bluuebunny/crossref_metadata_2025 huggingface dataset:
GD02 (P46) A step towards zero leprosy: experiences of Nepal in leprosy data verification
Authors: Baskota Rabindra , Baral Rashmi
Published: June 2023

Records and reports are the sources of data for health programme planning, monitoring and evaluation. Accurate and timely data are crucial to ensure quality leprosy services, including drug supply, complication management and disability prevention. Data verification and validation are the initial steps to achieve the global goal of zero leprosy. The objectives of leprosy data verification were to strengthen the reporting system, to update personal health records and to provide on-site training to leprosy focal persons. Leprosy data verification was conducted in 15 endemic districts of Nepal by a team of national leprosy programme managers, leprosy focal persons, statisticians, dermatologists, paramedic health workers and World Health Organization consultants. The team visited health facilities that provide leprosy services and their corresponding municipalities from August 2021 to December 2021. The team examined the completeness and accuracy of data and information on the patient card, treatment register and monthly reporting form. Data were then compared with the municipal and national database, edited, cleaned and verified for duplications, and on-site coaching was provided to the leprosy focal persons. Verification of 1210 health records of 15 districts from four provinces was conducted. The number of new leprosy cases was found to be under-reported by 5.5%. Likewise, under-reporting was observed in released-from-treatment cases (19.2% variation) and transfer-out cases (21.4% variation). Over-reporting was observed in re-treatment cases (7% variation), defaulter cases (10.6% variation) and new paediatric cases (38% variation). Common reasons for data variation were error in counting while reporting, error in compiling data from health facilities and lack of training of focal persons in data recording and reporting. A limitation of the data verification study was that it was conducted in the selected 15 endemic districts and municipalities only. The study suggested that verification, validation and on-site coaching are effective approaches to obtaining quality data on leprosy. Such programmes can be conducted routinely or even during the integrated monitoring and supervision visits of experts from the centre to the local health facilities but should be carried out at the data entry site.
GD03 Identifying core outcome domains and development of a cutaneous leishmaniasis core outcome measure for use in clinical practice and trials
Authors: Senarathne Sujai , Ranasinghe Shalindra , Kahawita Indira , Somaratne Vijani , Wickramasinghe Amila , Parkash Vivak , Lacey Charles , Kaye Paul , Layton Alison
Published: June 2023

Cutaneous leishmaniasis (CL) is caused by an intracellular protozoan parasite transmitted through a sand fly bite. A review of clinical trials examining different treatment modalities for CL found studies to be deficient in design, execution, analysis and reporting. Core outcome sets (COS), including agreed domains and measures, have been developed for several dermatological disorders. The aims of this study were to reach consensus on the most important core outcome domains to measure when assessing CL, agree on parameters to measure the domains and develop a clinical tool to assess CL. Potential outcome domains for CL were identified through a collaborative international approach involving virtual discussions and e-consultations with stakeholders, including teams caring for CL from Sri Lanka, India, Brazil and the UK. A subsequent judgement process was then undertaken, using the multidisciplinary stakeholder panel of international experts, adhering to nominal group technique to reach final agreement on the core outcome domains. Clinicians presented cases representing the clinical and psychosocial impact of CL to ensure the patient’s perspective was considered. Established core outcome domains included signs and symptoms (objective and subjective), treatment efficacy, treatment impact, clinical sequelae (scarring and pigment) and health-related quality of life (HRQoL). For each core outcome domain, a review of previous approaches to measure the domain was considered. Items to measure the domains were then evaluated by multiple rounds until the panel of experts reached consensus. It was agreed that ‘signs and symptoms’ should capture clinical morphology, diameter and induration of an index lesion with the aid of a palpability score; ‘treatment efficacy and impact’ should capture patient and investigator views through visual analogue scores, percentage change in size of the lesion and re-epithelialization compared with baseline. Sequelae assessment rated pigment, as well as atrophic and hypertrophic/keloid scars. Two open-ended questions were included as a means of capturing some aspects of HRQoL. CutLeishCOM was then generated to capture demographic details, reflect the core outcome domains and assess outcome measurements in each patient. CutLeishCOM has been validated in a small cohort in this study; further validation is required. A specific patient-reported outcome measure should also be considered to ensure adverse effects from treatments, and negative impacts are captured when assessing CL, thus enabling a patient-focused and empathic approach to management.
GD04 Patient education for all! Skin of colour ­under-represented again
Authors: Long Amy , Long Alison , Feighery Cliona
Published: June 2023

