bluuebunny/crossref_metadata_2025 huggingface dataset:
PA06 Impact of clinical pharmacist-led isotretinoin management and acne care education at a multispecialty clinic
Authors: Tran Huynh Wynn , Le Phuong
Published: June 2023

Isotretinoin, an oral retinoid derived from vitamin A, is one of the most effective medications in the treatment of severe acne vulgaris. However, it carries serious risks due to the teratogenic nature of the drug. The iPledge national programme in the USA has been founded to reduce and prevent adverse isotretinoin reactions and complications by ensuring its safe use by patients. Owing to the strict monitoring parameters of isotretinoin, an increased workload is placed on prescribing physicians for accurate and timely iPledge authorization, comprehensive counselling, laboratory testing and many patient follow-up visits. The most commonly reported reasons for delay were iPledge-related, including issues navigating the iPledge website, missed pick-up windows, and missed or delayed doctor appointments or laboratory tests. To remedy the difficulties with isotretinoin monitoring, physicians can look to clinical pharmacists as a valuable asset to their practice. Because clinical pharmacists are well trained in isotretinoin dispensing and iPledge regulation and consultation, they can play a crucial role in the management and education of patients with severe acne vulgaris. This retrospective, longitudinal case study takes place at a multispeciality clinic with internal medicine, rheumatology and dermatology. At this multispecialty clinic, a clinical pharmacist will be integrated into the practice with complete patient appointments and isotretinoin follow-ups under the training and direction of a dermatological specialist. The initial evaluation, diagnosis and prescribing of isotretinoin will be completed by the physician. The clinical pharmacist will follow-up the patients in subsequent visits in conjunction with the physician. The study population is approximately 50 patients with existing diagnoses of severe acne vulgaris. The inclusion criteria will include patients with acne who complete a clinical pharmacist visit for isotretinoin acne treatment from September 2022 to March 2023. At each follow-up clinical pharmacist visit, patients receive management and counselling on medications, a review of laboratory values, iPledge verification, and monitoring of symptoms and quality of life. Primary outcomes are patient symptoms and quality of life, acne grade and severity and side-effects; secondary outcomes are navigation of the iPledge website, number of misses in pick-up windows and doctor appointment adherence. The preliminary results showed significant improvement in primary and secondary outcomes. Patient acne grade decreased, while satisfaction increased; there was also a decreased risk of missed pick-up windows and improved doctor appointment adherence compared with the national standard. In addition, a clinical pharmacist-led iPledge programme can substantially reduce the time required for administrative work on managing isotretinoin while maintaining the same quality of care for patients with severe acne.
PA10 You and Your Skin: developing and trialling a new history-taking aid for psychological wellbeing in children and young people with skin conditions
Authors: Ali Rukshana , Choong Cheryl , Ravenscroft Jane , McPherson Tess , Baron Susannah
Published: June 2023

The mental health burden in children and young people (CYP) living with skin conditions is profound and well documented. There is a lack of integrated psychology/psychiatry provision within paediatric dermatology departments, and dermatologists can struggle to explore psychological wellbeing as part of their clinic consultations due to limited time and/or a lack of confidence and/or training. The British Society for Paediatric and Adolescent Dermatology formed a working group to address the mental health needs of CYP presenting with skin conditions. A multidisciplinary consensus group was formed to assess evidence and develop appropriate guidance. A systematic review found that no single psychological measure or patient-related outcome measure (PROM) adequately captures the psychological burden and impact of living with a skin condition. Patient feedback was clear that PROMs can be less useful than an appropriate clinical consultation. This identified a need for an appropriate clinical tool to help explore CYP psychological wellbeing as part of dermatology consultations: You and Your Skin (YAYS) was developed as a self-completed history-taking aid for CYP > 8 years old and a parent/carer for those < 8 years old. The YAYS was created iteratively using adapted validated and clinically relevant domains from the Children’s Dermatology Quality of Life Questionnaire, the Teenage Quality of Life Questionnaire, the British Association of Dermatologists Acne 3 questions and the Patient Health Questionnaire-9, including self-harm and risk. Questions explore how CYP feel about their skin today and how their skin condition has affected their daily life, caused embarrassment and bullying, and impacted on sleep and mood, and whether they had any thoughts of life not being worth living. The YAYS was co-developed with patients, parents/carers and an external expert stakeholder consensus group (dermatologists, psychologists, psychiatrists, general practitioners, nurse specialists and patient support groups) with revisions done according to feedback on the usability, accessibility and appropriateness of questions. This process has involved 12 revisions of YAYS for CYP and eight revisions of the YAYS parent/carer form, and has been trialled in three paediatric dermatology centres in London, Oxford and Nottingham with 354 CYP and 29 parent/carer forms completed to date. The YAYS development process, findings from YAYS and feedback will be presented. The purpose of YAYS is to enable CYP to raise issues and guide clinicians in evaluation and discussion of mental health concerns in CYP, collaboratively as part of their clinic appointment. Feedback has been very positive from CYP who feel empowered that the impact of their skin disease on all areas of wellbeing can be addressed.
PA12 A case of pustular psoriasis in epidermolytic ichthyosis: coincidence or common pathway?
Authors: Lynch Fiona , Sadlier Muriel , Irvine Alan
Published: June 2023

