bluuebunny/crossref_metadata_2025 huggingface dataset:
P46 A step toward 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 onsite 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, and edited, cleaned and verified for duplications, and onsite 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 a 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.
P54 Blood tumour burden does not correlate with skin tumour burden in early-stage mycosis fungoides: analysis of the PROspective Cutaneous Lymphoma International Prognostic Index international registry
Authors: Charalambides Maria , Rooke Bethanie , Shah Farida , Irwin Clive , Murray Duncan , Evison Felicity , Scarisbrick Julia
Published: June 2023

Blood involvement B1, defined as absolute counts 250–1000 IU of an aberrant CD4+CD7– or CD4+CD26– phenotype, may be found in early-stage mycosis fungoides (MF). There is a suggestion that B1 blood involvement is a poor prognostic marker, but there is limited evidence investigating the prognostic significance of B0 or B1 blood involvement in early-stage MF. Loss of CD26 and/or CD7 expression on CD4 cells may occur in MF; however, it is unclear whether loss of either one of these immunophenotypic markers bears more significance on prognosis. For B2 blood involvement (> 1000 IU), the International Society for Cutaneous Lymphomas (ISCL) criteria define Sézary syndrome as CD26 loss of > 30% or CD7 loss of > 40%. Understanding the impact of B1 and comparative loss of CD26 and/or CD7 in early-stage MF may allow patients at higher risk of stage progression to be identified and selected for better therapeutic options. The aims of this study were to analyse B0 vs. B1 blood involvement at diagnosis in patients with early-stage MF (IA–IIA) and evaluate the relative CD4+CD7– and CD4+CD26– absolute cell counts. Prospective data from the PROCLIPI registry were analysed. Ninety-four patients with early-stage MF were identified from our database, 67 (71%) of whom were B0 [stage IA, n = 23 (34%); stage IB, n = 24 (36%); stage IIA, n = 20 (30%)] and 27 (29%) were B1 [stage IA, n = 12 (44%); stage IB, n = 10 (37%); stage IIA, n = 5 (18%)]. Median age at diagnosis in B0 patients was 59 years (range 20–91) vs. 61 years (range 21–81) in B1 patients. Median CD4+CD7– cell count was 16.4% (range 0–41%) in patients with B0 involvement and 28.1% (range12–45%) in B1 patients. Median CD4+CD26– cell count was 16% (range 0–39.1%) in B0 and 28% (range 0–44%) in B1 patients. The Median Modified Severity-Weighted Assessment Tool score in B1 patients was 11 (range 1–73) vs. 20 (range 0.5–100) in B0 patients. There was no significant difference in progression to the advanced stage between B0 and B1 (P = 0.112) patients or overall survival between B0 and B1 patients during median follow-ups of 49 months and 45 months, respectively. These results suggest that blood tumour burden in early-stage MF, measured by the percentage aberrancy in CD4+CD7– and CD4+CD26– cell counts, does not correlate with clinical stage, skin tumour burden or stage progression. This suggests that in B1 involvement, atypical lymphocytes may lose their skin-homing properties. Interestingly, levels of CD4+7– and CD26– are similar in B1 involvement, despite the ISCL criteria defining B2 involvement as a lower relative loss of CD26–. Identifying B1 patients is important as certain therapeutic options such as extracorporeal photopheresis and mogamulizumab may be indicated in patients with early-stage MF, refractory to skin-directed therapies.
P55 Real-world clinical and patient-reported outcomes of talimogene laherparepvec (T-VEC) treatment for melanoma in transit and nodal metastases at a UK centre
Authors: Bennett Hannah , Butterfield Kellie , Robinson Joanne , Sugden Joh , Muinonen-Martin Andrew , Mitra Angana
Published: June 2023

Talimogene laherparepvec (T-VEC) is a National Institute for Health and Care Excellence-approved oncolytic viral intralesional immunotherapy licensed for unresectable stage III(B)–IV(M1a) melanoma. It is a genetically modified herpes simplex virus that selectively replicates in tumour cells, leading to local and systemic antitumour immune responses, improving overall survival. The randomized phase III OPTiM trial reported a complete response in 28.2% of patients (Andtbacka RH, Collichio F, Harrington KJ et al. Final analyses of OPTiM: a randomized phase III trial of talimogene laherparepvec vs. granulocyte-macrophage colony-stimulating factor in unresectable stage III–IV melanoma. J Immunother Cancer 2019; 7:145). We report a retrospective review of clinical and patient-reported outcomes of a dermatology-led T-VEC service at a regional UK melanoma centre between January 2019 and January 2023. Treatment involves a loading dose and then two-weekly nurse-delivered intralesional injections. Patient demographics, clinical characteristics, toxicities, treatment responses and patient satisfaction were recorded. Sixteen patients (11 women and five men) were treated; the average patient age was 73 years (range 42–87). Seven patients had stage IIIB disease, six stage IIIC and three stage IVM1a. Eight had received prior nonsurgical treatments (adjuvant therapy, electrochemotherapy, diphencyprone). The number of lesions treated per visit ranged from 1 to 24 (median 5) over a median of six visits (range 2–24). Four patients (25%) had a complete response (CR), with median time to CR being 8 weeks; all have maintained the response (range 6–45 months). Eight (50%) showed partial response (PR), with three continuing treatment. Nine patients overall had progressive disease (five in the PR group and four who were nonresponders). In total, five patients died. Patients experienced mainly flu-like symptoms (44%), pyrexia (31%), fatigue (19%), muscle pain (19%), nausea (19%), headache (19%), diarrhoea (6%), joint pain (6%), local swelling (19%), lymphadenopathy (6%) and mild pain (25%). No grade 3 or 4 toxicity occurred. A patient satisfaction questionnaire was returned by seven of eight patients who completed treatment. All said they received adequate information to make treatment decisions. Eighty-six per cent rated the service excellent. Our results show comparable efficacy and side-effects to published clinical trials and demonstrate that T-VEC is a well-tolerated and safe treatment option, delaying or potentially avoiding need for more toxic systemic agents. We highlight that dermatologists and nurse specialists are well placed to deliver T-VEC in patients with melanoma.
P71 Dupilumab improves patient-reported itch and other signs and symptoms of disease in adults with prurigo nodularis (LIBERTY-PN PRIME and PRIME2)
Authors: Kwatra Shawn G , Yosipovitch Gil , Ständer Sonja , Guillemin Isabelle , Msihid Jérôme , Wiggins Simmi , Levit Noah A , McDonald Robert , Bansal Ashish , O’Malley John T , Bahloul Donia , Thomas Ryan B
Published: June 2023