Disparities in healthcare provision have a detrimental impact on health outcomes, which have been suffered by many patient cohorts, whether they are defined socially, economically or by the colour of their skin (Buster KJ, Stevens EI, Elmets CA. Dermatologic health disparities. Dermatol Clin 2012; 30:53–9). In the field of dermatology, we rely hugely on visual presentations. As dermatologists, the visible manifestations of disease, and their evolution, are fundamental to how we formulate diagnoses and treatment strategies. Similarly, visual depiction is important for patients to garner a wider understanding of their condition. This study aimed to analyse skin colour representation in patient information resources for a number of inflammatory conditions, including acne, atopic dermatitis, hidradenitis suppurativa, psoriasis and rosacea. Resources from multiple dermatological bodies including the British Skin Foundation, Irish Skin Foundation, American Academy of Dermatology Association, Canadian Dermatology Association, Dermatology Society of South Africa and the Australasian College of Dermatology were reviewed. Hard-copy pamphlets published by the associations were analysed; where pamphlets were unavailable, websites pertaining to each inflammatory condition were included. Images were divided by Fitzpatrick skin type into two categories: Fitzpatrick skin types I–IV and Fitzpatrick skin types V/VI. There is no formal definition of skin of colour, and for the purposes of this study, we referred to Fitzpatrick skin types V/VI. In total, 115 images were reviewed. People with skin of colour were represented in 5% (n = 6) of the images. This stark over-representation of Fitzpatrick skin types I–IV highlights the lack of inclusivity in current patient education resources. Consequently, patients with skin of colour may feel overlooked. This may foster a poor rapport between patients and physicians and could lead to mistrust and reduced engagement with healthcare services. Dermatological communities must join the global effort to eliminate racial disparities. The first steps have already been taken by many, in publishing and medical education, including the British Journal of Dermatology, which aims to enhance resources to study, describe and improve care for people with skin of colour (Guckian J, Ingram JR, Rajan N, Linos E. Dermatology is finally talking about race. Br J Dermatol 2021; 185:875–6). Patient information resources are another facet of our practice that need focus and reform. We must improve approachability, inclusiveness and trust within our specialty and work towards the overarching aim of delivering healthcare that is racially just.
GD05 ‘Ghosts’: changing perceptions of people with albinism in Tanzania
Authors: Adeyemi Stephanie
Published: June 2023

Albinism, derived from the Latin word albus meaning white, is a rare genetic condition characterized by an absence of melanin leading to an individual having pale skin, eyes and hair. It is believed that Tanzania has the highest rate of albinism in Africa with the autosomal recessive gene being carried by one in 19 Tanzanians and the condition impacting one in 1400 people (Cruz-Inigo AE, Ladizinski B, Sethi A. Albinism in Africa: stigma, slaughter and awareness campaigns. Dermatol Clin 2011; 29:79–87). We aim to analyse the perception of individuals with albinism in Tanzania and strive to consider the future of those with albinism and reflect on the work being done. A recurring theme throughout the literature is the fact that those living with albinism in Tanzania are often shrouded in mysticism, stigma and violence. Referred to as ‘ghosts’, they are often on the fringes of society, ostracised by their communities and labelled as having supernatural powers. It is this superstition that has led to the brutal attack and murder of members of the disenfranchised albino population in Tanzania with the belief that their body parts, which can be sold for as high as $75 000, bring luck, as well as possessing powers. It is only in recent times that attention has been brought to their plight and work has begun to unravel these deeply entrenched beliefs. The United Nations (UN)-sanctioned International Albinism Awareness Day is on 13 June and aims to shed a light on the work being done to support people living with albinism globally. In 2013, the UN Human Rights Council adopted legislation to prevent violence against people with albinism, as well as a 2015 Mandate of an Independent Expert on the enjoyment of human rights by persons with albinism. A lot of work is being done on the ground by charitable organizations to empower people living with albinism in Tanzania through education and provision of safe shelter and resources. The role of dermatologists in the support of people with albinism in Tanzania cannot be ignored. Owing to decreased melanin levels in those with albinism, there is an increased risk of skin cancer due to a lack of protection against ultraviolent radiation. Dermatologists can play a crucial role, as part of a multidisciplinary team, in providing skin cancer prevention education, as well as providing education to reduce stigma against those living with albinism (McBride SR, Leppard BJ. Attitudes and beliefs of an albino population towards sun avoidance: advice and services provided by an outreach albino clinic in Tanzania. Arch Dermatol 2002; 138:629–32).
GD07 The role of the dermatologist in the fight against female genital mutilation
Authors: Adeyemi Stephanie
Published: June 2023

Female genital mutilation (FGM) is a practice that the World Health Organization (WHO) estimates to affect 200 million women globally. The practice of FGM is often attributed to the Middle East, sub-Saharan Africa, North Africa and, to a lesser extent, Asia; however, it is now being witnessed in cities worldwide with high numbers of FGM-practising communities. The WHO defines FGM as ‘all procedures that involve partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reason’. While FGM has no health benefits, in certain cultures, the practice confers upon women full social acceptability and integration into the community and serves as a rite of passage to womanhood and marriage (Mpinga EK, Marcias A, Hasselgard-Rowe J et al. Female genital mutilation: a systematic review of research on its economic and social impacts across four decades. Glob Health Action 2016; 4:9). This systematic review aimed to assess the dermatological impact of FGM on women and the role dermatologists can play in the fight against the practice. A systematic review was carried out in accordance with the PRISMA guidelines. PubMed (n = 98), Cochrane (n = 1), CINAHL (n = 8) and Embase (n = 38) were searched for articles published between January 1990 and January 2023 with the phrase ‘female genital mutilation and skin or dermatology’. A total of 148 studies were initially identified; following screening, 21 articles were deemed suitable for inclusion and analysed. The literature highlighted that the main dermatological consequences of FGM were severe keloid formation, hypertrophic scars, vitiligo lesions, clitoral neuromas and, most commonly, epidermal inclusion cysts (Dave AJ, Sethi A, Morrone A. Female genital mutilation: what every American dermatologist needs to know. Dermatol Clin 2011; 29:103–9). A study of women in Somalia who had been admitted to the hospital following complications due to FGM noted that 55.1% of women (n = 65/118) had developed epidermal inclusion cysts. The literature suggests women often feel shame approaching clinicians for help; however, without support, these women can experience years of dyspareunia, dysuria, pruritus, pelvic pain and obstetric complications, as well as increased transmission of sexually transmitted infections and HIV following damage to the vaginal epithelium. By analysing the literature, it is clear further research into the dermatological consequences of FGM is necessary so that a conversation can be had about the ways in which dermatologists can effectively support survivors of FGM. It is important that each woman is recognized as an individual with her own story to tell, her own lived experience and her own humanity.
H02 The Foundling-Chapel brawl 1804: Robert and Mary Willan, trial by social media
Authors: Millard Les
Published: June 2023

