bluuebunny/crossref_metadata_2025 huggingface dataset:
BG02 A rare case of necrolytic migratory erythema
Authors: Katira Arnav , Gaikwad Sophie
Published: June 2024

We present the case of a 72-year-old White man who had a several months’ history of multiple crusted annular plaques starting in the groin and spreading to the lower limbs and upper back. He also had an erythematous scaly rash on the face in a seborrhoeic distribution and a sore tongue. Systemic enquiry highlighted significant weight loss. Additionally, he had a recent diagnosis of borderline diabetes mellitus and later developed steatorrhoea. He also had a palpable mass behind his umbilicus. Laboratory studies showed a mild normocytic anaemia. Plasma glucagon levels were markedly raised at 230 pmol L−1. Levels of zinc, other trace metals and haematinics were normal. Computed tomography imaging identified a lesion to the body and tail of the pancreas, which was locally invasive and partly calcified. Histology from the rash showed confluent parakeratosis containing few neutrophils. The epidermis was mildly acanthotic with mild spongiosis and dyskeratotic cells and some vacuolated keratinocytes. There was mild lymphocytic exocytosis, but no significant lichenoid reaction. There were moderate perivascular lymphoplasmacytic infiltrates with mild oedema in the epidermis. No immune deposits were seen on direct immunofluorescence. He was referred to the general surgeons and the neuroendocrine multidisciplinary team (MDT). A well-differentiated neuroendocrine tumour, in keeping with a glucagonoma, was seen on histology of the tail of the pancreas. He was treated with zinc supplements and topical steroids, as well as having staging scans and further management of his glucagonoma. Necrolytic migratory erythema is a rare clinical entity usually occurring with a glucagonoma, an alpha-cell tumour of the pancreatic islets. The elevated glucagon levels may lead to diabetes mellitus, weight loss, diarrhoea, neuropsychiatric problems, venous thromboembolism and anaemia. The rash normally improves with management of the underlying tumour. This may include surgical management or suppression of raised glucagon levels by a glucagon antagonist. Patients should be referred to a specialist neuroendocrine MDT and have staging scans. Zinc supplementation may also improve the rash. Early diagnosis of the rash may help to prevent morbidity and mortality from the underlying neoplasia and reduce the chance of metastasis.
Poster presentationsBG05 Menopause and the skin: prevalence of skin symptoms in patients attending a menopause clinic
Authors: Salih Hamisha , Hum Olivia , Schaedel Zoe , DeGiovanni Claudia
Published: June 2024

The peri- and postmenopausal period of a person’s life is a natural part of physiological ageing driven by declining ovarian function. A hypo-oestrogenic state follows the onset of the menopause and persists for the remainder of their lives. The skin contains oestrogen receptors, and impairment of the skin barrier is noted in oestrogen-deficient skin (Rzepecki A, Murase J, Juran R et al. Estrogen-deficient skin: the role of topical therapy. Int J Womens Dermatol 2019; 5: 85–90). It is therefore expected that this may affect the normal function of the skin and common skin conditions. We suspect that these symptoms experienced may be under-reported and, when they are reported, may not be considered associated to the menopause. We have conducted an observational study exploring the symptoms that patients experience during the perimenopausal and postmenopausal time. Patients seen in a community-based specialist menopause clinic were invited to complete a questionnaire enquiring about skin, oral, genital and hair symptoms. In total, 32 responses were collected. Overall, 46% of respondents still had menstrual periods and 77% were on hormonal treatments, of which oestrogen therapy was most frequently taken. The most reported skin symptoms included dry skin (78%) and itchiness (75%). Dry mouth was the commonest reported oral symptom, and 84% of patients had experienced at least one hair symptom since the onset of their menopause. In total, 91% reported experiencing at least one vulval symptom, with the most common being dryness (66%), itchiness (55%) and soreness (41%). One-half (50%) noticed worsening in a previously diagnosed dermatological disorder. In total, 63% patients reported skin symptoms that they had attempted to manage themselves without consulting their doctor. The Dermatology Life Quality Index was also collected for each patient, which showed an average score of 6 out of 30 and ranged up to 17 out of 30, indicating that skin symptoms cause a moderate impact on the quality of life of peri- and postmenopausal people. Our results highlight the significant effect the menopause can have on quality of life and the wide range of dermatological symptoms associated with it. Patients appear reluctant to seek medical support for skin symptoms related to the menopause and consequently may not receive optimal treatment. It is paramount that dermatologists and menopause specialists are aware of the immense impact menopause has on the skin, hair, vulva and mouth in order to improve the quality of life for affected patients. Further research is required to explore management options, including hormone replacement therapy, for skin symptoms associated with the menopause.
BG06 Patient perspectives on living with multiple actinic keratoses: a qualitative study
Authors: Drumm Ciara , Moloney Aoife , Moriarty Blaithin , Lally Aoife
Published: June 2024