Prurigo nodularis (PN) is characterized by the presence of itchy nodules on the trunk/extremities and is often accompanied by skin pain and sleep disruption. Patient needs are highest regarding symptom control and improvement of itch, which is one of the main hallmarks of PN. Using pooled blinded data from two randomized, double-blind, placebo-controlled phase III trials of dupilumab in adults with PN uncontrolled on topical therapies, LIBERTY-PN PRIME (NCT04183335) and PRIME2 (NCT04202679), the psychometric validation and within-patient meaningful change thresholds for three patient-reported outcome (PRO) instruments of the trial were assessed in patients with PN: Worst Itch Numerical Rating Scale (WI-NRS), Skin Pain-NRS and Sleep-NRS. The proportion of patients achieving clinically meaningful improvement in these PRO scores in LIBERTY-PN PRIME and PRIME2 was investigated in this post hoc analysis. Adults with PN inadequately controlled on topical prescription therapies, or when those therapies were not advisable, were randomized 1 : 1 to dupilumab 300 mg every 2 weeks or matched placebo. Here, we report the proportion of patients meeting a defined improvement threshold in weekly averages from baseline to week 24 of ≥ 4 points in WI-NRS, ≥ 4 points in Skin Pain-NRS and ≥ 2 points in Sleep-NRS (within-patient meaningful improvement thresholds defined in the context of the LIBERTY-PN PRIME and PRIME2 studies, range 0–10), and the proportion of patients who achieved a new composite endpoint, meaningful improvement in WI-NRS and either Skin Pain-NRS or Sleep-NRS at week 24. A total of 311 patients were randomized (dupilumab, n = 153; placebo, n = 158). Baseline scores for WI-NRS, Skin Pain-NRS and Sleep-NRS were balanced between treatment groups. Significantly more patients treated with dupilumab vs. placebo achieved in-­patient meaningful improvement in WI-NRS (58.8% vs. 19.0%; P < 0.001), Skin Pain-NRS (49.7% vs. 20.9%; P < 0.001) and Sleep-NRS (42.5% vs. 23.4%; P < 0.001) from baseline to week 24. More patients treated with dupilumab experienced clinically meaningful improvement in WI-NRS and either Skin Pain-NRS or Sleep-NRS vs. placebo (53.6% vs. 18.4%; P < 0.001). Adults with PN uncontrolled on topical therapies treated with dupilumab achieved statistically significant and clinically meaningful improvement in itch, skin pain and sleep quality individually, and in itch combined with either skin pain or sleep. The safety profile of dupilumab was consistent with the known safety profile in its approved indications.

Funding sources: research sponsored by Sanofi and Regeneron Pharmaceuticals Inc.
P76 Management of aciclovir-resistant mucocutaneous herpes simplex virus infection: a systematic review
Authors: Valladares Herbert Castillo , Rudd Nora , Leslie Kieron
Published: June 2023