The social media of the late 18th and early 19th centuries was no less humorous, critical and potentially personally destructive than now, despite its form, distribution and time frame being quantitatively different. Cartoons and prints, broadsheets, leaflets and pamphlets were widely distributed by hand for sale cheaply, being passed on for maximal effect. Gillray, Rowlandson and the Cruikshanks were the masters of these media, but others were prolific and no less accomplished at targeting royalty, religions, politicians and individuals of particular merit, such as physicians. One such satirical caricaturist and pamphleteer was James Sayers (1748–1823), a favourite of Prime Minister William Pitt. In 1804, he wrote a verse satire, attacking Dr Robert Willan (1757–1812) and his wife Mary (1770–1844) after an incident in the Chapel at The Foundling Hospital (Nichols RH, Wray FA. History of the Foundling Hospital. Oxford: Oxford University Press, 1935), where his sister Elizabeth was in dispute with them over the occupancy of a pew (pews were rented by the hospital governors on an annual basis). They were both subjected to a clever—not always subtle—diatribe for some 2 years about their personal and professional integrity, including their religion. Willan was described as a ‘learned leech’, with the implication that this successful physician was not just bleeding patients therapeutically, but also financially. His patients were ‘scabby’ and therefore detestable, and he was a lesser man because he was no longer a Quaker. For Mary, there were intimations about her temperament, her motives for marriage and her personal hygiene. The recently married couple had moved from 14 Bloomsbury Square to nearby number 10, with her two daughters by her previous marriage. There, their son Richard was born in 1802. Robert Willan withdrew from his work at the Carey Street Dispensary in 1803. Re-reading this rare publication by Sayers, which may seem a negative satire, inadvertently provides clues to the personal and social context of the Willan’s early married life.
H03 Madam C.J. Walker and her wonderful hair grower
Authors: Doyle Claire
Published: June 2023

Madam C.J. Walker was born Sarah Breedlove in December 1867 in Louisiana, USA. She was the first child in her family born to freedom following the abolition of slavery in the USA in 1865. She was orphaned at the age of 7 years and began working as a domestic servant at the age of 10 years. She married when she was 14 years old and became the sole parent of a 2-year-old daughter following the death of her husband in 1887. Seeking a way out of poverty, in 1889, she moved to St Louis, Missouri, where her four brothers were barbers. During the 1890s, she developed significant hair loss. In an attempt to tackle the said hair loss, she consulted her brothers for advice and experimented with many homemade remedies and store-bought products. In 1906, she married Charles Joseph Walker and became known as Madam C.J. Walker. By this time, she had developed her own formula to heal scalps and spur hair growth specifically for Black women who had been overlooked by the beauty and haircare industries. The initial product was known as ‘Madam Walker’s Wonderful Hair Grower’, which she began selling in 1907. Ingredients included precipitated sulfur, copper sulfate, beeswax, petroleum jelly, coconut oil and a violet extract perfume to cover the sulfur smell. At the time, sulfur was commonly used to treat dandruff. Along with her hair grower, Walker’s early products included Glossine (a pressing oil) and a vegetable shampoo. She urged clients to shampoo more often and to follow her ‘Walker System’, using the hair grower, oil and hot combs to make ‘lacklustre and brittle hair become softer’. Her products became widely used and her strong customer base led her to becoming the USA’s first self-made female millionaire. She died due to kidney failure in 1919. Her company still exists under the name Madam C.J. Walker Beauty Culture. Madam C.J. Walker was not a dermatologist and was not medically trained, but she was one of the first people to pay attention to the issue of hair loss experienced by Black women. Over 100 years later, the field of dermatology is still trying to address the lack of attention and research given to presentations in those with skin of colour.
H05 Jean-Nicolas Marjolin (1780–1850): a name to remember
Authors: Andrew Kashini , Al-Kutubi Huda , Salimi Maryam , Patel Pooja , Orpin Stephen , King-Stokes Natalie
Published: June 2023