An 8-year-old boy with epidermolytic ichthyosis (EI) due to a heterozygous KRT1 mutation presented with a striking bullous skin eruption. Microbiological swabs were sent, and oral antibiotics were prescribed for suspected bullous impetigo. He deteriorated clinically, developing a fever and more extensive pustular rash reminiscent of generalized pustular psoriasis (GPP). Skin biopsies from two distinct cutaneous sites revealed histology strongly supportive of pustular psoriasis. Oral ciclosporin was commenced in addition to intensive topical emollient therapy. Following widespread desquamation, the pustular eruption fully resolved. Recurrence upon weaning of ciclosporin necessitated the introduction of ustekinumab. The rash remains controlled on this therapy. The EI is caused by heterozygous mutations in KRT1 or KRT10, and presents at birth with erythroderma and widespread skin denudation. The erythema and skin fragility abate in early childhood, giving way to prominent hyperkeratosis. Severe palmoplantar keratoderma is seen in those with KRT1 mutations. The GPP is a rare but life-threatening condition characterized by sterile pustules with or without systemic involvement. Interleukin (IL)-36-mediated inflammatory signalling plays a pathogenic role, as evidenced by loss of function mutations in IL36RN, which encodes an IL-36 receptor antagonist (Marrakchi S, Guigue P, Renshaw BR et al. Interleukin-36-receptor antagonist deficiency and generalized pustular psoriasis. N Engl J Med 2011; 365:620–8), and the efficacy of IL-36 receptor inhibitor spesolimab in a recent phase II trial. Both EI and GPP are rare, and the confluence of these entities in this case is striking. Four other cases in the literature describe a GPP-like eruption in patients with congenital ichthyoses. The coexistence of these conditions might be explained by their immunological profiles. Studies of the skin of patients with congenital ichthyoses have shown immune dysregulation with T helper 17/IL-23 skewing, and upregulation of associated inflammatory cytokines, including IL-36γ. The latter encodes for an IL-36 receptor agonist (Paller AS, Renert-Yuval Y, Suprun M et al. An IL-17-dominant immune profile is shared across the major orphan forms of ichthyosis. J Allergy Clin Immunol 2017; 139:152–65). Thus, increased IL-36 receptor agonist activity in congenital ichthyosis could theoretically lead to GPP in genetically predisposed individuals with already upregulated IL-36 receptor-mediated signalling.
PA15 Becker naevus syndrome associated with a mosaic pathogenic variant in ACTB
Authors: Bali Radhika , Hussain Khawar , Roberts Nerys , Laguda Bisola
Published: June 2023

A 15-year-old girl presented with an 8-year history of a gradually enlarging, irregular, nonconfluent hyperpigmented patch on her left flank. The lesion demonstrated an area of increased hair growth, did not cross the midline and was mildly pruritic but otherwise asymptomatic. Another pigmented patch, present since birth, was also noted on her right lower back and was consistent with a café-au-lait macule. Medical history included a marfanoid phenotype with musculoskeletal complications including scoliosis and joint hypermobility, for which she was under the care of the orthopaedic team for bilateral patellar instability associated with recurrent dislocation. She was also noted to have increased skin laxity, mild pectus excavatum, mitral valve prolapse and symptomatic tachyarrhythmias. She was born at term, to nonconsanguineous parents, with no postnatal developmental concerns. There was a family history of an older brother with significant scoliosis and hip dysplasia requiring hip replacements, developing from the age of 14 years. Genetic testing was negative for FBN1 and five other genes associated with Marfan syndrome. Thyroid function and bone profile were normal. Menarche occurred at 11 years of age, and a full hormone profile was normal except for a mildly raised prolactin level, deemed to be a normal variant in puberty. Abdominal and pelvic ultrasounds were normal. Skin biopsy from the left flank revealed orthokeratosis, irregular elongation of rete ridges and sparse perivascular chronic inflammation in the superficial dermis. Next-generation sequencing and droplet digital polymerase chain reaction from DNA extracted from skin revealed de novo mosaic pathogenic variants in ACTB, which encodes β-actin, an intracellular protein involved in cell migration, signalling and proliferation. Recurrent mosaic variants in ACTB have previously been associated with 61% of Becker naevi and one case of Becker naevus syndrome in one study (Cai ED, Sun BK, Chian A et al. Postzygotic mutations in beta-actin are associated with Becker’s nevus and Becker’s Nevus syndrome. J Invest Dermatol 2017; 137:1795–8), as well as congenital smooth muscle hamartomas and odontomaxillary dysplasia. Our patient had cutaneous and extracutaneous features suggestive of Becker naevus syndrome. This rare syndrome predominantly involves skeletal and soft tissue abnormalities, with breast hypoplasia most frequently reported. Notable features here include a café-au-lait macule, scoliosis and pectus excavatum. This case highlights the value of DNA analysis from skin in confirming a diagnosis, after 9 years of presentation to paediatric services. Given the heterogeneous extracutaneous phenotypes, there are also important implications for counselling and screening of associated conditions.
PA26 Paediatric atopic dermatitis: correlation between Eczema Area Severity Index, quality of life and visual analogue scale severity scores reported by children and their parents, and in different age groups
Authors: Sambi Pavan , Warburton Katharine , Montgomery Rachel , Thompson Mia , Majeethia Parisha , Clark Sheila
Published: June 2023