Aciclovir resistance results in immunocompromised hosts due to long-term antiviral therapy and ongoing viral replication. Aciclovir resistance in herpes simplex virus (HSV) poses a major concern, as this can lead to chronic and recalcitrant infection that significantly impacts on the quality of life. While different treatment options exist, there are currently no standardized clinical treatment guidelines for mucocutaneous aciclovir-resistant (ACV-R) HSV infection. This systematic review seeks to identify safe and effective treatments for mucocutaneous ACV-R HSV infection. For this systematic review, PubMed/MEDLINE and Embase were searched in September 2022 for all articles published between 1 January 1980 and 1 September 2022. Studies were included if they described the use of a medication for the treatment of mucocutaneous ACV-R HSV infection. From the initial search that yielded 1066 studies, 86 met the inclusion criteria and were selected. Of the 86 studies, 6 were clinical trials and 80 were case reports/series. A total of 318 patients were included in our review. Foscarnet [intravenous (IV) and topical] was studied in 5 clinical trials and 25 case reports/series, leading to complete response in most patients, with adverse effects including renal toxicity and electrolyte abnormalities. Vidarabine (IV) was found to be inferior to foscarnet in a clinical trial and reported in two case reports. Common side-effects included nausea, anaemia and renal impairment. Trifluridine (topical) was studied in a clinical trial and a case report, showing complete response in some patients. Cidofovir (IV, topical, intralesional) was studied in 21 case reports/series, showing complete response in most patients, with renal impairment as the most common adverse effect. Imiquimod (topical) was studied in eight case reports/series, showing complete response and no side-effects. Pritelivir (oral) was reported in two case reports/series, showing complete response and no side-effects. Combination treatment was reported in 10 case reports/series with variable clinical response. Our review also identified reports of less widely used treatments. These include artesunate, zidovudine, varicella-zoster virus vaccine, leflunomide and surgical excision, which achieved variable response rates but have not been widely studied. While foscarnet and cidofovir have the most robust evidence, IV administration of these agents is associated with significant side-effects and may be limiting. Intralesional and topical formulations of cidofovir, trifluridine and imiquimod are alternative options appropriate for outpatient management. Pritelivir is a novel and promising treatment of mucocutaneous ACV-R HSV infection.
P85 Switching from adalimumab originator to biosimilar: a 3-year retrospective cohort analysis
Authors: Killion Lisa , Alsharqi Ali , Kirby Brian
Published: June 2023

Biological drugs have revolutionized the treatment of immune-mediated inflammatory diseases. Clinical experience and evidence suggest that biosimilars can be used as safely and effectively as their originator. However, patients’ perceptions of biosimilars are that they are inferior to the originator. Currently, few studies have assessed the tolerability and efficacy of switching from the adalimumab originator to a biosimilar in patients with well-controlled moderate-to-severe psoriasis. Our objective was to describe the clinical experience of switching patients from the adalimumab originator to a biosimilar and that of switching back to the originator for those intolerant to biosimilars. A single-centre, retrospective cohort study was conducted to identify patients with moderate-to-severe psoriasis who had switched from the adalimumab originator (Humira®) to a biosimilar (Amgevita® or Imraldi®) from 2018 to 2022. Patient data were obtained from a combination of patient records and databases, including the British Association of Dermatologists Biologics and Immunomodulators Register (BADBIR) and the National High Tech Prescribing Hub. Patients were excluded from the study if their treatment duration on an adalimumab biosimilar was < 16 weeks or if they were being treated for an indication other than psoriasis. From 2018 to 2022, 100 patients who switched from the adalimumab originator to a biosimilar were identified. At week 16, 81 patients (81%) maintained their initial switch from the adalimumab originator to biosimilar. Nineteen (19%) patients who were switched to an adalimumab biosimilar were switched back to the originator secondary to adverse events. Maintenance or improvement in baseline Psoriasis Area and Severity Index (PASI) and Dermatology Life Quality Index (DLQI) was observed in 91% and 90%, respectively, in patients who remained on a biosimilar. For those intolerant to biosimilars, maintenance or improvement in baseline PASI and DLQI was still observed although in fewer patients: 63% and 47%, respectively. Our study demonstrates that drug efficacy was recaptured and adverse events were ameliorated for all patients switched from an adalimumab biosimilar back to the originator. For patients who did not tolerate biosimilar switch, reasons for switching back to the originator mirrored those reported in the literature. All patients who switched back to the originator from a biosimilar recovered from loss of efficiency and the adverse events they had reported. Physicians should be confident in switching patients with well-controlled psoriasis to adalimumab biosimilars. For the small proportion of patients who experienced loss of efficacy or adverse events, all were recaptured by either switching to an alternative adalimumab biosimilar or switching back to the adalimumab originator.
P95 A single-centre retrospective study of the association between subacute cutaneous lupus erythematosus and malignancy
Authors: Duff Eimear , Gilhooley Eimear , O’Shea Finbar , Wynne Bairbre
Published: June 2023