Actinic keratoses (AKs) are chronic recurrent erythematous scaly lesions that appear most commonly on sun-damaged skin. Although many AKs will regress, up to 16% will progress to cutaneous squamous cell carcinoma. Therefore, field treatment is advised. Due to the long-term recurrence rates with the current available treatments and the need for repeated courses of treatment, there may be a substantial burden on patients. In this qualitative study, we aimed to understand the challenges experienced by patients with multiple AKs. Purposive sampling was used to recruit patients with a history of multiple AKs to two patient focus groups. To facilitate discussion, only 10 patients were invited to attend each focus group. Six patients were able to attend the first focus group and seven the second patient focus group, with circumstances such as personal or family illness resulting in four patients missing the first focus group and three the second. The first focus group was unscripted, unstructured, and conducted by the lead investigator and a cancer specialist nurse. The discussions that arose during the first focus group were then used to guide and structure the second focus group. An interview guide was developed by the lead investigator and reviewed by a consultant dermatologist. The second focus group was semistructured to allow flow of discussion and was conducted by the lead investigator and two specialist nurses. This focus group was audio-recorded with written and informed consent from all participants and then transcribed and analysed using Gioia methodology on NVivo software (version 12; QSR International, Doncaster, Australia). This research adopts constructivist ontological and subjectivist epistemological assumptions, which recognize that patients have unique experiences, values and preferences that should be considered in their treatment choices. Four themes and 16 subthemes were identified through analysis of the transcript. The first theme, physical and emotional impacts, was subdivided into impact on mood, living with uncertainty and recurrence, insecurity and coping mechanisms. The second theme focused on the impact of the COVID-19 pandemic and covered access to care, reduction in functioning and loss of support. The third theme refers to patient support and experience and explored individualized treatment, neglected examination areas, lack of reassurance, awareness campaigns and the benefits of sharing personal experiences. The final theme looked at communication and information through patient empowerment and understanding, individual variations in treatment, accessibility of information, evidence-based information, and the communication gap. The burden and impact of AKs is poorly understood. This qualitative study explores the experiences, concerns and priorities of patients with multiple AKs, and may assist development of shared decision-making pathways for this group.
PA02 A case series of refractory, paediatric atopic dermatitis effectively treated with dupilumab in combination with abrocitinib
Authors: Fong Wei Chern Gavin , Win Kaung Htet Hla , Lopes Rhea , Kanji Alpa , Ravenscroft Jane , Tang Ting Seng , Flohr Carsten
Published: June 2024

A range of systemic treatment options are available for children with atopic dermatitis (AD) who do not respond to standard topical therapy. However, real-world data have revealed a subset of patients who remain significantly affected despite treatment with all of the available topical and systemic therapies, including novel therapeutic agents such as dupilumab and Janus kinase (JAK) inhibitors. To achieve disease control, these individuals may require novel approaches such as utilizing systemic treatments in combination. However, there is insufficient published evidence about the efficacy and safety of this approach. We present three paediatric cases with severe refractory AD who required combined systemic therapy with dupilumab and abrocitinib to achieve adequate disease control and improvement in quality of life. The third patient had coexistent extensive alopecia areata, which also responded well to treatment. These individuals had exhausted all conventional systemic therapies, and had undergone treatment with both dupilumab and abrocitinib individually and in various combinations with methotrexate. However, despite this, they continued to experience inadequate disease control and significant adverse effects. It was only when the combination of dupilumab and abrocitinib was introduced that they finally achieved noticeable and sustained improvements in AD control. The heightened observed efficacy of dupilumab and abrocitinib in combination may be attributed to the inhibition of interleukin-4 and interleukin-13 at two separate stages, at the receptor (dupilumab) and intracellularly (abrocitinib). Furthermore, an additional advantage of this combined regimen is that JAK inhibitors, with their broader mechanism of action, may attenuate cytokines implicated in comorbid diseases such as dupilumab-related eye disease, seen in our first two cases, and alopecia areata in our third case. In conclusion, the concurrent use of dupilumab with abrocitinib represents a potentially effective and tolerated therapeutic approach for children with severe, refractory AD who exhibit inadequate control with other treatments. Larger studies are warranted to ascertain the long-term efficacy and safety of this treatment strategy.
PA11 An indolent course of paediatric primary cutaneous γ/δ T-cell lymphoma
Authors: Deng Pierce , Polcari Ingrid , Miller Daniel
Published: June 2024

A 16-year-old girl with a history of antinuclear antibody (ANA) positivity, Raynaud phenomenon, arthralgias and night sweats presented to our paediatric dermatology clinic for relapsing and remitting tender subcutaneous nodules on the trunk and extremities over the past year. The nodules arise spontaneously within a couple of days and resolve over a few days or up to a month later without overlying skin changes or ulceration. At one time, she had six nodules altogether, but typically she has one to four nodules that come and go every month. Prior rheumatology evaluation had considered systemic lupus erythematosus; however, multiple repeated autoimmune serologies had returned negative, including repeat ANAs, extractable nuclear antigen antibody panels, and DNA double-stranded antibodies. Physical exam at the initial dermatology visit demonstrated a single small deep subcutaneous nodule on the left buttock. Inflammatory panniculitis was suspected and a biopsy was considered, but it was ultimately deferred given that the present nodule was very deep and already resolving. The patient returned to clinic a year later given continued formation of subcutaneous nodules. An incisional punch biopsy from her right flank was performed, which revealed a subcutaneous, predominantly lobular infiltrate of mostly CD3-positive T cells with prominent atypia, high Ki-67 labelling, significant positivity on T-cell receptor δ immunostaining and cytotoxic markers, and a positive T-cell gene rearrangement study. These findings were consistent with primary cutaneous γ/δ T-cell lymphoma (PCGD-TCL). The patient was subsequently referred to haematology and oncology. Peripheral blood smear, positron emission tomography scan, and bone marrow biopsy were reassuring, with no evidence of haemophagocytic syndrome or malignancy. Treatment with methotrexate was initiated and the patient experienced some mild improvement initially; however, the nodules soon returned to the same frequency and intensity as before. Interestingly, she did report resolution of her night sweats since starting methotrexate. Currently, she is seeking additional expert opinions with consideration for a repeat biopsy, as well as second-line therapies such as ciclosporin, mycophenolate or bexarotene. PCGD-TCL is a rare lymphoma of γ/δ T cells that usually presents with generalized subcutaneous nodules or ulceronecrotic plaques, and is classically associated with a poor prognosis. The apparent indolent course in this patient supports the notion that PCGD-TCL may be more heterogeneous than traditionally described, and a subset of PCGD-TCL follows a more indolent course analogous to the α/β phenotype of subcutaneous panniculitis-like T-cell lymphoma. This case also highlights a rare paediatric presentation of PCGD-TCL and the often overlapping clinical and microscopic features of the panniculitic cutaneous lymphomas with lupus panniculitis.
PA12 Fats and figures: how abnormal lipids unravel the truth
Authors: Teoh Yee Ping , Gold Adam , Yesudian Paul D
Published: June 2024

