This covered a catchment area of approximately 800 000 patients. To identify patients who were diagnosed with PAM, we investigated the cohort of patients who were registered as female and aged between 20 and 50 years, a commonly used definition in the literature. Details on the pregnancies and melanoma were obtained from the electronic medical records. Four years of data from multidisciplinary meetings were processed, from December 2019 to November 2023. During this period, there were 85 female patients of childbearing age who were diagnosed with melanoma. Six patients had PAM, five of whom were diagnosed postpartum. The Breslow thicknesses ranged from 0.3 to 2.2 mm. The patient who was identified perinatally did not have her treatment delayed due to the pregnancy, and there was no record of the placenta being sent for histology or the baby being given a full-skin examination. Regarding the outcome for these patients, when the data were collected in December 2023, five were currently under follow-up and one had completed follow-up. PAM is a relatively rare condition, but with maternal ages rising in the developed world, the incidence could be expected to increase. National data collection is therefore required to identify trends and associations to gain consensus on its management.
DS20 Challenges and considerations of Mohs surgery in the ear
Authors: Kloczko Ewa , Wilsher Mark , Naparus Andreas , Kulendra Kevin , Anjum Navara
Published: June 2024

Malignancy of the external ear represents 6% of all skin cancers, and basal cell carcinomas (BCCs) account for 40% of those. When infiltrative, these BCCs may pose unique treatment challenges given the complexity of the local anatomy and the proximity to other local structures, such as the parotid gland, the external auditory canal, the tympanic membrane, the middle ear and the facial nerve. We describe a case of a 69-year-old man who presented with a 5-year history of a crusted lesion in the left year. Inability to wear a hearing aid due to pain and discharge from the left ear prompted the patient to attend the emergency department. Following the ear–nose–throat assessment, he was referred to skin cancer clinic. Initial biopsy confirmed a clinical suspicion of an infiltrative BCC affecting the left antihelix and conchal bowl extending to the entrance of the external auditory meatus (EAM). Following a multidisciplinary approach between plastic surgery, dermatology and the head and neck team, three treatment options were discussed with the patient: Mohs micrographic surgery, standard excision, and radiotherapy. Preoperative imaging revealed the tumour abutting the parotid gland, but there was no involvement of the bony or cartilaginous aspects of the EAM. The patient pursued the Mohs procedure to preserve function and cosmesis of the ear. After two stages margins remained positive. The decision was made to stop the procedure, given the evidence of extension to the EAM. Two days later the patient underwent partial pinnectomy, which had evidence of a BCC extending to all margins with infiltration into the parotid gland and cartilaginous ear canal. Focal perineural invasion was present. Subsequently, this case was discussed with the head and neck team, with a multidisciplinary decision recommending a definitive resection. The patient underwent superficial left parotidectomy and complete pinnectomy including the cartilaginous external ear canal and tympanic membrane, followed by reconstruction with an anterolateral-thigh free flap. The patient received a prosthetic left ear and is currently awaiting an assessment for a bone-anchored hearing aid. Histologically, aggressive BCC was detected in clinically unremarkable areas of the pinna. It is likely that the multiple embryonic fusion planes within the EAM account for less predictable tumour spread. This case highlights the complexity of Mohs surgery on the ear and the need for a collaborative approach in management of those areas to provide the best quality of care for our patients.