Atopic dermatitis (AD) often has a significant impact on the quality of life (QoL) of those affected and their families. Validated QoL and visual analogue scales (VAS) are widely used in dermatology to measure the impact of this common disease. As part of a larger prospective study, we subanalysed data to look at the correlation between Eczema Area and Severity Index (EASI) score, three different QoL scores and parental/child VAS scores for overall severity, itch and sleep disturbance. Data were analysed from 68 paediatric patients with AD (42 males, 26 females), aged 4–16 years (mean 10 years, 0 months). Patient age groups were subdivided into 4–8 years (n = 17), 8–12 years (n = 25) and 12–16 years (n = 26). Scores for EASI, Children’s Dermatology Life Quality Index (CDLQI), Patient Oriented Eczema Measure (POEM) and Dermatitis Family Impact questionnaire (DFI) were measured, and VAS scores (0–10) were assessed for overall severity, itch and sleep loss. The mean EASI score for the cohort was 18.3, and comparable for all age groups: 4–8 years (17.6), 8–12 years (18.1) and 12–16 years (19.0). The CDLQI correlated with DFI (r = 0.72), POEM (r = 0.66) and overall VAS severity scores (r = 0.61). Further analysis by age group showed CDLQI correlated with POEM and DFI most strongly in younger age groups (4–8 years: POEM r = 0.86; DFI r = 0.77; 8–12 years: POEM r = 0.72; DFI r = 0.81) compared with older children aged (12–16 years: POEM r = 0.41; DFI r = 0.53). The CDLQI and VAS overall severity scores correlated consistently across age groups (4–8 years, r = 0.59; 8–12 years, r = 0.67; 12–16 years, r = 0.66). By comparing EASI with CDLQI scores, moderate correlation was found between the age groups (4–8 years, r = 0.39; 8–12 years, r = 0.53; 12–16 years, r = 0.46). Comparing EASI with the three VAS severity scores, we found poor correlation between EASI score and overall severity score (r = 0.24). This was most marked in the 4–8 years group (n = 17, r = 0.04) vs. the 8–12 years group (n = 25, r = 0.27) and 12–16 years group (n = 22, r = 0.33). Similarly, there was poor correlation between EASI and sleep loss score (r = 0.21) and itch score (r = 0.35) across all age groups. In our study, all of the existing validated QoL scores above correlated well with each other and across different age groups. The CDLQI and VAS severity scores also correlated consistently at all ages. There was poor correlation between EASI and VAS severity scores. This was more apparent in younger age groups, implying a high degree of caregiver distress due to eczema in younger children. This may indicate that as children mature their own perception of eczema may diverge from the perceived parental disease severity/impact on the family.
PD02 Home daylight photodynamic therapy
Authors: O’Reilly Marese , Goodman Carol , Yule Susan , Lesar Andrea , Eadie Ewan , Ibbotson Sally
Published: June 2023

Actinic keratoses (AK) on the face and scalp are often extensive and are a major cause of morbidity and associated with increased risk of skin cancer. Field-directed treatment approaches, such as daylight photodynamic therapy (DPDT) are required, and this has been shown to be effective, well-tolerated and feasible in the UK between April and September. We have used DPDT since 2013, with good outcomes. Patient engagement indicated that convenience and tolerability were rated as highly as efficacy, and we therefore developed an entirely home-based approach ‘home DPDT (H-DPDT)’ in 2021. Working with an art-and-design student, we developed a fully recyclable home kit to enable patients to self-treat with H-DPDT entirely in their home environment. Patients were selected by a dermatologist and then received nurse-led training prior to treatment. In-person review after the second treatment was undertaken to assess response and decide if further treatment was needed, and telephone follow-up was undertaken after the first and third treatments. Final clinician review was undertaken 3–6 months after the last treatment. We reported on implementation in 2021 and introduced this into our routine PDT service options, and we now wish to report our findings from 2021–22. Seventeen patients (82% male) were treated in 2021–2022 for AK on the head and neck. Each patient completed an average of four (range 2–5) treatments. Clinical response was good (≥ 75% response) in nine of 15 (60%) patients assessed. Response was moderate in one (7%) patient (50–75% response) and the remaining five (33%) had a poor response (< 50% response). Treatment success correlated with grade of disease. Patients with more hyperkeratotic disease had poorer outcomes. In 2022, five patients responded to the routine daylight PDT questionnaire. Of these, two rated the H-DPDT as Excellent and the other three rated it as Good. Four patients stated that they had tried other AK treatments, two of which thought that H-PDT was better. One patient felt alternative treatments were more effective but they tolerated H-PDT better. Three of the five patients expressed a preference for H-DPDT for repeat treatment and would recommend it. This innovative H-DPDT service enables patients to self-treat in their home environment, and the initial results showed high rates of patient satisfaction. Treatment outcomes were better for those with milder disease, highlighting the need for careful patient selection and good surface preparation. As a proof of concept, H-DPDT is a feasible therapeutic option and empowers patients, but it may have more of a place in the treatment of milder AK disease, and further work to optimize this approach is indicated.
PD03 Afamelanotide reduces the ultraviolet radiation erythemal response soon after application in healthy volunteers with skin phototypes II–III
Authors: Griffin Liezel , Nucci Jessica , Bilbao Pilar , Rhodes Lesley , Farrar Mark
Published: June 2023