Oral isotretinoin is the most effective treatment for severe acne vulgaris. However, its use may be limited by adverse drug reactions, including hyperlipidaemia. A 22-year-old man with a 2-year history of severe nodulocystic acne involving the face, chest and back was commenced on low-dose prednisolone and isotretinoin. His acne did not respond as expected to the isotretinoin. Baseline screening of lipids, and liver function tests were unremarkable. Lipid monitoring during therapy revealed progressively worsening hyperlipidaemia with a peak low-density lipoprotein cholesterol (LDL-C) of 10.6 mmol L−1 (normal < 3.0 mmol L−1), triglycerides 4.1 mmol L−1 (normal < 2.0 mmol L−1) and reduced high-density lipoprotein cholesterol (HDL-C) of 0.2 mmol L−1 (normal > 1.0 mmol L−1). Biochemists intervened, suspecting possible familial hypercholesterolaemia. On further questioning, the patient admitted to self-administering multiple anabolic steroids and testosterone, as well as consuming high-protein supplements. Laboratory testing revealed markedly elevated testosterone levels, above the laboratory limit > 52 nmol L−1 (normal range 9.0–31.0 nmol L−1). The differential diagnoses for isolated high LDL include familial hypercholesterolaemia and hypothyroidism. However, the combination of very low HDL and high LDL cholesterol suggests secondary aetiologies such as exogenous testosterone or anabolic steroid use in young men. In older individuals, multiple myeloma or haematological cancers can similarly present, although LDL is often normal in cancer. The underlying aetiology of anabolic-steroid-induced lowering of HDL is thought to be mediated via an increase in activity of hepatic triglyceride lipase (HTGL), an enzyme that facilitates catabolism of HDL. HTGL stimulates breakdown of HDL particles, significantly decreasing HDL-C levels. However, the mechanism behind the adverse effect of anabolic steroids on increased LDL-C levels remains to be completely elucidated. Previous case reports reveal that there may be unintentional ingestion of anabolic steroids that have been added to consumer products like whey proteins. Conversely, patients may not disclose substance use without direct questioning. This case highlights important considerations for interpreting and managing abnormal lipid profiles in patients receiving isotretinoin treatment for acne. Unexplained markedly elevated LDL-C, especially accompanied by very low HDL-C, should prompt evaluation of testosterone levels, as it may indicate undisclosed exogenous testosterone or anabolic steroid use.
PA19 The importance of a paediatric biopsy service in dermatology departments: a service evaluation
Authors: Wells Helena , Ramesh Raakhee
Published: June 2024

Access to paediatric skin biopsy services in dermatology departments varies widely. A timely skin biopsy can result in a quicker diagnosis for the family and child and hence swifter management, which is crucial for a paediatric dermatology service to run efficiently. Some services may be reliant upon assistance from other specialists, such as the plastic surgeon, to perform these procedures, which are sometimes preformed unnecessarily under a general anaesthetic. This can complicate the patient pathway, resulting in breaks in continuity of care and delays to investigations. Overall, there is a paucity of published data on skin biopsies in children, particularly on the indications and spectrum of diagnoses. We performed a service evaluation of our paediatric biopsy service at a busy district general hospital, to understand the role and importance of this service. We have a total of four paediatric dermatologists, who have regular clinics and theatre lists. We collected data retrospectively on paediatric biopsies performed between April 2020 and March 2023 (a 35-month period). Nearly all patients attending for a biopsy had clinical images taken. In total 71 biopsies were performed on children during this timeframe. Most patients were aged between 11 and 15 years (61%), with 7% aged 16–18 years, and the remainder aged < 10 years (32%). There was an even sex distribution, with 35 male patients and 36 female patients. A variety of procedures were performed, with punch biopsies (30%) and excision biopsies (24%) being the most common type. Regarding the body site, 17% of procedures were performed on the head and neck, and 8% on the scalp. In total, 41% were performed on the limbs, and 32% on the torso or abdomen. The biopsies were categorized as lesional or inflammatory. Forty-six biopsies (65%) were performed for lesions, of which pyogenic granuloma was the most common cause (15%), alongside spitz naevus (11%). Twenty-five biopsies (35%) were performed for inflammatory conditions, including folliculitis decalvans (1%), ichthyosis (1%), lymphangioma circumscriptum (1%) and confluent and reticulated papillomatosis (1%), alongside many other pathologies. Of lesional biopsies, 37 (80%) had the correct diagnosis listed prior to the procedure and 9 (20%) were incorrect. Of the inflammatory pathologies, 17 (68%) were correct, and 8 (32%) incorrect. This demonstrates the importance of the biopsy in identifying the diagnosis. Our data demonstrate the importance of a paediatric dermatology biopsy service offered at all sites where paediatric dermatology is undertaken, to aid in the diagnosis and management of paediatric patients in a timely fashion.
PA25 Sleep disruption in caregivers of infants with atopic dermatitis
Authors: O’Connor Cathal , O’Halloran Kate , Irvine Alan D , Murray Deirdre , Hourihane Jonathan , Murphy Michelle , Boylan Geraldine
Published: June 2024