Jean-Nicolas Marjolin was born in Ray-sur-Saone, in eastern France, in 1780. His education was sponsored by his mother as his father had died when he was 1 year old, leaving them impoverished. He studied Medicine at The Commercy Hospital, north-eastern France, before he left for Hôtel-Dieu hospital in Paris where he met Guillaume Dupuytren, who recruited him to the ‘Societe Anatomique’, a society created to promote the study of clinical anatomy. He became, successively, an assistant in anatomy (1805), a prosector (1806) and a doctor (MD) in 1808. He even established his own medical school in 1810. It was very popular as he admitted students from less privileged backgrounds to study medicine for free. His brilliant teaching style caused conflict with his ambitious mentor Dupuytren, who saw him as a threat after he was hired as Dupuytren’s assistant at Hôtel-Dieu. Marjolin was also a member of the Académie de Médecine, and surgeon to Louis-Philippe I, the French king at the time. His son René also became a surgeon and married Cornelia Scheffer, the daughter of the famous painter Ary Scheffer. In 1828, Marjolin described four types of ulcers that he named ‘ulcere verruqueux’ in Mimoires de l’Acadimie de Chirurgie, which was a manual of anatomy at that time. However, he did not specify whether the ulcers were malignant or associated with longstanding ulcers. In 1850, the year that Marjolin died, Robert Smith, Professor of Surgery at Trinity College, Dublin, described locally destructive ulcers that developed in scars following burns, floggings and lacerations as the ‘warty ulcers’ of Marjolin. After Smith’s death in 1873, Marjolin was again forgotten until 30 years later, when John Chalmers DaCosta, Professor of Surgery at Jefferson Medical College, Philadelphia, described two cases of carcinomatous change in chronic varicose leg ulcers as examples of Marjolin ulcers. John Fordyce, an American dermatologist, subsequently described a chronic ulcer undergoing malignant change as a Marjolin ulcer in 1907. These definitions of Marjolin ulcer by DaCosta and Fordyce included malignancy developing in sinuses, as well as malignancy in scars and persistent ulcers. These declarations defined the term ‘Marjolin ulcer’ in modern usage and preserved Marjolins’ name for future generations. Currently ‘Marjolin ulcer’ refers to a rare malignant transformation within chronic ulcers or scars with squamous cell carcinoma as the commonest subtype. Its exact cause remains unknown, despite being described by Jean-Nicolas Marjolin almost 200 years ago.
H08 The Crimson Chronicles of acne rosacea: a fascinating tale of medicine and culture
Authors: Adeyemi Stephanie , Gupta Sachi
Published: June 2023

Acne rosacea is a common skin condition that affects people with Fitzpatrick skin types I–III and is characterized by flushing, erythema, telangiectasia, pustules, papules and phyma (Jansen T. Clinical presentations and classification of rosacea. Ann Dermatol Venereol 2011; 138:3). This condition has been around for centuries and is referred to in literature and art throughout history. The earliest reference to acne rosacea can be traced back to the third century Bc, where it was mentioned in the writings of Greek poet Theocritus. It has also been referred to in various forms of literature, including the character of Summoner in Chaucer’s Canterbury Tales and Bardolf in Shakespeare’s Henry VI (Cribier B. Histoires de visages rouges. Ann Dermatol Venereol 2011; 138:2). In art, the condition is famously depicted in Italian Renaissance painter Domenico Ghirlandaio’s ‘The Old Man and His Grandson’, now housed in the Louvre. The colour red, a prominent characteristic of acne rosacea, has had a significant role in literature, symbolizing everything from love and passion to anger and violence. French novelists Balzac and Proust used it as a motif in ‘The Red Face’ or ‘Le Visage Rouge’ to denote violence and as a marker of the working classes. In the 14th century, French surgeon Guy de Chauliac was the first to document clinically the condition, referring to it as goutterose or ‘pink droplet’. It was in the 18th and 19th centuries that significant strides were made in understanding the nature of acne rosacea. Dr Jean Astruc, known as the father of venereal diseases, characterized the condition as ‘erythematous, varicose and scaly’. In 1812, the official term ‘acne rosacea’ first appeared in a medical text by English dermatologist Dr Thomas Bateman. Further references to the condition can be found in the 1817 publication On Cutaneous Diseases by dermatology pioneer Dr Robert Willan. In 1834, physician Robert Macnish explicitly linked acne rosacea to alcohol consumption in his book Anatomy of Drunkenness. The differentiation between acne vulgaris and acne rosacea was firmly established following the work of Austrian dermatologist Hebra and French dermatologist Darier. In the past, treatments for acne rosacea included salves containing mercury, sulfur, bull’s blood, blood-letting and leeches. Today, topical and oral antibiotics are the standard treatments, a far cry from the remedies of yesteryear. In conclusion, the history of acne rosacea, which is so much more than just le visage rouge, is a captivating journey that spans centuries, from its earliest references in literature and art to the contemporary understanding and treatment of the condition.
H09 Is cannabis use in dermatology topical? Reviving the historical highs
Authors: Moon Emily , Unter Simon , Gee Bruce
Published: June 2023