DP14 ALK-positive histiocytosis with involvement confined to the skin: report of two cases in adults
Authors: Lim Su Xin , Pugalenthy Sarajeni , Wilson Niall , Vasile Cristina , Bakshi Arti , Cohen Stuart
Published: June 2024

We present two interesting cases of anaplastic lymphoma kinase (ALK)-positive histiocytosis in adults. The first was a 79-year-old woman with a 10-year history of a firm, violaceous, exophytic nodule on her right upper arm. It was asymptomatic, and stable in size and colour. It measured 11 mm in diameter and had a scaly surface. Dermoscopy was nondiagnostic, showing a featureless, violaceous appearance. Histology revealed a dermal histiocytic infiltrate with epithelioid and foamy histiocytes and occasional Touton-type giant cells. Immunohistochemistry showed the histiocytes to be CD68 and ALK positive (clone AlkD5F3). S100 and CD1a were negative. The second case was a 42-year-old man with an enlarging, latterly tender lesion on the chest for many years. Examination showed a nonspecific 5 × 4-mm shiny pink papule. Excision histology revealed a dermal histiocytic infiltrate, with numerous lymphocytes and focal emperipolesis. Immunohistochemistry showed the histiocytes to be CD68 and S100 positive with patchy ALK positivity (clone AlkD5F3). CD1a was negative. A diagnosis of ALK-positive histiocytosis was concluded in both cases. This rare subtype involves a genetic alteration in genes encoding receptor tyrosine kinases. Its full clinicopathological features have not been fully elucidated. It most commonly presents in young infants as a multisystem disease with liver and haematological disturbances. Localized disease is more common in adults, for which the prognosis is good. Clinicopathological correlation is important as the clinical features are usually nonspecific. Previous reports involving cutaneous disease have tended to focus on extracutaneous manifestations, although papules, which may be yellow or purple, at various sites have been described. Symptoms from the skin lesions have not been clearly reported. Histopathologists need to be aware of this new entity and include ALK immunostain in all dermal histiocytic lesions. The morphology is variable, consisting of an admixture of epithelioid and foamy histiocytes, sometimes with emperipolesis and thus mimicking juvenile xanthogranuloma and Rosai–Dorfman disease morphologically. Previous cases have found gene fusions of KIF5B–ALK, TPM3–ALK, CLTC–ALK, TFG–ALK, EML4–ALK and DCTN1–ALK, and ALK-fluorescence in situ hybridization positivity. The clinical relevance of this gene fusion is not known. Blood tests and imaging to assess for other organ involvement should be considered. Retrospectively our cases showed no signs or symptoms of other organ involvement, and investigations were clear. Targeted ALK inhibitor therapy has shown responsive results in treating ALK-positive histiocytosis with multisystem involvement. Surgical resection has been successful in treating cutaneous disease, with no reported recurrence. As further cases of this rare condition come to light, its full clinicopathological and molecular features may become more apparent.
PA27 Expanding the phenotype of congenital erosive and vesicular dermatosis
Authors: Moxham Lindy , Felton Sarah , Lam Joseph
Published: June 2024

Congenital erosive and vesicular dermatosis (CEVD) is a rare condition that typically presents at birth with erosions and vesicles (Cohen B, Esterly N, Nelson P. Congenital erosive and vesicular dermatosis healing with reticulated and supple scarring. Arch Dermatol 1985; 121: 361–7). Lesions heal with distinctive reticulate and supple scarring and can involve > 75% of the skin surface (Tlougan BE, Paller AM, Schaffer JV et al. Congenital erosive and vesicular dermatosis with reticulated supple scarring: unifying clinical features. J Am Acad Dermatol 2013; 69: 909–15). The pathogenesis of CEVD is unknown, although hypotheses include intrauterine infection, amniotic adhesions, or a developmental defect in skin healing. Histopathological findings early in the disease process can include epidermal necrosis, subepidermal vesiculation and an eroded epidermis. Older lesions demonstrate scar formation, decreased hair follicles, and absent eccrine glands. Historically, CEVD has been described as preferentially affecting the trunk and limbs, with sparing of the face and volar surfaces. Patients with CEVD have been reported to have higher prevalence of premature birth, neurodevelopmental abnormalities, nail abnormalities, tongue atrophy or sores, alopecia, and cardiac defects. Here, we highlight two patients with presumed CEVD with atypical features. Patient A presented at 13 months with a history of linear erosions and vesiculation over their scalp, forehead and posterior left flank. The lesions were present at birth and healed with reticulate scarring with no further flares. Patient B presented at 11 months with a history of stellate scarring over the lower abdomen, with noncontiguous involvement of the right and left axillae, scalp, and right forehead. The lesions were also present at birth and were initially more erythematous and developed milia-like cysts. The cysts resolved, leaving reticulate and supple scarring. Of note, patient B had no erosions or vesicles. At the time of assessment, both children were otherwise healthy and developing normally. These cases add to evidence that CEVD is neither facial nor scalp sparing, as commonly described, and can be more localized than previously thought, but affect noncontiguous sites. Case B also demonstrates that, despite the name, CEVD can present without erosions, and instead with milia-like cysts. The cases also demonstrate that CEVD can occur in the absence of other congenital abnormalities; outcomes for children with the condition are then more favourable. Both families were provided with reassurance that although the scarring would not disappear completely, and can be of cosmetic concern, CEVD is a nonprogressive condition and thus no specific treatment is indicated.