Subacute cutaneous lupus erythematosus (SCLE) is a rare photosensitive dermatosis that has been classically categorized as idiopathic or drug-induced. A proliferation of case reports and small case series support the hypothesis that the presentation of new-onset idiopathic SCLE can be a facultative paraneoplastic phenomenon. There remains a lack of consensus regarding the investigations that this dermatosis should initiate, and in which patients. The aims were to investigate the proportion of patients with biopsy-consistent SCLE who had an underlying malignancy, and to analyse the demographic, clinical and laboratory characteristics associated with this. We conducted a histopathology database word search of skin biopsy reports from 1995 to 2021. We performed a retrospective chart review of electronic and paper records and analysed demographic, clinical and laboratory data of patients with possible SCLE. This study received full ethical approval from the relevant local research ethics committee. Of 64 patients initially identified, 35 had SCLE following clinicopathological correlation and had sufficient data available for inclusion. In this cohort, a total of 16 (46%) patients had a malignancy, either preceding or following SCLE diagnosis. In eight (23%) patients, malignancy was diagnosed within 1 year of SCLE onset. SCLE was considered drug induced in 14 (40%) of cases. Eleven (31%) cases were considered to be idiopathic; of these, five (45%) were subsequently diagnosed with malignancy. Malignancies subsequent to the diagnosis of idiopathic SCLE all occurred in women (aged 66–74 years). There were no significant differences in the autoantibody profiles between patients with malignancy and the overall SCLE cohort. Malignancies were detected, on average, 41 days (range 11–74) after the diagnosis of SCLE. Subtypes of cancer diagnosed post-SCLE were lung (n = 4, all current or ex-smokers) and colorectal (n = 1, a never smoker). In four of these cases, investigation for malignancy was specifically advised by dermatology. This is the first reported retrospective study to explore the under-recognized association between SCLE and malignancy. Clinicians should be aware of the potential paraneoplastic nature of SCLE, especially in the context of risk factors such as smoking history and an older age profile.
P99 Skin disease in people living with HIV in the UK: a retrospective analysis
Authors: McCluskey Jamie , Hickling Louis , Iwuji, Collins , Chandler David
Published: June 2023

The spectrum of skin disease associated with advanced HIV infection is well described and can vary between countries, potentially as a result of genetic differences and access to antiretroviral treatment (ART). Effective ART has modified the skin manifestations of HIV in the modern era. The aim of this study was to characterize the profile of skin disease in a UK-based population of people living with HIV (PLHIV). A retrospective review of inpatient admission records was conducted of all patients admitted to a tertiary hospital between June 2020 and October 2022. Data were collected using a standardized data extraction form in Microsoft Excel. Descriptive analysis was undertaken within Excel. Ninety-seven patients were identified (median age 55 years), of whom 82 (85%) were male. Median duration of HIV infection was 15 years [interquartile range (IQR) 8.66–19.58], with a median duration on ART of 9 years (IQR 3–16). Fourteen patients were ART naïve and were diagnosed as being HIV positive on admission. Median CD4 count at presentation was 351 × 106 cells L−1 (IQR 136–579). Fifty-five patients presented with a single dermatological condition, 30 presented with 2 and 10 presented with 3. Of the conditions identified, 48% were skin infections, 18% were skin tumours, 10% were inflammatory dermatoses and 2.8% were drug reactions. In the remaining 21%, the diagnosis was unknown; this included rashes (44%), skin lesions (33%) and ulcers (22%). The most common dermatological condition identified was cellulitis (n = 18; 19%). Of the infections seen, 46% were primary bacterial infections, 27% were primary viral infections, 22% were primary fungal, 3% were primary parasitic and 1% were systemic bacterial infection with skin involvement. Ten per cent of patients presented with Kaposi sarcoma, an AIDS-defining illness. Of the 97 patients, 27% presented with advanced HIV (CD4 < 200 × 106 cells L−1). The most common conditions in this group were oral candidiasis (30%), cellulitis (15%), seborrhoeic dermatitis (15%) and Kaposi sarcoma (15%). Bacterial skin infections were the most common dermatological conditions overall, while oral candidiasis was the most common condition in those with advanced HIV. The causes of almost one-quarter of dermatological presentations were unknown during inpatient admission, highlighting the importance of expert dermatological input. Further work is needed to validate these findings in a larger population of PLHIV, including those managed in an outpatient setting.
P103 A retrospective observational study of toxic epidermal necrolysis at a tertiary referral centre from 2015 to 2022
Authors: Watson Nicola , Best Katie , Meggitt Simon , Hampton Phil
Published: June 2023

Toxic epidermal necrolysis (TEN) is associated with high mortality and morbidity. Owing to a lack of robust evidence, treatment guidelines are ambiguous and clinicians must use discretion in management decisions, specifically with regard to the use and choice of systemic agents, including immunosuppressants. We present a retrospective study of cases referred to a tertiary referral centre between 2015 and 2022. Cases were identified using histopathology coding and a database compiled by clinicians. Forty cases were categorized as follows: TEN (n = 12); Stevens–Johnson syndrome (SJS)/TEN overlap (n = 5); SJS (n = 5); unclear (n = 9); insufficient information (n = 5) and others [n = 9 (lupus, n = 4; erythema multiforme major, n = 3; burn, n = 1; recurrent erythema multiforme, n = 1)]. The median age of patients with TEN was 66 [interquartile range (IQR) 53.3–74; 33% men, 67% women]. The median percentage body surface area of epidermal loss was 40% (n = 8; IQR 30–70). Forty-two per cent of patients had an underlying malignancy. Implicated medications included nivolumab/ipilimumab (n = 2), co-trimoxazole (n = 2), carbamazepine (n = 1) and proton pump inhibitors (n = 3). Sixty-seven per cent of patients with TEN were managed by the burns centre, with a further 17% admitted to the intensive care unit. One patient presented directly to the dermatology team and 58% were transferred from other hospitals. The median time from the documented onset of rash to transfer to specialist care was 5 days (IQR 2.8–11.5). Thirty-three per cent of patients were given immunosuppression (intravenous methylprednisolone). The median duration of admission was 14 days (IQR 7.5–21.5). Fifty-eight per cent of patients (n = 7) survived. None of the five patients who died had received immunosuppression. The median time from onset of rash to receiving specialist care was 3.5 days for those who survived (n = 4) vs. 10 days for those who did not (n = 3; P = 0.03). Thirty-three per cent of patients had documented chronic complications (severe ophthalmic sequelae, n = 2; circumcision for phimosis, n = 1). This study was limited by the retrospective collection of data and the method used to identify cases. The current evidence for the treatment of TEN is primarily derived from small case series that often combine heterogeneous cases of TEN, SJS/TEN overlap and SJS. This is highly problematic as the risk–benefit dynamic varies greatly between patients with SJS, who have an excellent prognosis without treatment, and patients with TEN with a high associated mortality, who potentially have more to gain from immunosuppression. Our data support the need for patients to access specialist care promptly, to allow for early consideration of immunosuppression. Future research should focus on effective treatments for reducing mortality in cases of TEN specifically.
BH01 Experiences of nail pathology seen within a specialist clinic over 1 year
Authors: Wolfe Charlotte , Ye Christina , Li Ling , Yiu Daniel , Laheru Dhruvkumar
Published: June 2023