Afamelanotide is a potent α-melanocyte stimulating hormone analogue that binds to the melanocortin 1 receptor and, over time, promotes tanning, conferring systemic photoprotection. Afamelanotide also has antioxidant properties and may promote repair of ultraviolet (UV) radiation (UVR)-induced DNA damage. The objectives of this study were to examine the short-term impact of afamelanotide on DNA damage repair mechanisms, UVR erythema and melanogenic responses in healthy human skin following exposure to UVR. Healthy men and women (n = 10) volunteers aged 27–43 years (median 34) of skin phototypes II–III were recruited. Reflectance spectrophotometry was performed on six body sites (photoexposed and photoprotected) to assess skin pigmentation, and then a geometric series of erythemally weighted doses (7–80 mJ cm−2) of broadband UVB (∼60% UVB, 40% UVA; Philips TL12) was applied to unexposed upper buttock skin. After 24 h, the minimal erythema dose (MED) was assessed and erythema intensity (CIE a*) was measured at each dose site. A subcutaneous implant of afamelanotide 16 mg was administered; 5 days later, the same UVR dose series was applied to unexposed contralateral upper buttock skin. After 24 h, the MED was assessed and repeat skin reflectance measurements were performed. The overall UVR–erythema dose response (area under curve) showed a significant decrease post-afamelanotide (mean 3.5 vs. 2.7; P = 0.018). There was an apparent increase in the median MED post-afamelanotide (24.5 vs. 29.9 mJ cm−2; not statistically significant). Reflectance measurements showed skin lightness (CIE L*) significantly decreased at only one site (central forehead, from 63.0 to 61.0; P = 0.015), while determination of melanin density by reflectance at 420 and 400 nm showed a statistically significant increase in density at all sites except the right abdomen, with a mean overall increase from 2.5% to 2.9% (P = 0.001). Our results indicate that afamelanotide reduces the overall UVR–erythema dose response in healthy human skin shortly after administration, with a small increase in melanogenesis, suggesting other nonmelanogenic properties of this agent contribute to the erythema protection. Further investigation will examine whether enhanced repair of UVR-induced DNA damage plays a role.

Funding sources: research sponsored by CLINUVEL (UK) Ltd.
PD05 Investigating the course of atopic eczema up to 1 year following completion of narrowband ultraviolet B phototherapy
Authors: Jain Dimple , Bajaj Sonali , Desai Prachi , Wahie Shyamal
Published: June 2023

Narrowband UVB (NBUVB) is a recommended second-line treatment for moderate-to-severe atopic eczema unresponsive to adequate topical therapy, and is known to induce good short-term improvement of eczema severity (Reynolds NJ, Franklin V, Gray JC et al. NBUVB and broad-band ultraviolet A phototherapy in adult atopic eczema: a randomised controlled trial. Lancet 2001; 357:2012–16). However, it is unclear how adult patients fare with their eczema severity long after completion of a course of NBUVB. We aimed to investigate the severity of atopic eczema in adults, 1 year following the completion of NBUVB, using validated clinical activity measures. We hypothesized that, after 1 year, eczema severity would remain better than at baseline (prior to having NBUVB). We undertook a multicentre prospective observational study of adults with atopic eczema (as per Hanifin and Rajka criteria) prescribed NBUVB as part of their standard clinical care. Participants had moderate-to-severe disease, with a minimum objective SCORAD of 15 and minimum Investigator’s Global Assessment (IGA) of 3, and were resistant to at least one conventional treatment (e.g. potent topical steroid). Eczema severity was assessed by selected investigators using SCORAD and IGA. Assessments were made at baseline, at the end of NBUVB and at 4, 8 and 12 months after completion of NBUVB. We aimed to recruit 80 patients at the outset to provide us with about 25–30 patients for analysis at the 1 year post-NBUVB follow-up. Eighty patients (47 men, 33 women) with a mean age of 37 years (range 18–83) were recruited, with a baseline mean (SD) SCORAD of 39.2 (12.5). Forty-nine patients could not attend to complete NBUVB or the follow-up visits thereafter. Three patients had to stop NBUVB as their eczema flared. Mean baseline SCORAD of the 28 patients who completed the study was 41.3 (14.7), with the mean IGA being 3 (range 3–4; reflecting moderate to severe disease, respectively). Compared with baseline, mean SCORAD was significantly lower at the end of NBUVB [19.1 (13); P < 0.001] and at 4 months post-NBUVB [21.9 (11.9); P < 0.001]. Furthermore, compared with baseline, there was a sustained ongoing reduction of mean SCORAD at 8 months [22.6 (13.1); P < 0.001] and 12 months post-NBUVB [21.1 (14.8); P < 0.001]. Mean SCORAD at 1 year was not statistically significantly different to that on completion of NBUVB (P > 0.5). Change in IGA matched similar sustained improvement trends with SCORAD. These findings indicate that NBUVB may provide a long-lasting effect for patients who complete a course, helping to diminish their eczema severity to a more manageable level. These data can further inform consultations with patients, when outlining the approach of NBUVB for their care.
PD10 Objective evaluation of sunscreen in a patient with solar urticaria
Authors: Gajebasia Sareena , McMullan Alexandra , Patullo Laura , Eadie Ewan , Ibbotson Sally
Published: June 2023