Atopic dermatitis (AD) commonly presents in infancy and is characterized by dermatitis, itch and sleep disturbance. The burdens of disease and treatment in AD are very high. Caregivers of infants with AD are loaded with provision of medical care, emotional distress and sleep disruption. The aim of this study was to assess the sleep of parents of infants with AD in the first year of life by comparing them with parents of healthy age-matched control infants, using both quantitative and qualitative measures. Parental sleep and infant sleep were quantitatively assessed using the Pittsburgh Sleep Quality Index and Brief Infant Sleep Questionnaire at 6, 9 and 12 months. Data on infant AD severity and infant itch were collected using the Eczema Area and Severity Index and a numerical rating scale. Detailed interviews were conducted at 12 months with 10 parents of infants with AD. There were 31 cases and 32 controls. Mothers of cases slept less than mothers of control infants at all timepoints: 6.3, 6.8 and 6.7 h at 6, 9 and 12 months (vs. 7.1, 7.3 and 7.5 h). Sleep onset latency was longer for mothers of infants with AD at 6 months (27.1 vs. 12.8 min, P < 0.05) and 12 months (20.8 vs. 12.6 min, P < 0.05). Sleep efficiency was worse for cases at all timepoints. Fathers had longer sleep onset latency and worse sleep efficiency than controls at 9 months. Themes regarding parental sleep disruption included the relationships between AD severity, itch and sleep disruption; bedtime routine; daytime loss of function; impact on parental relationship, infant bonding and family planning; sleep futility; and strategies to cope with sleep disruption. Mothers, but not fathers, of infants with AD experience significant sleep disruption in the first year of life. Factors that affect parental sleep include infant AD severity and itch.
BI19 SCAR: more than just a mark on the skin
Authors: Carroll Emma , Leahy Marion , Dhonncha Eilis Nic
Published: June 2024

Drug-induced hypersensitivity syndrome (DIHS) is a severe and potentially life-threatening condition characterized by a delayed onset of hypersensitivity reactions, occurring days to weeks after exposure to a causative drug in predisposed individuals. Here, we present the case of a 34-year-old female patient with DIHS that demonstrated an uncommon response to initial high-dose immunosuppression. The patient was admitted to hospital with an erythematous, maculopapular rash affecting the abdomen and chest, having undergone three cycles of ipilimumab/nivolumab immunotherapy for pT4a N1 malignant melanoma of the anal canal. The rash rapidly progressed to involve 90% of the body surface area within a matter of days. Concurrently, blood investigations revealed an acute liver injury and thyrotoxicosis. Notably, eosinophil levels were within normal limits. A skin biopsy displayed features consistent with DIHS, including interface dermatitis and basal vacuolar degeneration. Initial management involved intravenous high-dose methylprednisolone and mycophenolate mofetil following guidelines for acute liver injury. However, the patient’s skin deteriorated further and became dusky, despite high-dose immunosuppression. Her liver function also continued to decline. Following discussion with the hepatology unit, it was determined that the patient exhibited an atypical resistance to significant doses of immunosuppression, posing a unique challenge in the management of DIHS. After literature review and discussion with a DIHS specialist, treatment was transitioned to ciclosporin. Remarkably, within days of ciclosporin initiation, the patient demonstrated notable improvement in both cutaneous manifestations and liver function. This case underscores the complexity in managing DIHS, particularly when confronted with an unexpected lack of response to conventional high-dose immunosuppressive regimens. Currently there is a lack of formal clinical guidance regarding the management of complex cases of DIHS. This case highlights the challenges posed to clinicians when faced with such scenarios.
BI23 ‘Not so, my Lord; I am too much i’ the sun.’ Sun protection behaviours and awareness among an immunosuppressed neurology cohort
Authors: McFeely Orla , Tuohy Orla , Griffin Laoise , Yong Ji Fung , Cozman Anita , Durack Alana , O’Connell Michael , Paul Lyndsey
Published: June 2024