Nail disorders comprise an important subset of dermatological conditions that can pose diagnostic and therapeutic challenges for clinicians. The pathology can be limited to the nail or reflect wider systemic processes. We present a single-centre cross-sectional study on nail conditions seen within a specialist nail clinic over a 12-month period. Demographic and clinical data were collected retrospectively using electronic patient records and analysed using a coding framework. In total, 62 new patients, including 12 paediatric patients, were seen between August 2021 and July 2022. The average patient age was 41 years. Only four patients were seen twice. In terms of ethnicity, 28 patients were White, six were Asian, two were Black and one patient was of mixed race. Ethnicity data were unavailable for 25 patients. Although most patients presented with a single pathology (76%), 24% presented with two or more pathologies. In total, 79 nail diagnoses were given for 62 patients; aetiological categories included infection (onychomycosis, infection other), inflammatory, tumour, trauma, melanonychia, congenital, structural, systemic and idiopathic. Patients had fingernail involvement alone, toenail involvement alone or involvement of both sites. The most common pathologies seen were infection (other) and infection (onychomycosis), accounting for 33% of the conditions seen; melanonychia was next most frequently observed at 18%. Onychomycosis accounts for up to 40% of all nail diseases in the UK. In our nail clinic, onychomycosis consisted of 17.7% of diagnoses. Across Europe, the overall prevalence has been reported to be 23%. In France, the prevalence of onychomycosis is reported to be 20–30% within general practice and dermatology. The true incidence is difficult to assess due to the lack of large-scale studies. We may see fewer cases in secondary care due to the podiatry service available in the UK. The availability of podiatry professionals varies across the world and we believe this plays a role in the presentation of nail diseases to physician-led clinics. Our review here did not encompass UK 2-week-wait cancer referrals, which were accommodated with our consultant as soon as possible. Patients often present to our clinic due to diagnostic uncertainty, especially regarding linear melanonychia, which generates anxiety in primary care. Secondary complications such as nail dystrophy and toenail displacement are also frequent causes for referral. This review, although single centre and retrospective, is a comprehensive snapshot of nail pathology at a UK specialist centre and demonstrates the pathologies encountered in secondary care, helping to plan future services and direct both primary care and trainee teaching.
BH02 Online psychological support for patients with alopecia areata: an evaluation of available online psychological support material based on the National Centre for Complementary and Integrated Health guidelines
Authors: Lumley Rebecca , Asfour Leila , Montgomery Kerry
Published: June 2023

Alopecia areata is an autoimmune disorder causing nonscarring hair loss that is associated with significant psychological comorbidity (Macbeth AE, Holmes S, Harries M et al. The associated burden of mental health conditions in alopecia areata: a population-based study in UK primary care. Br J Dermatol 2022; 187:73–81). In addition to seeking psychological support from medical professionals, patients will often turn to online resources. In this study, we evaluated the range and quality of the online psychological support material available for patients with alopecia areata. A Google search was undertaken using private browsing on 5 June 2022, with several search terms: ‘alopecia areata online support group UK’, ‘alopecia support’ and ‘alopecia areata psychology’. The National Centre for Complementary and Integrated Health (NCCIH) guidelines for the evaluation of online resources were used. These guidelines assess information source and accuracy, funding, peer review status, linking policies and contemporaneity. Our search generated a total of 154 000 results. Advertisements, scientific articles, educational resources and duplicates were excluded, with nine resources included in the final analysis. Of the nine resources reviewed, three were specific for patients with alopecia areata, with the remaining resources focused on other types of hair loss. Six were authored or reviewed by dermatologists and seven had a documented peer review process of their content. One resource had no clear authorship and three had no clear peer review process. Nine of the resources were charity funded and one was a National Health Service resource. Four had been updated in the last 3 years and a further two within 5 years. All resources had clearly documented security and linking policies. All resources acknowledged the psychological impact of hair loss and eight had links to support groups or discussion forums. Only five had psychological support and advice on their website, with others only referring to the psychological burden and then signposting patients on to other sources for support. Only three of the resources referred to therapies such as cognitive behavioural therapy. The prevalence of mental health comorbidity in alopecia areata is high compared to the general population (Macbeth et al.). Our preliminary study has shown that the online psychological support available is lacking. With patients increasingly turning to the Internet for support and health information, there is an opportunity and need for development in this area.
BH05 Successful treatment of acrodermatitis continua of Hallopeau with methotrexate
Authors: Bala Laksha , Hussain Khawar , Phillips Derrick
Published: June 2023