Sunscreens are an important part of photoprotection for patients with photodermatoses, such as solar urticaria (SU). Despite long ultraviolet (UV)A and visible wavelength photosensitivity in many patients with SU, sunscreens can still be beneficial (Beattie PE, Dawe RS, Ibbotson SH, Ferguson J. Characteristics and prognosis of idiopathic solar urticaria: a cohort of 87 cases. Arch Dermatol 2003; 139:1149–54). However, unlike the objective assessment of photosensitivity by monochromator phototesting, formal evaluation of sunscreens’ effects is more challenging. We report a 32-year-old man with a 2-year history of immediate-onset photosensitivity, confirmed as SU on monochromator phototesting, with an action spectrum of UVB, UVA and visible light (305–460 nm). He had been using Nivea Sun SPF (sun protection factor) 50+ (Beiersdorf) and reported that this increased his tolerance of natural light from 10 to 60 min. Based on the sunscreen constituents, we were surprised to hear that it was so effective as there was no mineral constituent. Therefore, we evaluated his SU photosensitivity by UVA testing using a metal halide source [Honle UVASPOT 400 T; 24.09 mW cm−2; minimal urticaria dose (MUD) < 0.13 J cm−2] through his own sunscreen and, for comparison, Dundee Cream Beige (Tayside Pharmaceuticals) and LaRoche Posay Mineral One shade 01 (L’Oreal), both of which contain reflectant titanium dioxide. Three areas, measuring 15 × 10 cm, were marked out on his back and 0.15 mL of one sunscreen was applied to each. Each area was then irradiated through a Daavlin template using multiples (1×10) of the MUD and sites were observed for 30 min. As he was so severely photosensitive, none of the sunscreens affected the threshold MUD, but we noted delay in the induction of SU. Dundee Cream Beige offered minimal photoprotection, with urticaria occurring at 10 min vs. 5 min without sunscreen at 1 × MUD. LaRoche Posay SPF delayed the onset of SU to 30 min, and the reaction was less intense at 1 × MUD. However, the most marked effect was with his own Nivea SPF 50+. Urticaria induction was delayed to 30 min at 1 × MUD and was less intense, but it was also delayed to 15 min and less intense at a dose of 4 × MUD, confirming his impression that this sunscreen was of clinical benefit. We highlight this case to show how photodiagnostic testing can be employed to evaluate objectively the sunscreen effects in patients with photosensitivity. Conventionally, it is assumed that titanium dioxide-based products, such as the Dundee creams, are required in patients with longer UVA/visible light sensitivity, but with refinements in the development of new sunscreen products, this may not necessarily be the case.
PD12 An audit of the photodynamic therapy service at the Birmingham Skin Centre
Authors: Khan Taherah , Dalal Fatima , Thomson Michelle
Published: June 2023

Photodynamic therapy (PDT) is licensed in the UK for treating at least one nonmelanoma skin cancer and premalignant lesions. The PDT is a service offered at our centre but is anecdotally underutilized with no up-to-date outcome measures. The aim was to audit the PDT service at the Birmingham Skin Centre against the 2018 British Association of Dermatologists and British Photodermatology Group PDT guidelines, and make recommendations for improvement. Retrospective data were gathered on consecutive patients treated with topical PDT between 12 March 2019 and 28 August 2022 at the Birmingham Skin Centre and compared with the recommended audit points in the national guidelines. A clinician survey was conducted to assess service awareness, satisfaction and referral process. Thirty-four patients received topical PDT during the specified time period; two patients were excluded from data analysis as the last treatment fell within the 3-month assessment period (n = 32). Differentiation between ambulatory and standard PDT was not recorded. Treatment was licensed in all cases (n = 32): actinic keratosis (AK; n = 18), squamous cell carcinoma (SCC; n = 7) in situ, superficial basal cell carcinoma (BCC; n = 4), nodular BCC (n = 1) and other (n = 2). Clearance assessment at 3 months was recorded in 21 of 32 cases; accounting for this, the clearance rate for AK, SCC in situ and superficial BCC at 3 months after last treatment was 52% (n = 11/21; guideline recommendation ≥ 75%). Eleven of 32 patients treated for SCC in situ and superficial BCC within the data set were due 12-month clearance assessment. Four of 11 patients had clearance assessment recorded. Accounting for this, the clearance rate for SCC in situ and superficial BCC at 12 months after last treatment was 50% (n = 2/4; guideline recommendation ≥ 75%). No patient had an individual pain-management plan documented. Patient satisfaction of the service was recorded in 9% (n = 3/32) of cases; of these, 67% (n = 2/3) of patients were ‘very satisfied’ and 33% ‘satisfied’. Patient satisfaction of cosmetic result was recorded in one case as ‘excellent’. The PDT was a popular treatment method among the clinicians surveyed. Some clinicians asked for PDT-based teaching. The general consensus supported online referrals and documentation. The PDT is used for licensed indications and popular with clinicians in our department. Clearance rates at 3 (52%) and 12 (50%) months are below the national guideline recommendation of 75%. Limited documentation across audit points limits interpretation of clearance rates, patient satisfaction and adverse effects. We plan to implement a new standardized digital referral and documentation system to improve the service.
PS01 Prevalence of baseline anxiety and depression in patients attending a tertiary virtual acne service
Authors: Vincent Rosie , Hutchison Eliza , King Natalie , Shipley Debbie
Published: June 2023