PA28 Reactive infectious mucocutaneous eruption: a case series of four children
Authors: Muttoni Elisabetta , Hale Gordon , Jury Catherine , Beattie Paula
Published: June 2024

Reactive infectious mucocutaneous eruption (RIME) is a reactive inflammatory mucositis most commonly but not exclusively associated with Mycoplasma pneumoniae. It presents with a mucosal- predominant eruption with sparse to no skin involvement. We describe four recent cases in children between 6 and 13 years of age. All four children presented with increasing lip discomfort with subsequent lip swelling, sloughing and crusting. The intraoral mucosa was affected to varying degrees. All described a prodromal illness with cough and general malaise, and three patients also reported fevers. Skin manifestation varied, with two patients having no cutaneous involvement while two patients had sparse pink macules and negative Nikolsky sign. Investigations included an extended respiratory screen and chest X-ray to check for underlying infection, and M. pneumoniae was detected in two patients. Skin swabs for virology and bacteriology were also taken. Management focused on pain control, nutritional support and good mouth care. The patients required admission to hospital for fluid resuscitation and analgesia. Mouth care was implemented with regular benzydamine hydrochloride spray and Gelclair gel, and white soft paraffin alongside Trimovate cream (oxytetracycline and nystatin) for the lips. Due to ongoing diffuse erosions of the buccal mucosae with haemorrhagic crusting of the lips, one patient required a short course of oral steroids. Reactive infectious mucocutaneous eruption was previously termed Mycoplasma pneumoniae-induced rash and mucositis; however, reports of this entity being caused by other infections including enterovirus, influenza B virus and SARS-Cov-2 has led to a change in terminology (Mahama A, Kojder P, Thibodeaux Q, Ruth J. Reactive infectious mucocutaneous eruption following COVID-19 in an adolescent boy: case report and review of the literature. Pediatr Dermatol 2023; 40: 162–5). Mucosal membranes are significantly more affected than skin in RIME. Skin involvement can be sparse or absent, differentiating it from Stevens–Johnson syndrome/toxic epidermal necrolysis, which presents with rapidly progressive skin necrosis and is often drug induced, and from erythema multiforme, which is characterized by typical target lesions (Tonkin R, Ladha M, Johnson N et al. Reactive infectious mucocutaneous eruption – repeat etanercept after intravenous immunoglobulin: a case report. SAGE Open Med Case Rep 2022; doi: 10.1177/2050313X221117887). Investigations for underlying respiratory infection and treatment with appropriate antibiotic therapy should be implemented. Supportive care in the form of pain relief, and nutritional and fluid support is important. Systemic steroids may be required to truncate the inflammatory response, although there is a lack of prospective data. In conclusion, our aim is to bring awareness to this condition to facilitate its recognition, diagnosis and treatment.