The effect of immunomodulatory medications in the development of skin cancer was first reported over 50 years ago in the context of transplant recipients. Immunosuppressant medications used to treat autoimmune conditions, such as inflammatory bowel disease and multiple sclerosis, have been implicated in the development of nonmelanoma skin cancer. While there are reports emphasizing the need for skin cancer awareness among immunosuppressed gastroenterology patients, the same cannot be said of a high-risk neurology cohort. We aimed to explore the sun protection behaviours and knowledge of an outpatient immunosuppressed neurology population. We distributed anonymous questionnaires to patients prescribed immunomodulatory treatments in a dedicated multiple sclerosis clinic. Baseline demographics including sex and age were collected, as well as underlying diagnosis, name and duration of immunosuppressant treatment, history of previous skin cancer and sun protection measures undertaken. Of the patients who were included in this study, the median patient age was 32 years and all patients were female. The median time of prescribed immunosuppressive treatment was 4 years. Half of the patients reported performing self-skin examinations and no patient had undergone healthcare professional skin examinations. All patients reported factor 50 sunscreen use and 33% of patients reported sunscreen application year round. Overall, 66% of patients were uncertain of sinister skin changes to look for. No patient had a prior history of skin cancer. In total, 33% of patients were actively seeking a tan, with a further 33% describing sunbed use. This study highlights that sun protection measures and skin cancer awareness are lacking in this immunosuppressed neurology cohort. Consequently, these patients practise suboptimal sun protection measures. To the authors’ knowledge, this is the first study emphasizing the need for further education regarding safe sun habits among this population.
BI27 New-onset hidradenitis suppurativa secondary to combination therapy with programmed cell death ligand -1 inhibitor atezolizumab and vascular endothelial growth factor inhibitor bevacizumab
Authors: Fagan Nicole , Victory Liana , Pender Emily , Kirby Brian , Alsharqi Ali
Published: June 2024

Hidradenitis suppurativa (HS) is a chronic inflammatory condition characterized by recurrent inflammatory nodules and abscesses thought to develop via follicular occlusion, a disrupted microbiome and subsequent inflammation and follicular rupture. A 50-year-old man with no prior history of skin disease was referred from hepatology with a 3-month history of recurrent inflammatory nodules of the axillae and bilateral groin. He had been diagnosed with advanced metastatic segment II/III hepatocellular carcinoma and portal vein thrombosis on a background of cirrhosis 7 months previously. He received palliative radiotherapy for T12/L1 spinal metastases and endoscopic banding of grade 2 oesophageal varices. Concomitant treatment with the programmed cell death ligand (PDL)-1 inhibitor atezolizumab and bevacizumab, a vascular endothelial growth factor (VEGF) inhibitor, was commenced 1 month postdiagnosis. After 2 months of combination immunotherapy, the patient reported the development of recurrent inflammatory nodules and abscesses. Examination was consistent with HS Hurley stage II. Of note, the patient had no other risk factors for HS including smoking, sex, family history, comorbidities or raised body mass index. Immune checkpoint inhibitors are associated with a myriad of cutaneous toxicities. Anti-PDL-1-induced HS has been described with nivolumab with an upregulation of the interleukin-17 axis postulated as a mechanism [Ayoubi N, Gerhardt AC, Hennessy K et al. Hidradenitis suppurativa secondary to nivolumab. J Am Acad Dermatol 2022; 87 (Suppl.): AB171]. The occurrence of new-onset HS in patients on checkpoint inhibitors supports the concept of HS as a primary inflammatory disease. Cases of HS have also been reported with sunitinib, a VEGF inhibitor (Montero-Vilchez T, Bueno-Rodriguez A, Salvador-Rodriguez L et al. Could vascular endothelial growth factor inhibitors induce hidradenitis suppurativa? Report of three patients with renal cancer treated with sunitinib. Dermatol Ther 2020; 33: e13306). Although the exact culprit drug in this patient’s case cannot be definitively stated, given the effect that HS has on quality of life, the association of HS with both PDL-1 and VEGF inhibition should be noted along with prompt referral to a dermatologist and initiation of appropriate treatment.
BI36 An infiltrative subcutaneous mass presenting as the first sign of relapse in a patient with T prolymphocytic leukaemia
Authors: Yoo Li Jie Helena , Kearney Nicola , Quinn John , Raghallaigh Siona Ni
Published: June 2024