A 39-year-old woman was referred with a 3-month history of brittle nails, painful fingertips and psoriasiform plaques affecting her torso and limbs. She had a past medical history of macrocytic anaemia secondary to dietary B12 and folate deficiencies, which required inpatient transfusions. She had no previous dermatological concerns, and there was no history of infection or trauma to the affected sites. On examination of her hands and feet, there was evidence of nailbed pustulation, subungual hyperkeratosis, onychodystrophy, anonychia of multiple nails and dactylitis, consistent with acrodermatitis continua of Hallopeau (ACH) with associated psoriasis. At diagnosis, the patient’s Dermatology Life Quality Index (DLQI) was 16, she had a Psoriasis Area and Severity Index (PASI) score of 18 and a Psoriasis Epidemiology Screening Tool (PEST) score of 4. Nail fungal culture was negative. Plain radiographs of the hands and feet demonstrated a flexion deformity of the left fifth finger distal interphalangeal joint, with otherwise normal bone texture, alignment and joint spaces. The patient was initially treated with potent topical corticosteroids and vitamin D analogues, with little improvement. The patient was commenced on 15 mg subcutaneous methotrexate (MTX), with close monitoring of serum and red cell folate given her background of folate deficiency, which was being actively replaced. Within 3 months of starting MTX monotherapy, the patient’s hands had dramatically improved with skin and fingernail changes largely resolved, and an improvement in manual dexterity (DLQI 11, PASI 3, PEST 5). MTX was increased to 20 mg once weekly and the patient was also started on sulfasalazine 500 mg twice daily by her rheumatologist for psoriatic arthritis. ACH is a chronic pustular eruption initially affecting distal phalanges with gradual proximal progression and the potential development of generalized pustular psoriasis. ACH is considered a variant of palmoplantar pustulosis, commonly affecting adult females with localized trauma and infection as possible triggers. Given the rarity of ACH, the evidence base for therapy is limited to case reports and series, with no standardized treatment guidelines. Topical therapies include corticosteroids, calcineurin inhibitors and vitamin D analogues. Local phototherapy and systemic therapy with acitretin, MTX and ciclosporin have been described, with wide-ranging results. In severe cases such as this, patients typically receive biologic therapy, with variable responses reported with tumour necrosis factor-α inhibitors, anti-interleukin (IL)-6 therapy, and anti-IL-12/IL-23 and anti-IL-17 therapy. We present a rare case of severe ACH and psoriasis, treated with MTX monotherapy, which was not only clinically effective but also cost-effective.
BI13 (P99) Skin disease in people living with HIV in the UK: a retrospective analysis
Authors: McCluskey Jamie , Hickling Louis , Iwuji Collins , Chandler David
Published: June 2023

The spectrum of skin disease associated with advanced HIV infection is well described and can vary between countries, potentially as a result of genetic differences and access to antiretroviral treatment (ART). Effective ART has modified the skin manifestations of HIV in the modern era. The aim of this study was to characterize the profile of skin disease in a UK-based population of people living with HIV (PLHIV). A retrospective review of inpatient admission records was conducted for all patients admitted to a tertiary hospital between June 2020 and October 2022. Data were collected using a standardized data extraction form in Microsoft Excel. Descriptive analysis was undertaken within Excel. Ninety-seven patients were identified (median age 55 years), of whom 82 (85%) were male. Median duration of HIV infection was 15 years [interquartile range (IQR) 8.66–19.58], with a median duration on ART of 9 years (IQR 3–16). Fourteen patients were ART naïve and were diagnosed as being HIV positive on admission. Median CD4 count at presentation was 351 × 106 cells L–1 (IQR 136–579). Fifty-five patients presented with a single dermatological condition, 30 presented with two and 10 presented with three. Of the conditions identified, 48% were skin infections, 18% were skin tumours, 10% were inflammatory dermatoses and 2.8% were drug reactions. In the remaining 21%, the diagnosis was unknown; this included rashes (44%), skin lesions (33%) and ulcers (22%). The most common dermatological condition identified was cellulitis (n = 18; 19%). Of the infections seen, 46% were primary bacterial infections, 27% were primary viral infections, 22% were primary fungal, 3% were primary parasitic and 1% were systemic bacterial infection with skin involvement. Ten per cent of patients presented with Kaposi sarcoma, an AIDS-defining illness. Of the 97 patients, 27% presented with advanced HIV (CD4 < 200 × 106 cells L–1). The most common conditions in this group were oral candidiasis (30%), cellulitis (15%), seborrhoeic dermatitis (15%) and Kaposi sarcoma (15%). Bacterial skin infections were the most common dermatological conditions overall, while oral candidiasis was the most common condition in those with advanced HIV. The causes of almost one-quarter of dermatological presentations were unknown during inpatient admission, highlighting the importance of expert dermatological input. Further work is needed to validate these findings in a larger population of PLHIV, including those managed in an outpatient setting.
BI28 Phaeohyphomycosis in the immunosuppressed patients: the challenges of treatment
Authors: Khan Farishta , Jayaprakash Sindoora , Verpetinske Indre
Published: June 2023