Cannabis refers to product derived from a plant species known as Cannabis sativa. The plant contains cannabinoids, two of the most prominent being tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is the primary psychoactive component in cannabis, while CBD, discovered by chemist Roger Adams in 1942, is nonpsychoactive. Cannabis with high THC levels is referred to as marijuana. With global policy changes and government approvals, CBD has recently garnered significant interest due to increased awareness of its therapeutic potential. This surge in demand has fuelled the multi-billion-dollar global CBD market with projections of sustained growth in the future. The use of cannabis for medicinal purposes has a rich history, dating back to ancient civilizations. From traditional Chinese medicine using cannabis preparations for rashes to ancient Egyptians using it for wounds to Arab traditional medicine using it to treat lichen planus, the therapeutic benefits of cannabis have been widely recognized throughout history. Sir William O’Shaughnessy, an Irish physician, discovered the therapeutic properties of cannabis in India in the 19th century and led to its widespread use in Europe and North America. However, in the early 20th century, cannabis was banned in many countries as part of a movement to control the use of addictive substances. The discovery of the endocannabinoid system in the late 20th century marked a turning point in the understanding of how cannabinoids interact with our bodies. This intricate network, made up of endocannabinoids, cannabinoid receptors and enzymes, regulates pain perception, metabolism, circadian rhythm, immune system, and more. Preclinical evidence supports the therapeutic potential of topical CBD for dermatological inflammatory diseases such as acne and eczema, as well as skin cancer (Lowe H, Toyang N, Steele B et al. The endocannabinoid system: a potential target for the treatment of various diseases. Int J Mol Sci 2021; 22:9472). The accumulation of evidence supporting its therapeutic potential has led to a change in societal and cultural perspectives toward cannabis, resulting in the UK government’s approval of limited medicinal use in 2018, as well as the opening of the nation’s first legal cannabis farm in 2021. In 2018, Epidyolex® (cannabidiol) became the first US Food and Drug Administration-approved medical-grade CBD for treating rare forms of epilepsy. Cannabis’ potential therapeutic properties offer a promising outlook for cannabis-based medicine in dermatology. While CBD’s lipophilic nature and its instability in solution pose challenges for its transdermal delivery, ongoing research and study may offer solutions. It is imperative that dermatologists stay informed about CBD advancements as its growing availability and potential indications are likely to drive its popularity.
H10 An Oscar for Lassar
Authors: Al-Kutubi Huda , Salimi Maryam , Patel Pooja , Andrew Kashini , King-Stokes Natalie , Orpin Stephe
Published: June 2023

Oscar Lassar (1849–1907) was born in Hamburg to a wealthy merchant family and received a top-class education. After enrolling in the school of medicine at Heidelberg, he volunteered for military service at the outbreak of the Franco–Prussian war in 1870. He served on the front line, was promoted to officer in reserves and decorated with the Iron Cross for his bravery. He returned to complete his medical training and would eventually open a dermatology hospital in Berlin, which unified patient care, research and teaching. In only a few years this hospital would become world renowned. Catering for both inpatient and outpatient care, he was able to offer a wide range of treatments, including complex topical therapy, electrotherapy and surgical procedures. His pasta salicylica (Lassar’s paste) remains to this day a great topical treatment for atopic dermatitis. Lassar recognized the importance of an experienced nursing team to support these activities. Furthermore, he understood the importance of a well-equipped dermatology department and was quick to acquire innovative technology to expand therapeutic options, including X-ray equipment for the treatment of tumours and a Finsen carbon arc lamp for treating lupus vulgaris, thus augmenting his reputation as a Wunderarzt. Lassar made great contributions towards solidifying dermatology as a highly regarded speciality through the establishment of journals and speciality societies. He involved himself in public health measures by campaigning for the establishment of public baths, which would allow even the poorest in society to enjoy clean water facilities at a low cost, thereby reducing the spread of infectious diseases. As a man, he was described as a larger-than-life character with a personal style that meant newspapers gladly reported on his activities, making him an excellent public relations master. Lassar’s recreation was chiefly riding and driving. He was an excellent linguist, an admirable host and fond of children, for whom he wrote Geschichten und Gedichten fiir kleine Kinder (Stories and Poems for Little Children). He died in an automobile accident and his burial on Christmas Eve was marked nationally by the German newspapers, and internationally by his patients and colleagues. In Lassar, we have a great historical example of effective visionary leadership that enabled the expansion of dermatological practice and the promotion of patient care at the time.
H12 Royal rashes: a potted dermatology history in the British monarchy
Authors: Wolfe Charlotte , Fisher Rachel
Published: June 2023