PA32 A rare case of symmetrical giant facial plaque-type juvenile xanthogranuloma
Authors: Darne Sharmela , Makanjuola Abiola
Published: June 2024

Juvenile xanthogranuloma (JXG), a form of non-Langerhans cell histiocytosis, is a rare benign condition estimated to affect 1 per million children. In 80% it presents as a solitary papule or nodule. There are several described subtypes of JXG including mixed, giant, subcutaneous, eruptive, clustered and plaque-like. Symmetrical giant facial plaque-type JXG is a very rare subtype, first described by Gunson and Birchall in 2008 [Gunson TH, Birchall NM. Symmetrical giant facial plaque-type juvenile xanthogranuloma. J Am Acad Dermatol 2008; 59 (2 Suppl. 1): S56–7]. We present a 2-year-old girl with a slowly progressive, asymptomatic, symmetrical orange-coloured rash on both cheeks that started around age 1 year. She was otherwise well. Examination showed well demarcated, orange-coloured indurated plaques covering both cheeks in a mask-like distribution. There was no lymphadenopathy or hepatosplenomegaly. There were no signs of neurofibromatosis. Full blood count, renal and liver function tests and lipids were normal. Biopsy showed subepidermal sheets of histiocytic proliferation. Lesional cells were positive for CD68 and negative for SOX10, compatible with JXG. She is currently awaiting ophthalmology assessment and an ultrasound scan of her abdomen. Over the course of her follow-up, the plaques have slowly extended, spreading onto the temples and chin, the axillae and both upper arms. JXG belongs to the proliferative dendritic-cell-related disorders and is the commonest form of non-Langerhans histiocytosis (Itin K, Häusermann P, Itin P, Fosse N. Symmetrical facial giant plaque-type juvenile xanthogranuloma: case report and review of the literature. Case Rep Dermatol 2021; 13: 399–406). It is most often characterized by a solitary red–yellowish benign papule (< 0.5 cm) or nodule (< 2 cm) that usually involves the head and neck (42%) or trunk (20–40%), although involvement at any body site can occur, including extracutaneous sites (the eye being the most common). It may be congenital, but most cases develop in the first year of life. It more commonly affects male patients, in a ratio of up to 7 : 1. There is usually spontaneous resolution, which takes months to years, leaving an atrophic scar. The giant symmetric facial subtype of JXG is exceptionally rare, with only five reported cases worldwide. In these cases, there was no spontaneous resolution during a follow-up period of between 2 and 6 years. None of the reported cases had systemic or extracutaneous involvement. Treatment options are undefined – one child had a partial response to a single fractionated CO2 laser treatment. We present this case to highlight awareness of this unusual presentation.
BI13 (P065) Attitudes and practices of patients with inflammatory bowel disease towards skin cancer risk and sun protection
Authors: Herlihy Maeve , Blake Eve , Courtney Garry
Published: June 2024

Skin cancer is the most common form of cancer in Ireland, with over 13 000 new cases diagnosed annually. People with inflammatory bowel disease (IBD) may be at higher risk of skin cancer. A meta-analysis performed on more than 170 000 patients diagnosed with IBD found that patients with IBD had a 37% higher risk of developing melanoma than expected in the general population (relative risk 1.37, 95% confidence interval 1.10–1.70). This increased risk was independent of IBD treatment. Additionally, many of the treatments used for IBD involve suppressing or altering the immune system. Immunosuppression is a risk factor for all types of skin cancer, and cutaneous malignancies in immunocompromised patients tend to behave more aggressively compared with those in the general population. The British Association of Dermatologists has published preventive guidelines for patients on immunosuppression, but specific gastroenterology recommendations are lacking. Prevention and early detection are therefore of paramount importance. Our aim was to assess knowledge of skin cancer risk factors and photoprotective behaviours in an Irish cohort of at-risk patients with IBD. A questionnaire was given to patients attending our IBD clinic. Clinical data were recorded including diagnosis, immunosuppressants, skin cancer risk factors and photoprotective behaviours. In total, 87 patients (52% women) with IBD (63% Crohn disease, 35% ulcerative colitis) were included. All participants were White, with 77% recorded as having ‘fair’ or ‘very fair’ skin. Most patients (97%) were on treatment for their IBD (66% on biologics, 25% on immunomodulators). Over one-third of participants (35%) were unaware of an increased skin cancer risk associated with IBD. Four patients had a history of skin cancer, two of which were melanoma. Half of patients (48%) had been sunburnt in the last year, and 36% had more than 10 burns in their lifetime. In total, 57% of patients reported a history of blistering sunburn and 22% of patients had used sunbeds. Knowledge of skin cancer risk factors and worrisome features was generally good, and the majority of our cohort (74%) always wore suncream abroad. However, less than half wore suncream frequently in Ireland (37%) or when it is cloudy (22%), and also did not take other important measures, such as reapplying suncream every 2 h (43%), or wearing a hat (26%) or protective clothing (32%). Our study highlights gaps in the education of our IBD cohort regarding skin cancer risk and prevention, and suggests that primary prevention of skin cancer in this IBD cohort is suboptimal. Ideally, educational interventions to enhance patient awareness and encourage adequate photoprotection and skin self-surveillance should be undertaken and assessed.