Phaeohyphomycosis is a group of multisystem mycoses owed to heterogeneous organisms called ‘dematiaceous’ or ‘melanized’ fungi. The presence of melanin in their cell walls is a distinguishing feature, likely to be acting as a virulence factor. Widely abundant in the environment, these organisms commonly infect humans through traumatic inoculation and have many clinical forms of presentation, including cutaneous, subcutaneous, systemic, and rarely disseminated. Both immunocompetent and immunocompromised hosts are affected. Diagnosis of the cutaneous infection is primarily reliant on histology and culture; treatment is not standardized and is based on clinical experience. We report a case of a 39-year-old man who presented to the dermatology clinic with ‘lumps’ on his lower limbs. His background included poorly controlled hypertension and diabetes mellitus type 2 leading to nephropathy and necessitating a renal transplant, which failed. A 5-year period of dialysis involving a sedentary lifestyle was followed by a repeat renal transplant during which time he developed multiple warty-looking nodules of varying size, with pseudomilia cysts on his lower limbs in addition to stasis changes. Histology reported a pigmented mould infection (probably phaeohyphomycosis), and there was no growth on culture. The patient was trialled on two azole antifungals at different times, but on both occasions, he dived into congestive cardiac failure needing intensive care unit admissions. Reducing immunosuppression therapy was difficult considering his previous failed renal transplant. Owing to the extent and multiplicity of the lesions on the background of immunosuppression, the surgical treatment option poses significant risks. Currently, he is managed on topical treatment with some stabilization of the lesions; however, it is unclear how these will progress in the future. Although uncommon, the number of patients with phaeohyphomycosis has increased due to awareness of melanized fungi on a background of the global COVID-19 pandemic, with SARS-CoV-2, and the use of immunosuppressive agents such as glucocorticoid therapy increasing the risk of infections of deep mycosis. Treatment for phaeohyphomycosis has largely been surgical excision for localized lesions in addition to oral antifungals. Our case highlights that, in transplant patients, therapeutics are difficult, with life-threatening complications from oral antifungals and the risks of surgical intervention including ulceration, bleeding and infections. In addition, the cosmetic appearance of the prevalent noticeable lesions for a relatively young patient is also significant and patient counselling is vital, especially when treatment options are minimal.
BI29 Crusted scabies: a complicated course in a renal transplant recipient
Authors: Duff Eimear , Lyons Daniel , Eustace Karen , Collins Sinead
Published: June 2023

A 55-year-old man of Nigerian origin was admitted with a 3-month history of a generalized rash that was intensely pruritic at night. He had received a renal transplant 1 year prior for end-stage kidney disease in the context of hypertensive nephropathy. His maintenance immunosuppressive regimen includes mycophenolate mofetil, tacrolimus and prednisolone. No household contacts were affected by itch. He had been treated with the topical scabicide permethrin cream in the community, resulting in a painful fissuring of the lower limbs that prompted presentation to the emergency department. Full skin examination revealed an extensive scaling eruption, with profuse skin shedding and lichenified fissuring of the lower limbs. There were also loosely adherent, grey, hyperkeratotic scaling plaques widely extending from the genitals to mid-thigh and posterior upper limbs, with involvement of the ear lobes. There was relative sparing of the acral areas. He was initially treated empirically with oral ivermectin, oral flucloxacillin and topical clobetasol propionate ointment and paraffin gel. A full blood count revealed a prominent eosinophilia. A punch biopsy later revealed a number of scabies mites. He was prescribed ivermectin as per the Centers for Disease Control guidelines for crusted scabies in immunosuppressed populations with oral ivermectin 200 μg kg–1 on days 1, 2, 8, 9, 15, 22 and 29. Supply issues in the community delayed his treatment course. Further topical antiscabietic therapy was deferred until tolerated. He was subsequently re-admitted with methicillin-sensitive Staphylococcus aureus bacteraemia with pyelonephritis of the transplant kidney. The prescribed treatment regime of oral ivermectin, a topical keratolytic cream and topical permethrin cream daily for 7 days was completed as an inpatient. This yielded complete resolution of his crusted lesions. He responded well to a prolonged course of intravenous flucloxacillin. This case illustrates the challenge of diagnosing scabies in richly pigmented skin, as well in the immunosuppressed host (in this case due to defective T-cell responses). Maintaining a high index of suspicion is essential in the context of unexplained itch in the immunosuppressed as they may present with atypical presentations. Such vigilance will improve the recognition and management of this uncommon, potentially life-threatening infectious complication of crusted scabies in the transplant population (Wang MK, Chin-Yee B, Lo CKL et al. Crusted scabies in a renal transplant recipient treated with daily ivermectin: a case report and literature review. Transpl Infect Dis 2019; 21:e13077).
CD07 Corticosteroids: a complex case of friend and foe
Authors: Fleming Sarah , Galimova Tatiana , Cunnimgham Louise , Eustace Karen
Published: June 2023