Skin diseases have affected a significant proportion of the population throughout history, royalty being no exception. On reviewing monarchs over the centuries, underlying health conditions can be gleaned from their reported skin conditions and physical appearance. In the 14th century, King Henry IV seized the throne from his cousin Richard II. Henry IV was debilitated by a skin disease thought to be leprosy or severe psoriasis, believed to be a punishment from God for being the first king to execute an archbishop. He is reported to have developed great pustules and eventually necrotic ulcers. King Henry VIII, famous for his six wives, also suffered with poor health during his reign from 1509 to 1547. By the age of 44 years, he was reportedly significantly obese, suffering from bilateral leg ulcers that became recurrently infected, leaving him unable to walk. The aetiology of the king’s ulceration may encompass a range of potential diagnoses. It is likely to have been as a result of venous disease with stasis dermatitis alongside trauma and obesity. Henry’s daughter Queen Elizabeth I, who reigned from 1558 to 1603, suffered from smallpox in 1562, which left her face scarred. Her physical scars were concealed with early forms of lead-laced makeup. She also reportedly suffered from hair loss. This may have been telogen effluvium secondary to stress, or it is possible that she suffered from female pattern hair loss. Alternatively, the application of lead to her face may have contributed to her alopecia. The following century, Queen Anne, the monarch that unified England and Scotland and took ownership of Gibraltar, is thought to have suffered from systemic lupus erythematosus. Portraits have demonstrated the classic malar rash, facial oedema and joint swellings. She also suffered many miscarriages and eventually a lethal stroke, raising suspicion for associated antiphospholipid syndrome. Moving to the 20th century, Prince William of Gloucester, a grandson of King George V, suffered from a photoexacerbated blistering skin rash. Three years later, he was diagnosed with porphyria, giving credence to the theory that the madness of King George III, one of William’s ancestors, was due to porphyria. However, this has been disputed, and manic–depressive psychosis is felt to be the more likely explanation. With up to 33% of the UK population suffering with skin conditions at any one time, a significant number of the current royal family will have a variety of skin diseases. How will their dermatological history be told in the future?
H14 ‘Reflection for the day’
Authors: Long Amy , Long Alison
Published: June 2023

Thomas B. Fitzpatrick had a tremendous influence on the specialty of dermatology, including seminal scientific contributions, a legendary ability to teach and train, and remarkable innovations in clinical dermatology. Born in Wisconsin in 1919, he received his medical degree from Harvard, followed by a PhD in pathology. He served 2 years at an Army Chemical Centre, where his interest in skin pigmentation led to the discovery of human tyrosinase. Further innovation in basic sciences followed, with the discovery of the melanosome and epidermal melanin unit. He added to his academic accolades by completing a fellowship in chemistry at Oxford, then returned to the USA to pursue clinical dermatology training at Mayo Clinic. At the age of 32 years, following substantial success in his early career, he was appointed Professor and Chair of Dermatology at the University of Oregon. By 39 years of age, he was Chair of the Harvard Medical School Dermatology Department, Harvard’s youngest Professor and Chair, while serving as Chief of Dermatology at Massachusetts General Hospital. He was a master at motivating students and sharing his passion for dermatology. He often said ‘Practicing dermatologists are like the woodwind section of the orchestra—small in number, when they play they must play well’. In 1971, he wrote the first multiauthor medical textbook in the field entitled Fitzpatrick’s Dermatology in General Medicine, now in its eighth edition. Dr Fitzpatrick contributed heavily to the clinical advances in dermatology in the latter half of the 20th century. Alongside dermatopathologist Wallace Clark, he established the very first pigmented lesion clinic in 1966. From that clinic, studies enabled Dr Clark to devise the Clark level staging system for melanoma. Fitzpatrick described early diagnostic signs in melanoma, and the concept of sunlight as a factor in its aetiology. In 1975, he devised the Fitzpatrick scale of skin phototypes, which described a person’s skin type in terms of response to ultraviolet (UV) radiation exposure. To huge success, he experimented with psoralen and UVA to treat psoriasis, coining the term photochemotherapy, or PUVA. Fitzpatrick was a highly productive medical scholar, while having many other notable qualities and interests. He was an avid lover of music, a skilled pianist and a Johannes Brahms enthusiast. The Boston Globe called him a ‘dermatologist with an infectious enthusiasm for his specialty and philosopher’s love of a good quote’. For 20 years, he co-edited the Globe’s popular ‘Reflection for the Day’, alongside his loving wife Beatrice. Thomas Fitzpatrick was admired by many until his passing in 2003, leaving us with so much to remember him by.
H16 Arsenic to biologics: psoriasis treatment through the ages
Authors: Sarfraz Rabia
Published: June 2023