Poster presentationsBI18 The management of vulval intraepithelial neoplasia in immunosuppressed women: outcome and recommendations from a multidisciplinary vulval clinic
Authors: Bali Radhika , Chung Jenny , English Caroline , McDermott Jacqueline , Staley Helen , Harish Sapna , Cohen Charlotte , Palmer Elaine , Fuller Claire , Butler John , Akel Randa
Published: June 2024

Vulval intraepithelial neoplasia (VIN) is a premalignant change of the vulval epithelium that can progress to squamous cell carcinoma (SCC). Immunosuppressed patients are a high-risk subset, with a greater risk of recurrence with standard treatment. To date, there is limited research focusing on this vulnerable population. A retrospective study was designed to review the treatment outcomes of immunosuppressed patients with VIN in a tertiary, multidisciplinary vulval service. In total, 104 biopsy-proven adults with VIN were identified from a histological database from 1 April 2013 to 31 March 2023. Patient demographic data, disease type and treatment outcome were collected. Electronic records and medical photography, where available, were used to retrospectively map each vulval lesion in quadrants. Complete response (CR) was defined as being clinically and/or pathologically clear of disease at 3 months’ follow-up. Recurrence was defined as lesions reappearing in the same quadrant after achieving CR. Data analyses were performed using IBM SPSS Statistics for univariate analyses. Overall, 31 of 104 patients (30%) were immunosuppressed, developing 47 lesions in the study period. This was due to HIV (n = 9), diabetes (n = 5), active malignancy (n = 10) and other causes (n = 7). The mean age was 54 years (range 20–94) with a mean follow-up duration of 70 months (range 11–132). The histological subtypes of VIN included low-grade squamous intraepithelial lesion (11%), high-grade squamous intraepithelial lesion (72.3%), differentiated VIN (4.3%) and microinvasive SCC (14.9%). Immunosuppressed patients were more likely to have multifocal disease (57.4% vs. 29.8%, P = 0.003) with previous human papillomavirus (HPV) burden (66.7% vs. 36.6%, P = 0.008). For those screened during the study period, immunosuppressed patients were more likely to have associated anal intraepithelial neoplasia (25.8% vs. 6.9%, P = 0.02) and cervical intraepithelial neoplasia (29.0% vs. 15.2%, P = 0.031). The CR rate from first-line treatment (imiquimod, surgery, laser or PlasmaJet®) was 54.8% in the immunosuppressed cohort compared with 75.6% in the control group (P = 0.073). There was no difference in the rate of recurrence or progression to SCC. There was no death due to disease observed in the immunosuppressed group, compared with three patients in the control group. In summary, our high-risk population with VIN was found to have a higher burden of HPV and was more likely to have multicentric disease. The treatment outcome was noninferior to the control group’s, unlike similar previous case series. This highlights the need for multidisciplinary clinics offering long-term close monitoring, with early treatment and HPV surveillance.