T prolymphocytic leukaemia (TPLL) is a rare form of post-thymic T-cell neoplasm, often involving the peripheral blood, bone marrow and spleen. Cutaneous involvement can be found in 25–35% of patients (Mallet RB, Matutes E, Catovsky D et al. Cutaneous infiltration in T-cell prolymphocytic leukaemia. Br J Dermatol 1995; 132: 263–6). Cutaneous features are not well recognized in dermatological literature and have been reported only in a limited number of case series (Herling M, Valbuena JR, Jones D, Medeiros LJ. Skin involvement in T-cell prolymphocytic leukemia. J Am Acad Dermatol 2007; 57: 533–4). There is a predilection towards the face and trunk, and reported morphologies include oedema, macules, papules, infiltrative erythema, nodules and erythroderma. A 76-year-old woman was admitted with a 6-week history of a nontender, indurated rash on her left upper arm, feeling generally unwell with vomiting and diarrhoea. Prior to admission, she was treated with flucloxacillin, doxycycline and co-amoxiclav with presumed cellulitis, but with no relief. On examination, a well-demarcated indurated plaque with central clearing and expanding erythema resembling erythema migrans was noted on her left upper arm. A symmetrical petechial rash and erythematous plaques on her legs were also present. The patient had been diagnosed with TPLL 18 months previously and had completed six cycles of alemtuzumab with disease remission. Blood investigations on this admission revealed a haemoglobin of 10.5 g dL−1, lymphocytosis of 11.20 × 109 L−1, acute kidney injury with creatinine 160 µmol L−1, elevated lactate dehydrogenase 546 IU L−1 and C-reactive protein 15 mg L−1. Her blood cultures were negative. Blood film revealed atypical lymphocytosis consistent with relapse of TPLL. Given the induration associated with the left-upper-arm lesion, an ultrasound and magnetic resonance imaging were performed, which revealed a 5 × 3 × 7-cm mass infiltrating her triceps brachialis. Core biopsy showed atypical lymphocytic infiltration in the dermis and grenz zone with positive CD3, CD4, CD5 and CD7, consistent with TPLL infiltration of the skin. Skin biopsy from her lower limb also showed cutaneous TPLL infiltration. Computed tomography of the thorax, abdomen and pelvis revealed diffuse lymphadenopathy and splenomegaly. Bendamustine was started for relapsed TPLL with significant reduction in the size of her left-upper-arm mass. This case highlights the various morphologies of cutaneous eruption that can present in a patient with TPLL. To our knowledge, this is the second case reported in the literature in a patient with TPLL presenting with a subcutaneous mass. Cutaneous features of TPLL may herald disease relapse with an ensuing aggressive clinical course. A high index of suspicion and low threshold for biopsy are needed, as extranodal involvement itself meets the criteria for active TPLL warranting treatment.
H08 Post vacancy: Dublin’s first dermatologist
Authors: Howard-James Claudine
Published: June 2024

William Wallace (1791–1837), later known internationally as ‘Wallace of Dublin’, was Dublin’s first dermatologist. Born in County Down, he studied at the Royal College of Surgeons in Ireland (RCSI) from 1810 to 1813. During his time at RCSI, he was apprenticed to Charles Hawkes Todd, lecturer and surgeon in the Richmond and Lock Hospitals, both institutions experiencing high volumes of venereal and skin disease. Following receipt of his licence from RCSI in June 1813, Wallace travelled to London. Here he studied under established dermatologist Thomas Bateman (himself a pupil of Robert Willan), surgeon John Pearson, and expert venereal disease physician Joseph Adams, among others. Gaining significant experience in cutaneous and venereal disease during this time, he returned to Dublin in 1817 with the intention of utilizing this knowledge to establish a hospital. In his own words, the hospital’s mission was to ‘at once afford relief to the poor; supply the means of extending our knowledge of cutaneous diseases, by accurate clinical investigation and extensive observation; and establish a school for the instruction of medical students’. The following year, he personally founded and funded the Dublin Infirmary for Diseases of the Skin at 20 Moore Street, the first hospital in Europe or the British Empire exclusively devoted to skin disease. By 1837, an estimated 25 000 cases had been treated in the Dublin Skin Infirmary. Wallace made two internationally recognized contributions to medicine: introducing potassium iodide to the materia medica for treatment of syphilitic lesions and demonstrating the infectivity of secondary syphilis. The latter he proved unethically by the inoculation of ‘secretions from exanthematic sores’ into healthy individuals, demonstrating its transmissibility and incubation period. His publications include Observations on Sulphurious Fumigations as a Remedy in Rheumatism and Diseases of the Skin (1820) and A Treatise on the Venereal Disease and its Varieties (1833). During this time he was also appointed surgeon at Jervis Street Hospital, where he does not appear to have been an easy colleague; there were public rows with fellow surgeon James O’Beirne, complaints about the hospital’s cleanliness, and an increase in skin-related admissions while Wallace was on service, with a colleague commenting ‘certainly not one case of diseases of the skin was fit for an hospital’. While his ethics and behaviour as a colleague are at times questionable, his contribution to modern dermatology is undeniable. His sudden and untimely death in 1837 from typhus brought an end to the Dublin Skin Infirmary as his post lay vacant, owing to his habit of independence.
H09 Sir Jonathan Hutchinson’s melanotic whitlow: evolution of Hutchinson’s sign
Authors: Smith Abbey , Smith Hayley , Mitra Angana
Published: June 2024

‘It needs sometimes, the eye of faith to recognize the narrow band of black which borders the inflamed part’. – Hutchinson J. Notes towards the formation of clinical group of tumors. Am J Med Sci 1886; 91: 470.