Evidence suggests that the prevalence of depression and suicide in those with acne is higher than in the general population. There have also been case reports of suicide in patients taking isotretinoin for acne, although there is a lack of evidence to suggest a true causality. We know that many people with acne and acne scars struggle with impacts on emotions, social/daily activities, study, work and relationships. A prospective cohort study was undertaken, including 150 consecutive new patients in our acne clinics from 7 December 2021 to 5 July 2022 as part of a service evaluation. This project was registered with our local research and innovation team. We captured a snapshot of the demographics of our patients, including baseline Generalised Anxiety Disorder Assessments (GAD-7), Patient Health Questionnaires (PHQ-9) and pre-existing mental health problems. Mean age was 26 years (range 17–46). Sixty-four per cent of patients were women and 36% were men. Thirty per cent of patients reported a previous/current mental health problem, the most common being anxiety (19.3%) and depression (18.0%). The most common medications taken previously or currently were sertraline (4.0%) and propranolol (4.0%). Initial PHQ-9 scores ranged from 0 to 29 points: 49.1% had a score of ≥ 5; 29.1% a score of ≥ 10; and 18.2% a score of ≥ 15. As a comparison, in July–August 2021, the prevalence of depression (classified as a PHQ-8 of ≥ 10) was 32% in women and 20% in men aged 16–29 years in the UK. Rates of depression in our patient cohort were therefore similar to those in the general population in this age group. Interestingly, in the general population, 17% of those aged ≥ 16 years experienced depression during this time. This is significantly higher than the prepandemic prevalence rate of 10%. Initial GAD-7 scores in our cohort ranged from 0 to 21 points: 58.7% had a score of ≥ 5; 30.3% a score of ≥ 10; and 11.0% a score of ≥ 15. As a comparison, in September–October 2021, an estimated 28% of those 16–29 years old experienced moderate–severe anxiety in the UK (GAD-7 equivalent to ≥ 10), and the prevalence was higher in women. Anxiety levels were therefore similar in our cohort compared with the general population. The prevalence of anxiety and depression is high in young adults, which has increased with the COVID-19 pandemic, and the prevalence in our acne cohort is similar to that of the general population of a similar age. It remains that those with moderate–severe acne, regardless of what treatment is received, should be screened and monitored for anxiety and depression.
PS11 Dupilumab for moderate-to-severe atopic dermatitis: transformative changes in quality of life and low burden of treatment — a mixed-methods study
Authors: Porter Emma , O’Connor Cathal , Murphy Michelle
Published: June 2023

Moderate-to-severe atopic dermatitis (AD) has a significant impact on quality of life (QoL). The emergence of biologic agents has changed the treatment landscape for those with severe disease. Adult patients on biologic treatment for moderate-to-severe AD were invited to complete written questionnaires during scheduled clinical care. Questionnaires prompted reflection on QoL before and after treatment with dupilumab. Dermatology Life Quality Index (DLQI) and Burden of Treatment (BoT) scores were simultaneously assessed. Charts were retrospectively reviewed with respect to prior treatments, duration of biologic treatment, adverse events and clinical severity scoring. Statements were assessed qualitatively to identify common themes. Twenty-one patients participated in the study. The median age of participants was 38 years. Most (n = 14; 67%) were men. All patients were on subcutaneous dupilumab 300 mg, for a median duration of 10 months (range 3–61). Thirteen patients had trialled one immunosuppressant agent prior to commencing dupilumab, and five had failed two or more agents. Three had contraindications to immunosuppression. Median DLQI prior to commencing biologic treatment was 22 (range 9–30, SD 5.5), improving to 2 (range 0–11, SD 3.1) at the time of study participation. Median Eczema Area and Severity Index scores were 30.2 before dupilumab and 6.4 at the time of participation. Median BoT scores on dupilumab were low (range 0–3/10) across all domains, including burden related to emollients, topical steroids, injections, cost and scheduling of appointments. Themes identified in patients’ descriptions of prebiologics QoL included embarrassment, low self-esteem, anxiety, poor quality of social relationships, sleep disturbance, perceived loss of autonomy, loss of time, frustration with health services, high financial costs, negative childhood memories and hopelessness about the future. All patients described dramatic improvements on dupilumab. Themes included the disappearance of itch, confidence reacquisition, improved relationships, the ability to sleep, enjoyment of activities, freedom of clothing choice, greater free time, improved daily functioning, liberation from topical steroids and reclaiming control. Three patients (14%) reported disappointment with incomplete clearance, all relating to persisting facial dermatitis. Six patients (29%) reported side-effects on dupilumab, all described as mild eye symptoms, which did not affect QoL. This study highlights the profound impact of dupilumab therapy for moderate-to-severe AD on physical, psychological and social functioning. The transformative life changes described by patients on biologic treatment are compelling. Side-effects described were minor and more tolerable than with conventional immunomodulatory treatments, with a low burden of treatment in all patients.
PS13 Meeting the care needs of transgender patients in dermatology
Authors: O’Mahony Sarah , Tobin Anne Marie
Published: June 2023