BI22 A UK multicentre prospective study on the awareness and impact of azathioprine as a major risk factor for developing skin cancer in patients with inflammatory bowel disease: patient and clinician perspectives
Authors: Altayeb Alla , O’Kelly Sara Lupita , Howard Lucy , Deane Eleanor M , Walker-Smith Philippa , Birnie Andrew
Published: June 2024

Azathioprine is an immunosuppressive drug commonly prescribed in the treatment of inflammatory bowel disease. Its immunosuppressive properties in addition to other pharmacological features unique to azathioprine are known to significantly increase the risk of nonmelanoma skin cancers, necessitating the need for close monitoring and increased ultraviolet (UV) protection practices. In this study, written surveys were distributed to patients with inflammatory bowel disease treated with azathioprine to establish their awareness of the skin cancer risk and to gain an understanding of their photoprotective behaviours, in addition to surveying their responsible gastroenterology clinicians (doctors and nurses) on their current practices and risk management. Thirty-two patient and 11 clinician surveys were completed across 3 NHS hospital trusts in the southeast of England, between July and September 2023. Of these 32 patients, 17 (53%) were male and 15 (47%) were female, two-thirds of patients (n = 21) were aged 16–49 years, and 11 patients (34%) were > 50 years with only 1 patient over the age of 70 years. The majority (60%) had Fitzpatrick skin type I or II. The mean duration of azathioprine therapy varied; 17 patients (53%) took azathioprine for less than 1 year and 12 patients (38%) took it for more than 3 years. The results highlighted a high level of awareness of skin cancer risk (75%), with all participants reporting some sunscreen use. However, adequate use of broad-spectrum sunscreen (with UVA protection) was poor, with the majority (78%) limiting their sunscreen use only to sunny days or when outside for extended periods. Additionally, despite the relatively young patient cohort, 16% reported a previous diagnosis of sun damage (actinic keratosis) or skin cancer, and 28% reported episodes of sunburn within the past year. Of the clinicians surveyed, six (55%) enquired about previous skin cancer and UV exposure before or during prescription of azathioprine. Ten (91%) provided written information on skin cancer risk, while seven (64%) advised on sunscreen use when prescribing azathioprine. Despite this, only one (9%) reported feeling confident advising patients on sunscreen application and the appropriate sun protection factor rating, and only two (18%) gastroenterologists reported feeling confident in undertaking a full skin check for the identification of any possible skin cancers during the monitoring phase. Although small, this study highlights the need for increased targeted preventive measures to reduce the risk of skin cancer in this population, and a need for greater support and education to the clinicians prescribing this drug.
BI28 Invasive streptococcal infection in a patient with HIV
Authors: Diong Sophie , O’Rourke Michéal , Bergin Colm , Leonard Niamh , Wynne Bairbre , Ormond Patrick
Published: June 2024

A spectrum of severity exists in cutaneous infections with group A β-haemolytic streptococci (GABHSs), including life-threatening streptococcal toxic shock syndrome (STSS), which can follow minor trauma to skin or mucosa. We present a case of STSS with resultant necrotizing ecthyma-type infraorbital ulceration and necrotizing lymphadenitis in a patient with HIV. A 37-year-old Nigerian woman of no fixed abode presented with florid head and neck oedema, and vasopressor-dependent hypotension 1 day after accidental ocular inoculation with a camphor-based product, causing excoriation-induced microtrauma to periorbital skin. Of note, she had a background history of treated HIV infection, with undetectable viral load, and end-stage renal disease. Examination revealed generalized craniofacial swelling, with significant periorbital oedema, and bilateral infraorbital ulcers with discharge. Inflammatory markers were raised, with a C-reactive protein of 503 mg L−1. Multiorgan failure (MOF) was noted with a new mixed-pattern liver function derangement and an almost doubling in her baseline creatinine to 833 µmol L−1. Only a small area of epidermal loss (body surface area < 1%) was noted under her chin. Blood cultures were negative, but infraorbital swabs alongside culture biopsy from the infraorbital ulceration yielded Streptococcus pyogenes, a GABHS. Histopathology highlighted ulcerated skin, dermal necrosis and subcutaneous abscesses. The patient was diagnosed with STSS. Intravenous immunoglobulin, systemic steroids and antimicrobials allowed for stabilization. Cutaneous findings were slow to resolve, and complicated by submandibular necrotizing lymphadenitis. Given a prior history of keloidal scarring, secondary intention healing was trialled for the deep infraorbital ecthyma-type ulceration. Unfortunately, almost 2 months after the initial episode, no improvement was seen. Further Pseudomonas superinfection perpetuated ulceration, and full-thickness skin grafting was required, with good cosmetic and functional outcome for our patient. STSS is a superantigen-driven disease secondary to an invasive infection, leading to massive stimulation of T cells via exotoxins, inducing a cytokine cascade causing shock and MOF. While GABHSs are frequent in patients with HIV, the occurrence of STSS is less than expected, likely related to T-helper-cell dysfunction. When GABHSs are observed the disease is frequently protracted. Our case likely comes as a result of our patient’s compliance with HIV treatment, and resultant virological suppression. Ecthyma, a further invasive form of GABHS involving the dermis, carries a risk of scarring. GABHS skin and soft tissue infections are known to be independently associated with homelessness. This compounded the existing challenges of this case, including host immunodeficiency factors and subsequent bacterial superinfection, leading to refractory infraorbital ulcers.