In the 19th century when arsenic was the recommended treatment for psoriasis, little consideration was given to the toxic side-effects of the potent carcinogen. Thomas Girdlestone, an English physician, is said to have been the first to advocate for the use of arsenic to treat psoriasis. Girdlestone prescribed Fowler’s solution, a solution of potassium arsenite 1%. In 1876, Alexander John Balmanno Squire inadvertently discovered dithranol, a known treatment for ringworm, to be efficacious in treating psoriasis. However, it was Eugen Galewsky, in 1916, who then went on to synthesize anthralin, a synthetic form of dithranol, to target psoriasis. A key historical figure was William H. Geockerman, an American dermatologist, who developed Goekerman therapy—a regimen that combined the use of coal tar and ultraviolet (UV) light to treat moderate-to-severe plaque psoriasis. In 1953, John Ingram, an English dermatologist, discovered that the beneficial effects of dithranol paste could be enhanced by adding it to coal tar and UV light—later coined the ‘Ingram regimen’. Philip Showalter Hench, Edward Calvin Kendall and Tadeus Reichstein received the Nobel Prize in Medicine and Physiology for the development of cortisone; it proved to be useful in topically treating many skin diseases, but it had a limited effect on psoriasis. The production of synthetic corticosteroids soon followed, which, conversely, proved to be successful in treating psoriasis. However, the daunting side-effects of corticosteroids limited their long-term use. In 1951, a patient with rheumatoid arthritis showed dramatic improvement in their psoriasis when treated with aminopterin, as recorded by Richard Gubner, a New York cardiologist. PUVA was developed in the 1970s—a photochemotherapy for psoriasis that combined psoralen with UVA radiation to clear skin lesions. Interestingly, in 1500 Bc, the ancient Egyptians were known to use a combination of psoralen and sunlight to treat vitiligo. Furthermore, in the 1980s, researchers noted complete clearance of psoriasis in a patient with osteoporosis who was prescribed an oral form of vitamin D. This chance observation then led to the development of topical vitamin D analogues for the treatment of psoriasis that work by encouraging normal skin growth and slowing down overproduction of skin cells. Finally, in 2003, the first biologic treatments were approved for psoriasis by the US Food and Drug Administration—a significantly safer and more efficacious alternative to the controversial arsenic treatments that were used over 200 years ago.
H20 Gin or tonic: the dermatological hazards of cocktail-based quinine
Authors: Passby Lauren
Published: June 2023

Derived from Cinchona tree bark, quinine was first found to be beneficial to health by indigenous Amazonian peoples. Seventeenth-century Jesuit missionaries sent the bark and seeds back to Europe, where word of its therapeutic properties spread. Quinine was promoted as an antiseptic treatment for a range of ailments from the 1600s onward, including septicaemia, erysipelas and scarlet fever. The dermatological risks of quinine quickly became recognized, with Bartholow stating in his 1876 work that ‘The action of quinia has occasionally been attended by the appearance of an eruption on the skin. Sometimes the exanthem has been in the form of an erythema, sometimes it has assumed the appearance of urticaria.’ The pharmacological properties of quinine were exploited by colonial institutions such as the East India Company, who combined a pragmatic approach to antimalarial prophylaxis with a British penchant for aperitivos. The bitter taste of quinine in tonic water led to the addition of water, sugar, lime and gin, giving rise to the gin and tonic (G&T). Its enduring popularity is, in part, due to the astringent nature of quinine and its acidic content that acts as a ‘stomachic tonic; that is, promote appetite, the flow of gastric juice, and the digestive power’. However, since its advent, the G&T has been attributed to many cases of dermatological malaise, as discovered by this systemic review of the published PubMed and SCOPUS literature. To the adage ‘new drugs, new eruptions’, the G&T was no exception. The first published skin reaction to quinine in tonic water dates from 1955, occurring shortly after the patient attended a cocktail party after which they developed ‘a burning sensation in the groins and in his hands and feet’ with progressive oedema and erythema to these areas, spreading to involve nearly all of the body. Other published cases describe (in decreasing frequency) fixed drug eruptions, photosensitive reactions, allergic urticaria and lichenoid drug reactions triggered by quinine in G&Ts. The spectrum of eruptions triggered by tonic water extends to Stevens–Johnson syndrome/toxic epidermal necrolysis triggered by scotch and tonic water consumed at the patient’s peril during a convention in 1972. With an enduring popularity spanning two centuries, and a declaration from Churchill that ‘the gin and tonic has saved more Englishmen's lives, and minds, than all the doctors in the Empire,’ it is vital that dermatologists are aware of the potential dermatological hazards of the G&T.
H23 Traditional healing by skin cauterization (kaiy)
Authors: Al Haddabi Atheer , Williamson Emilia Duarte
Published: June 2023

The practice of kaiy is an ancient medical traditional therapy that is still used in Africa and the Middle East. Kaiy is the Arabic word for cautery; a red-hot iron or coal is placed to the skin. This causes sharp circular, oval or linear burns that are placed in a symmetrical configuration, usually resulting in permanent scars. This practice is undertaken by traditional healers. A Somali woman was referred by her general practitioner to dermatology for an itchy scar on her mid-upper abdomen. She reported that 40 years ago, she had traditional skin cautery therapy to the area for bone pain, which was later diagnosed as rheumatoid arthritis. On examination, she had a 4 × 0.7 cm keloid scar that was treated with a course of KenalogTM injections. This sparked an interest in understanding the practice of kaiy, and a literature review was performed. Cauterization results in the burning of tissue in order to close wounds or stop bleeding. The patient’s symptoms help to decide the location of cauterization. For example, if the presenting complaint is jaundice, the cautery is placed on the left hand. Other medical presentations that kaiy is used for include back pain, headache, depression, chest pain and exorcism. Is this practice useful or are patients being burned for no reason? Historically, it was felt that it was valuable in preventing infection; however, there is no scientific basis for this. The practice was believed to result in the destruction of pathogenic substances within the body due to the extreme heat. Patients who have undergone this therapy report that it gives them short-term relief of their symptoms; this is likely to be due to the release of endogenous opioids, allowing the body to stop the sensation of unremitting pain. Complications are commonly witnessed and consist of deep skin burns, deferred wound healing and secondary wound infections. More serious complications include septic shock, ulceration and viral transmission such as hepatitis B (Farid MK, El-Mansoury A. Kaiy (traditional cautery) in Benghazi, Libya: complications versus effectiveness. Panafr Med J 2015; 22:98; Budair F. Dermatoses due to Arabic cultural and traditional practices. Indian J Dermatol Venereol Leprosy 2019; 85:448–54). Kaiy should be included in the differential diagnosis of a patient presenting with multiple symmetrical scars. Some patients may not be forthcoming in admitting to the treatment if not specifically asked. This presentation aims to increase awareness in dermatologists of this practice.
PA04 (P05) A rare presentation of blistering in an adolescent
Authors: Watson Nicola , Charlton Fraser , Hampton Philip , Dubois Anna , Leech Suzy
Published: June 2023