This groundbreaking observation by Sir Jonathan Hutchinson in 1886, initially termed the ‘melanotic whitlow’, refers to pigmentation change in the nailfold, often accompanied by painful inflammation. Historically such lesions were considered traumatic; however, through careful clinical observation and meticulous documentation, Hutchinson recognized that this manifestation could be associated with malignancy. The melanotic whitlow later evolved into the eponymous Hutchinson sign, which we continue to use in today’s assessment of melanonychia. Sir Jonathan Hutchinson was born in 1882 in Selby, emerging from a modest background to become a pioneering figure in 19th-century medicine. He was a distinguished British surgeon and pathologist with an interest in dermatology, ophthalmology, neurology and the study of syphilis. More than a clinician, Hutchinson was a dedicated teacher, writer and philanthropist, actively sharpening medical education and research, with his medical bibliography consisting of over 1000 published reports. His work traversed a diverse range of medical domains, with numerous eponyms across various fields attributed to him. In dermatology, we commonly know him for Hutchinson freckle (lentigo maligna) and use Hutchinson sign to describe the periungual extension of a longitudinal pigmented band onto the nailfold, typically representing progression of subungual melanoma. Although it remains a crucial diagnostic marker of subungual melanoma, our understanding of this phenomenon and our ability to detect it have evolved over the last century. Over time the term ‘pseudo-Hutchinson sign’ has been coined as a mimic of Hutchinson sign due to the reflection of pigmentation of the nailbed and nail matrix through a transparent nailfold. This is seen in nonmelanoma conditions such as Bowen disease, ethnic melanonychia, nail naevi, subungual haematoma, Peutz–Jeghers or Laugier–Hunziker syndrome, and other inflammatory pathologies. Further evolution of this eponym can also be attributed to the advent of dermoscopy. The aptly named micro-Hutchinson sign, describes the dermoscopic detection of subtle cuticular pigmentation, often elusive to conventional naked-eye examination, and is thought to be indicative of malignancy. Hutchinson’s detailed description of the melanotic whitlow has contributed significantly to our assessment of nail pigmentation and melanoma. From his first description of the ‘narrow band of black’ to Hutchinson sign, we now have three variations of this eponymous term, used widely by modern-day dermatologists and aiding in the analysis of melanonychia.
H13 One scar too far: the perception of scarring through time
Authors: Long Alison , Long Amy
Published: June 2024

The English word, ‘scar,’ has roots in several languages: Latin (eschara), Old French (escharre), Greek (έσχάρα or eskhara), Middle English (skar) and Old Norse (skarð). Ancient civilizations such as the Romans, Greeks and Egyptians viewed scars in a sacred light, as scars were often linked to ritualistic practices. The Ancient Egyptians even employed scarring as a mark of authentication, to be displayed and observed. In Ancient Rome, the symbology of scarring was a practical element in ratifying democratic office after the fall of the Tarquin kings; scars demonstrated that these politicians were not godly as kings wished to be. If scars were to be treated in ancient times it was for symptomatic relief of pain or itching, rather than for aesthetic reasons. In more recent times, society has grown less accepting of facial imperfections and scarring. One example we often see is how scarring is portrayed on screen, highlighting the dichotomy between good and evil. There is a statistically higher preponderance for scarring in antagonistic characters vs. protagonists. Some movies go as far as to name the villain after their imperfections, such as Scar in The Lion King, and Al Pacino’s Scarface. When the ‘good guys’ are shown to have scarring it typically highlights their virtuousness, and can underpin an image of bravery, such as Harry Potter’s famous forehead scar. Recently, films have been criticized by their use of facial scarring on villains. In the James Bond film No Time To Die, the villain played by Rami Malek once again displays facial disfigurement. This was met with backlash for the villain cliché, resulting in the British Film Institute no longer funding films with facially scarred villains from 2018. Scars are often used as a shorthand for villainy, repeatedly exaggerated to depict a character flaw or convey an element of disquiet. Perpetuating these negative ideas will serve to bolster unsavoury views, foster prejudices and deepen the psychological impact that scarring can have. We now have various treatments that can be utilized to improve the appearance of scars, including medicated dressings, corticosteroid injection, laser therapy and surgery. However, scarring cannot be cured and so we must endeavour to promote a more accepting landscape for patients struggling with distressing scars.
PS07 (P107) Updating the Assessment of the Psychological and Social Effects of Acne (APSEA) through factor analysis: developing the novel APSEA-3
Authors: Jones Georgina , Morgan Jim , Lau Eva , Latt Moe , Lee Natasha , El-Mansori Ibtessam , Layton Alison
Published: June 2024

Health-related quality of life is now recognized as an essential outcome to assess in acne trials and practice. Many patient-reported outcomes exist, including the Assessment of the Psychological and Social Effects of Acne (APSEA), which is an acne-specific measure (Layton AM, Seukeran D, Cunliffe WJ. Scarred for life? Dermatology 1997; 195: 15–21). APSEA was developed in 1990s and subsequently psychometric standards and methods have progressed. The purpose of this study is to conduct an updated psychometric analysis of the APSEA among a cohort of patients being treated for acne in routine clinical practice. Exploratory factor analysis (EFA), a method of classical test construction, was carried out (n = 993). To test the adequacy of the sample size for undertaking factor analysis, values for the Kaiser–Meyer–Olkin test and Bartlett’s test of sphericity were calculated, as well as Cronbach’s alpha. Following the EFA and generation of the proposed scales, the individual domains were calculated and transformed onto a scale of 0–100 by summing the items within the scale, dividing by the total possible score within that domain. A confirmatory factor analysis (CFA) was then undertaken using a new second dataset (n = 501) to test the factor conceptual framework, using MPlus 8.6 software (http://www.statmodel.com). Descriptive statistics and tests of internal consistency reliability and construct validity (concurrent) were also undertaken using a priori hypotheses and comparisons with the Dermatology Life Quality Index (DLQI) and Patient Health Questionniare-9 (PHQ-9). The EFA suggested a three-domain model (anxiety and depression, body image and self-esteem, and social functioning), which was confirmed in the CFA analysis whereby the goodness of fit indices all indicated good model fit (root mean square error of approximation = 0.038, comparative fit index = 0.96, Tucker–Lewis index = 0.96, standardized root mean squared residual = 0.048). Cronbach’s alpha values exceeded 0.70, and item-total correlations exceeded 0.40 for all three domains, indicating good internal consistency reliability. All three APSEA domains were also positively correlated with the DLQI and the PHQ-9, indicating good construct validity of the tool. This EFA study has demonstrated the validity and reliability of a novel version of APSEA, which we have termed APSEA-3 to reflect the three unique domains it captures. Preliminary results show that the tool is responsive to change and useful for measuring the psychosocial impact of acne.
SG13 Managing cutaneous manifestations of FH-associated tumour predisposition syndrome: a systematic review of case reports
Authors: O’Brien Amber , Schirwani Schaida
Published: June 2024