Hypersensitivity reactions to corticosteroids, either immediate or delayed, represent a clinical paradox as one would not expect such reactions to compounds with anti-inflammatory and immunomodulatory effects. We present the case of a 67-year-old patient referred to our service with three episodes of a delayed hypersensitivity reaction to steroids. The first episode occurred in 2016 when the patient was treated for a chest infection with amoxicillin and 5-mg prednisolone. Following 1 day of treatment, the patient developed a widespread erythematous rash. The patient remained systemically well, and the rash resolved over 3 weeks. Subsequently, the patient tolerated penicillin with no issues. In April 2019, following a bupivacaine and triamcinolone steroid injection to the shoulder and back for pain management, the patient developed a widespread erythematous rash. The patient denied any blistering or peeling of the skin and was systemically well. This rash took ∼3 weeks to settle. In August 2019, the patient had a dexamethasone injection to her back and subsequently developed a widespread erythematous pruritic rash. On this occasion, the patient reported symptoms of nausea and headache. The patient has avoided all steroids since 2019 and has developed no rashes. The patient had a negative skin prick test to bupivacaine under the care of immunology. Patch testing results showed positivity to 10/13 compounds tested in the corticosteroid series (Table 1). The patient had a negative patch test result to tixocortol-21-pivalate (0.1%) and to hydrocortisone-21-acetate (1%). In the fragrance series, the patient tested positive to one compound, Santalum album oil (sandalwood oil) 2%. Corticosteroids are classified into four groups (A, B, C and D), with the last subdivided into D1 and D2. A further classification proposed divides corticosteroids into three groups based on their structural characteristics. Allergic reactions to corticosteroids have been reported, with an estimated prevalence of 0.1–0.3%, with contact dermatitis to corticosteroids having a higher frequency (0.5–5%). Although not life-threatening, contact allergy to corticosteroids can have significant impacts on quality of life and on treatment.Table 1Corticosteroid series patch testing resultsHapten/compound%48 h96 hBudesonide0.01+/–+++Betamethasone-17-valerate1++Triamcinolone acetonide1++Tixocortol-21-pivalate0.1Alclometasone-17,21-dipropionate1+/–Clobetasol-17-propionate1++Dexamethasone-21-phosphate disodium salt1+Hydrocortisone-17-butyrate+/–+++Desoximetasone1+++Betamethasone-17,21-dipropionate1+++Methylprednisolone aceponate1+++Corticosteroid mix2.1++++Hydrocortisone-21-acetate1
CD10 (P75) Are ‘hypoallergenic’ personal care products truly safe?
Authors: Hiranput Siwaporn , Smith Lucy , Yesudian Paul Devakar
Published: June 2023

It is estimated that one-fifth of the general population may have allergic contact dermatitis (ACD) to common environmental allergens. Skincare companies are increasingly advertising their products as ‘hypoallergenic’, targeting consumers who seek personal care products (PCPs) that are less likely to cause an allergic reaction. However, there are no Food and Drug Administration standards to regulate the use of the term hypoallergenic, allowing manufacturers to use the term freely. We evaluated PCPs marketed as hypoallergenic from two health and beauty retailers in the UK for the presence of allergens in the British Society of Cutaneous Allergy (BSCA) baseline series. Product and ingredient lists were obtained from www.boots.com and www.superdrug.com in November 2022 using the term hypoallergenic in the search box. PCPs without the term hypoallergenic in the product description, unrelated products (plasters, jewellery, sanitary towels, tampons, clothing and facial brushes) and duplicates (same products in different sizes) were excluded. In total, 208 PCPs met the inclusion criteria: 47 (22.6%) were rinse-off and 161 (77.4%) were leave-on products. At least one substance from the BSCA baseline series was an ingredient in 79 (38.0%) PCPs. Of these, 54 (26.0%) had one potential allergen, 21 (10.2%) had two, and four (1.9%) had three potential allergens from the series. The frequently encountered allergens were cetearyl alcohol and paraben mix, found in 42 (20.4%) and 37 (18.0%) of products, respectively. Other BSCA baseline series allergens identified in PCPs included 2-bromo-2-nitropropane-1,3-diol, lanolin, decyl glucoside, diazolidinyl urea, methylisothiazolinone, limonene and linalool. In addition, PCPs had chemicals that were related to and may cross-react with allergens in the BSCA baseline series. Parfum/fragrance, which can crossreact with fragrance mix I and II, was found in 85 (41.3%) PCPs. Sodium benzoate and/or benzoic acid, often used as preservatives in PCPs, were found in 66 (32.0%) products. Forty (19.4%) PCPs had ingredients that belong to the Asteraceae family and therefore may trigger an ACD in those with positive reaction to Compositae and/or sesquiterpene lactone mix. Twenty-three (11.2%) PCPs contained cetyl alcohol and/or stearyl alcohol, the two major components of cetearyl alcohol. Overall, 153 (74.3%) of 206 PCPs marketed as hypoallergenic contained BSCA baseline series allergens or ingredients that may cross-react with them. This highlights the need to increase public awareness and education about the potential dangers of purchasing ‘hypoallergenic’ PCPs.