BI38 A rare case of acquired epidermodysplasia verruciformis
Authors: Murphy Lisa , Leonard Niamh , O’Gorman Susan
Published: June 2024

Epidermodysplasia verruciformis (EV) is a rare, genetic disease characterized by an increased susceptibility to infection with specific types of human papillomavirus. These patients also have a higher likelihood of developing malignant skin tumours. We report the unusual case of a 51-year-old female patient who presented with 7-month history of tender, verrucous papules and nodules on the dorsum of both her hands. Her medical history was significant for sero­negative arthritis and diabetes mellitus, and she was being treated with methotrexate for her arthritis. She had never had lesions similar to these in the past and there was no history of a cutaneous malignancy. A biopsy from a lesion on the right elbow demonstrated epidermal acanthosis and a prominent granular layer suggestive of viral aetiology, such as EV. Acquired EV typically occurs in immunosuppressed patients such as those who have had transplants or haematological malignancies. The lesions generally appear at sun-exposed sites such as the hands and arms, as was seen in this case. Treatment options include topical treatments such as cryotherapy and fluorouracil, or oral agents such as acitretin. Photoprotection advice is also imperative. This case highlights the importance of considering EV in patients who are immunosuppressed, who present with a significant number of viral warts that are resistant to treatment.
H17 Dermatology in times of famine
Authors: O’Malley Seán , Feighery Cliona
Published: June 2024

From the years of 1845 to 1852, the Great Famine (An Gorta Mór) ravaged the island of Ireland. A multitude of factors contributed to the eventual extent of its devastation; however, at its core was the widespread failure of the potato crop. The most destitute year came in 1847, and by 1852 Ireland’s population is estimated to have declined from 8.5 million to 6.5 million, with 1 million having emigrated and another million dead. Starvation was the principal cause of death for some of those who succumbed to the Great Famine, but the majority who died did so as a result of illnesses arising from the crisis, both infectious and nutritional, and not only their toll on physical health but the consequent social ramifications. In this manner, infestations and cutaneous manifestations of illness played a vital role in the eventual morbidity and mortality of the Irish famine. General fever was common, mostly originating from lice infestation of the skin, which flourished in deteriorating conditions in settlements. Two variants developed that broadly separated between social classes: recurrent fever in the poor who had previous exposure, known colloquially as ‘getting the cool’, and the more deadly typhus fever that killed many of the middle and upper classes, in particular those who attempted to help the sick such as doctors and priests [Geary L. Epidemic diseases of the Great Famine. History Ireland. Available at: https://www.historyireland.com/epidemic-diseases-of-the-great-famine/ (last accessed 29 February 2024)]. Smallpox arose in frequent epidemics, and the associated widespread pustular rash, crusting lesions and eventual scabbing offered an obvious visual cue of illness. With limited quality food available, nutritional deficiencies contributed too to the deathly appearance of those afflicted. Lack of vitamin B3 resulted in pellagra, with its associated dermatitis, and a dire lack of vitamin C gave rise to scurvy, whose ecchymosis became known in Irish as ‘cos dubh’ or black leg. With such a constellation of symptoms, it can be appreciated why there was misunderstanding and fear of the sick. This led to division in communities about the construction of fever hospitals. Some pleaded for their establishment to quarantine the sick, while others resisted for fear of contagion and, in instances such as in Fethard, County Tipperary and Belturbet, County Cavan, committed arson attacks against the hospitals. Many who did not succumb were left pauperized and ostracized by their communities, in no small part as a result of their cutaneous manifestations of a multitude of diseases.