The cutaneous manifestations of fumarate hydratase (FH)-associated tumour predisposition syndrome, otherwise called hereditary leiomyomatosis and renal cell carcinoma (HLRCC), can be managed in a variety of ways including surgical excision, oral and topical analgesia, laser therapy and cryotherapy. While some of these methods are considered well established, others are less widely used and there is little evidence reported comparing the outcomes after treatment. This systematic review of case reports aims to determine how symptom burden after surgical excision of the cutaneous lesions differs from symptom burden after analgesic treatment or other methods. The databases OVID MEDLINE, Embase and Scopus were searched with terms such as ‘HLRCC’, ‘cutaneous’, ‘leiomyoma’ and ‘management’. In total, 19 case reports with a total of 23 patients diagnosed with HLRCC and cutaneous manifestations, for example leiomyomas, were included in this systematic review. These case reports were dated between 2009 and 2022. Eleven of these patients had their cutaneous lesions treated with surgical excision, eight were treated with analgesia and nine were treated with ‘other methods’. ‘Other methods’ was defined as any treatment that was not surgical or simple analgesia, and included carbon dioxide laser therapy, erbium laser therapy, liquid nitrogen cryotherapy, phototherapy, botulinum toxin, electrocoagulation, and immunosuppression with azathioprine. Some patients were treated with a combination of methods. Surgical excision showed the poorest symptom outcomes after treatment, with 9% of patients showing improvement of symptom control after treatment compared with 75% of patients having symptom improvement with analgesic treatment and 89% after ‘other methods’. When surgical excision was combined with analgesia or ‘other methods’, symptom control was improved compared with surgical excision when used alone. This review shows that surgical excision may not provide optimal symptom control for patients with cutaneous manifestations of HLRCC, and other treatments should be considered. Surgical excision of cutaneous lesions allows histopathological confirmation of leiomyomata and therefore has an important role in the diagnosis of HLRCC, so it should not be excluded from treatment recommendations. However, clinicians should consider combining excision with another treatment, for example analgesia with agents such as gabapentin. Further research in the form of a large cohort study or randomized control trial is necessary to confirm the observations made by this systematic review by providing more quantitative data.
BT25 Successfully utilizing a novel teledermatology pathway in a suspected skin cancer clinic: improving patient experience and reducing time from referral to assessment
Authors: Holloran Sophie , Quaresma Catarina , Roberts James , Ponpandian Dheeksha , Kordi Yousef , Ko Emily , Whitley Helen , Zakaraite Jolita
Published: June 2024

In the UK the incidence of skin cancer has increased by 26.1% since 2013, with 225 000 cases diagnosed in 2019. In response to the rising demand we must adapt our service pathways to ensure patients have a reliable, responsive service that meets the National Health Service Faster Diagnosis Standard. Prior to adapting our service, we had 600–900 referrals per month, with an increasing backlog of patients who were waiting to be seen, missing the 14-day target. For several years, an effective collaborative partnership with our plastic surgery colleagues has greatly improved our skin cancer service; patients were seen face to face, with dermatology and plastic surgery consultants working side by side in a polyclinic format. Despite this, the pressure on services still resulted in a backlog, with only 0.7% of referrals seen within 14 days in July 2023. In July, we introduced a teledermatology service to run in tandem to our face-to-face service; this allowed for increased capacity and also improved our referral response times. There are several exclusion criteria for our new pathway. If a general practitioner refers a lesion with a high level of concern for malignancy, if the patient is over 85 years old, or if there are multiple lesions, patients are assessed face to face; the remainder are reviewed via teledermatology. Within 7 days of referral, the patient is assessed face to face by an experienced dermatology healthcare assistant. They complete a skin cancer assessment and take macro and dermoscopic images of the lesion. This information is uploaded onto our electronic medical record and reviewed by a consultant within 5 days. If the lesion is concerning for malignancy or the diagnosis is unclear, patients are booked for face-to-face review within 14 days. The patient can also be directly listed for surgery; for those directly listed, they are sent a letter with our minor surgery patient leaflet and offered a face-to-face appointment prior to their procedure only if they desire. For benign lesions, the patient is discharged directly following teledermatology review. Our system has been designed to be flexible; if it is felt there are other lesions of concern by the healthcare authority, or if there is insufficient information or subquality images, the patient can be easily and quickly transferred to a face-to-face review. Within 6 months, we are now seeing over 95% of our referrals within 14 days. Our data demonstrate that by adapting our service and introducing a teledermatology pathway, we have significantly improved time from referral to assessment and improved the experience for patients. We aim to continually improve and adapt the service, adjusting it as needed with service demand.