Transgender persons are a diverse group whose gender identity differs from the sex recorded at birth. Some, but not all, choose to undergo medical treatment to align their physical appearance with their gender identity. It is important that clinicians understand the specific medical issues relevant to this population. Transgender individuals are at an increased risk of experiencing health inequalities, such as anxiety and depression, in addition to their own individual healthcare needs. It is important that staff in the healthcare setting are prepared to care for this population, to ensure the best patient outcomes. An understanding of transgender terminology and the experience of gender dysphoria is key. Improving the quality of care will reduce health disparities commonly faced by the transgender population. In our department, we have encountered difficulty in maintaining accurate gender identity data. We describe a case of a transgender woman attending the outpatient dermatology services for treatment of hidradenitis suppurativa and acne vulgaris. In addition to management of their dermatological conditions, there are issues with mislabelling in their chart. This includes the use of outdated labels and the inability to update their current forename from their original forename under their medical record number and on the patient information system. Electronic health records (EHRs) are the cornerstone in managing accurate patient information in hospitals. Healthcare institutions should have the capacity to collect accurate and up-to-date gender identity data, and gender-related demographic fields. However, the utility of gender identity fields in retrospectively identifying transgender patients, which is important for clinical care, as well as population health management, remains unknown. Clinic operations, EHRs, clinic culture, clinic environment, resource availability and staff education are all characteristics of healthcare clinics that can be improved to better facilitate high-quality dermatological care for transgender patients. In addition to basic demographic details, transgender individuals may face unique dermatological needs. Exogenous hormones affect hair and sebum production. Hormonal therapy leads to drastic skin alterations, impacting on sebum production, hair growth and acne, all of which may become a dermatological concern for transgender patients. Dermatologists have the opportunity to not only improve transgender patient care, but also their experience of healthcare. It is imperative that EHRs can provide accurate gender identity data and correct name use to close the gap in inequality in transgender population healthcare.
BT02 Use of teledermatology in the 2-week wait pathway: 5 years of positive data
Authors: Elias Jennifer , Synan-Jones Hannah , Singh-Raghunath Rakhi , Vlachou Christina , De Silva Bernadette
Published: June 2023

Our teledermatology service was started in 2018 to facilitate the dermatology department’s move offsite and allow for the continuation of inpatient care digitally without the need for increasing staff levels or cross-site working. Its implementation also allowed for efficient adaptation and use throughout the COVID-19 pandemic and recovery following this period. Alongside these aspects, teledermatology has become integral in the department’s rapid-access 2-week wait (2WW) capacity. The pathway involves patients attending the department and undergoing a nurse-led review with upload of the history alongside macroscopic and dermoscopic photographs to the platform for consultant review and management. The platform conforms to all aspects of the British Association of Dermatologists’ teledermatology guidelines and is hosted on the National Health Service’s Health and Social Care Network. Of almost 4000 2WW referrals assessed by digital teledermatology between 2018 and the present, no referrals have been rejected for poor quality, only 1% required urgent face-to-face review with a consultant, 32% were discharged, 53% were booked in for a minor surgical procedure of which half were suspected to be cancer or precancer and performed urgently, and 14% were booked for routine review due to risk factors such a multiple moles and need for a full skin check. Our consultants can assess 40 patients on the digital platform in a 4-h period, and the overall cost is approximately half of a face-to-face clinic, including admin. Of all 2WW referrals, general practitioner diagnosis has remained quite constant, with 30% of lesions thought to be malignant melanoma (MM), 36% squamous cell carcinoma (SCC) and 3% basal cell carcinoma (BCC); in the remaining 31%, no diagnosis was made. Of those referred for surgery by the dermatology consultants, the clinical diagnosis was BCC in 20%, SCC in 22% and MM or MM in situ in 6%; the remainder was thought to be precancerous, atypical naevi or other. We have continued to demonstrate through audit that the clinicopathological correlation in the digital teledermatology clinic is as good as face-to-face clinics for lesion diagnosis because of the quality of the history and images. Our most recent satisfaction survey in 2022 showed 96% patient satisfaction with the initial teledermatology assessment; of those booked for a procedure, 88% strongly agreed that all concerns were addressed prior to surgery. All patients would recommend the service to friends and family. With nearly 5 years of data and continuous evaluation, we have shown the effectiveness of a well-designed, connected digital system in supporting our service without duplication of effort by clinicians or prolongation of the patient’s journey.
BT03 (P63) Effectiveness of an image-analysing artificial intelligence-based digital health technology to diagnose nonmelanoma skin cancer and benign skin lesions
Authors: Marsden Helen , Palamaras Ioulios , Kemos Polychronis , Greenhalgh Jack
Published: June 2023

Squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) are common types of nonmelanoma skin cancer (NMSC). The DERM-003 study was a prospective multicentre single-arm masked study that aimed to demonstrate the effectiveness of an artificial intelligence-based digital health technology (AI-DHT) to identify SCC, BCC and premalignant conditions in dermoscopic images of suspicious skin lesions. Patients with at least one suspicious skin lesion that was suitable for photography were eligible. Each lesion was photographed with three smartphone cameras (iPhone 6S, iPhone 11 and Samsung 10) with a dermoscopic lens attached. Each image was assessed by the AI-DHT. A clinical diagnosis was made by the dermatologist, and histopathology results were obtained for biopsied lesions. The AI-DHT output was compared with the histopathology diagnosis, and the area under the receiver operating characteristic curve (AUROC) was calculated. Secondary endpoints included other diagnostic measures and assessment of premalignant lesions. Altogether, 572 patients (49.5% women, mean age 68.5 years, 96.9% Fitzpatrick skin types I–III) were recruited from four UK National Health Service trusts, providing images of 611 suspicious lesions. There were no exclusion criteria relating to skin type. In total, 592 lesions had images from all three cameras available; only one lesion had no images available. Altogether, 395 lesions had a histopathology result. Forty-seven biopsied lesions were diagnosed as SCC and 184 as BCC. The AUROCs for images taken by the iPhone 6S was 0.88 [95% confidence interval (CI) 0.83–0.93] for SCC and 0.87 (95% CI 0.84–0.91) for BCC. For the Samsung 10, the AUROCs were 0.85 (95% CI 0.79–0.90) and 0.87 (95% CI 0.83–0.90), and for the iPhone 11, they were 0.88 (95% CI 0.84–0.93) and 0.89 (95% CI 0.86–0.92) for SCC and BCC, respectively. Using images taken on the iPhone 6S of biopsied only lesions, the sensitivity in detecting SCC and BCC was 98% (95% CI 88–100) and 94% (95% CI 90–97), respectively; the specificity was 38% (95% CI 33–44) and 28% (95% CI 21–35), respectively; the positive predictive value was 17% (95% CI 16–19) and 59% (95% CI 56–61), respectively; and the NPV was 99% (95% CI 95–100) and 81% (95% CI 70–89), respectively. All 12 lesions diagnosed as Bowen disease were classified correctly by the AI-DHT. Of the 61 lesions diagnosed as actinic keratosis, 52 were correctly classified of the 22 lesions diagnosed as dysplastic, and 18 were correctly classified by the AI-DHT. All 16 lesions diagnosed as melanoma were classified as such by the AI-DHT. The AI-DHT has the potential to support the diagnosis of NMSC and premalignant lesions.
BT07 Creation of a skin lesion image pipeline: key steps in developing a mobile application with DICOM® fields and metadata
Authors: Chin Gillian X M , Coon Andrew , Wilde Chris , Muthiah Shareen , Morton Colin , Fleming Colin
Published: June 2023

A key issue facing artificial intelligence (AI) for dermatology is the lack of standardization around capture, transfer and storage of skin images and clinical data. To assist systematic capture of clinical data, we developed a nationally agreed proposed minimum dataset, based on Digital Imaging and Communications in Medicine (DICOM®) standards. Subsequently, we collaborated with an established image management system (IMS) supplier, Waba [supported by grants from our local National Health Service (NHS) innovation department], to incorporate these fields into a dermatology-specific mobile application (app), facilitating real-time capture and data transfer. We describe our steps in developing this app. The app integrates with the national Patient Administration System (SCI Store), allowing retrieval of real-time patient demographics linked to hospital or Community Health Index number. Each care episode captures a standardized dataset, including lesion views, clinical information and consent level. On episode completion, datasets are securely transferred to the IMS via WiFi or GPRS signal, following a fully auditable pathway. The IMS is a web-based app developed on a Microsoft Structured Query Language server, which allows authenticated users to access our trust’s centralized repository of nonradiological images. Adherence to industry-standard data storage format, patient safety reporting and specific access rights ensure compliance with Caldicott recommendations and data protection standards. For AI research, we are exploring conversion of datasets into DICOM format. Close collaboration between software developers and end users, including clinical photography, dermatology and general practice, was essential for app design. We worked on design architecture through fortnightly technical meetings, scheduled to progress development in months 1–8. Installation and functionality testing was performed in months 9 and 10, followed by comprehensive user testing in months 10–12. Live app test-of-change rollout was performed in months 13–16, with continued usability refinement during this period. To develop a standardized minimum dataset, we conducted a consensus exercise with the British Association of Dermatology AI working group. Based on DICOM standards, a comprehensive international standard for medical imaging, this could improve the quality, availability and interoperability of data for AI development. In summary, we have developed an app to standardize the capture, transmission and storage of skin lesion images and associated metadata. By collaborating with an industry partner with NHS experience, iterative user-led design and national engagement for standard-setting, we believe this is a useful step toward a national UK skin database for training and validating AI systems. Future work is planned to evaluate the output of this data pipeline.