A previously well 16-year-old male presented with florid and widespread tense bullae and erosions. He gave a 2-week history of an erythematous rash consisting of crusted erosions that started on his chest and face. He denied any new medications or over-the-counter preparations. There was no preceding systemic illness, and no history of cold sores or sexual contacts. In the 24 h prior to his admission, his rash had become widespread, involving his trunk, limbs, hands, ears, face, lips, oral and genital mucosa. He had started to feel systemically unwell and was in significant pain. On examination, he had a combination of heavily crusted erosions and extensive tense bullae containing straw-coloured fluid on a background of inflamed skin. The morphology was herpetiform in some areas. There was notable extension of bullae onto the palms and penis, as well as intraoral and labial erosions. Viral skin swabs were negative, and his biopsy subsequently demonstrated subepidermal blistering with neutrophil-rich inflammation and positive direct immunofluorescence (IMF) for C3 and IgG only. Serum autoantibodies were negative. Childhood bullous pemphigoid (BP) was initially the working diagnosis, but indirect IMF showed localization to the base of the blister and anticollagen VII antibodies later proved positive, consistent with a diagnosis of epidermolysis bullosa acquisita (EBA). Given the clinical features, it was classified as BP-like EBA. He was initially treated with high-dose oral prednisolone, superpotent topical steroids and analgesia as an inpatient. Mycophenolate mofetil (MMF) was initiated, and his corticosteroid dose was slowly tapered. His condition was completely controlled with MMF 500 mg twice daily at 4 months. The patient then elected to stop taking MMF and remains in complete remission at 7 months. The EBA is rare in adults and even more so in children. The mean age of onset is 44–54 years, but up to 5% of reported cases are in children/adolescents. Four subtypes are described: classic mechanobullous, BP-like, mucous membrane pemphigoid-like and linear IgA bullous dermatosis-like. The BP-like EBA is characterized by widespread vesicles and tense bullae, commonly on an inflammatory background and lacking skin fragility, scarring or milia. Oral and genital mucosae are frequently affected in paediatric cases of EBA. Various steroid-sparing treatment modalities are described, including dapsone, colchicine and MMF. The prognosis in the paediatric population is favourable compared with that of adults: the majority achieve complete remission or complete control on treatment.
PA05 A rare case of cardiocutaneous syndrome in a young child
Authors: Marini Susanna , Katugampola Ru
Published: June 2023

A 19-month-old infant came to our attention showing clinical signs consistent with focal keratoderma limited to the palms and soles, dystrophic pachyonychia of all his nails and scalp alopecia characterized by sparse curly hair. His oral cavity examination revealed periodontitis, early tooth decay and notching of the incisor teeth. The patient is the second child of a nonconsanguineous, otherwise healthy couple. No other family members were reported to have similar skin and oral alterations. Based on the characteristic appearance of his cutaneous lesions, he was investigated for a palmoplantar keratoderma disorder and was subjected to genetic testing. Results confirmed a mutation within DSP, a gene responsible for encoding the most abundant component of desmosomes, a major cell adhesion junction, particularly prominent in epidermal and cardiac tissue. Mutations in genes encoding desmosomal components are known to be associated with a broad spectrum of phenotypical alterations of skin and hair structures. The same genetic anomaly accounts for 40–50% of cases of arrhythmogenic cardiomyopathy (Pigors M, Schwieger-Briel A, Cosgarea R et al. Desmoplakin mutations with palmoplantar keratoderma, woolly hair and cardiomyopathy. Acta Derm Venereol 2015; 95:337–40). Despite being asymptomatic, our young patient was referred to cardiology for further investigations and surveillance. At the age of 7 years, routine electrocardiography revealed new conduction abnormalities. An echocardiogram confirmed a dilated cardiomyopathy that, combined with the previously described cutaneous and oral alterations, led to a diagnosis of cardiocutaneous syndrome. An overview of the clinical features associated with desmoplakin mutations reported in medical literature illustrates the complexity of this group of disorders and their genotype–phenotype correlations, which cannot be easily predicted. Our reported case is a paradigmatic example of diagnostic difficulties often encountered when facing concomitant dermatological and oral conditions in the same patient, emphasizing the importance of recognizing oral, dental and skin signs to be a potential risk factor for hidden cardiac diseases.