bluuebunny/crossref_metadata_2025 huggingface dataset:
BI14 Photoprotection and skin cancer awareness in kidney transplant recipients living with HIV: a single-centre cross-sectional study
Authors: Ali Fatima , Cronin Antonia
Published: June 2023

Kidney transplant recipients (KTRs) are up to 65 times more likely to develop nonmelanoma skin cancers than age-matched general populations. HIV has also been associated with increased skin cancer rates. However, to date, there has been no study evaluating photoprotection and skin cancer awareness in KTRs living with HIV (KTRLHIV).

Using validated photoprotection and skin cancer awareness questionnaires, we evaluated knowledge and practices in KTRLHIV and an HIV-negative KTR cohort, matched for age, sex, ethnicity and years since transplant. KTRLHIV (n = 27) and matched HIV-negative KTRs (n = 25) completed the questionnaires. Thirty-four (65%) were male and 37 (71%) were Black. The average age was 56 years (range 43–74). On average, patients were 7.3 years post-transplant (range 0.7–24). Twenty-two (81%) KTRLHIV vs. 15 (60%) matched HIV-negative KTRs had not seen a dermatologist in the last year. Only 14 (52%) KTRLHIV had received sun protection advice vs. 20 (80%) of the matched KTRs (P = 0.033). There were statistically significant lower rates of overall sunscreen use in KTRLHIV compared with matched HIV-negative KTRs (33% vs. 60%; P = 0.054). Only a small proportion used sunscreen daily (22% vs. 27%), of a sun protection factor > 25 (78% vs. 100%). A strongly positive tetrachoric correlation coefficient of 0.77 indicated that providing photoprotection advice correlates to sunscreen use. Significantly lower rates of photoprotection behaviours were seen in the KTRLHIV compared with HIV-negative KTRs, particularly never avoiding direct sunlight (59% vs. 16%; P = 0.001) and never dressing to protect from the sun (52% vs. 12%; P = 0.002). We have identified statistically significant lower knowledge of photoprotection and skin cancer awareness in KTRLHIV vs. matched HIV-negative KTRs. Lower rates of skin cancer protection advice may have resulted in lower rates of sunscreen use and poorer photoprotection behaviours in KTRLHIV. A dedicated skin cancer awareness education to promote patient-led skin cancer prevention alongside formal dermatology referral is recommended.
BI15 (P16) Cutaneous renal cell carcinoma metastasis with scrofuloderma as the initial presentation of metastatic renal cell carcinoma: a diagnostic challenge
Authors: Kothari Rohit
Published: June 2023

Renal cell carcinoma (RCC) with cutaneous metastasis is uncommon and accounts for approximately 3–5% of metastatic RCC, with an unfavourable prognosis. We present an unusual and difficult case of advanced RCC presenting initially with cutaneous metastasis and scrofuloderma, with identical morphology of the lesions. It also highlights the importance of dermatologists in the early diagnosis and management of such cases. A 50-year-old man presented with gradually progressive, multiple erythematous discharging nodules over the right side of his neck of 3 months’ duration. He described a weight loss of 10 kg, intermittent undocumented fever with headache and two episodes of uninvestigated transient haematuria in the last 6 months. He had received multiple courses of antibiotics without any relief. A skin biopsy and immunohistochemistry confirmed cutaneous RCC metastasis with a primary advanced metastatic left RCC, involving the brain as well. A total left nephrectomy was done and he was started on lenvatinib, everolimus and radiotherapy, following which there was suboptimal response and he started developing similar nodular lesions over the left axilla and chest wall, and a puckered crusted plaque over the left lateral abdomen 1 week post-treatment. Follow-up at 8 weeks revealed a significant response in the neck lesions; however, the new lesions on the left side did not respond, following which a dermatology consultation was sought again. A skin biopsy from the new lesions confirmed scrofuloderma. Tissue polymerase chain reaction and culture were positive for mycobacterium tuberculosis. He was diagnosed as having scrofuloderma and started on daily isoniazid, rifampicin, ethambutol and pyrazinamide for 2 months followed by daily isoniazid and rifampicin for 4 months. Follow-up at 6 months revealed well-healed lesions, and the systemic symptoms and discharge had abated. The cutaneous metastatic lesions had also healed completely. Here, we present an interesting case of cutaneous RCC metastasis with coexisting scrofuloderma as the initial manifestation of an advanced RCC, posing a diagnostic challenge due to similar morphology. On this background, a recurrence of cutaneous metastasis was the first possibility considered for the new skin lesions. The delay in diagnosis led to significant morbidity in our patient, emphasizing the role of early dermatology consultation in the management of such cases. A high index of suspicion for conditions masquerading as cutaneous metastasis, as well as a lower threshold for skin biopsy, may improve the prognosis dramatically.
BI16 (P41) An emerging role of interferon-targeted therapy for the treatment of cutaneous systemic lupus erythematosus: a prospective real-world evaluation of anifrolumab for refractory cutaneous lupus
Authors: Carter Lucy , Wigston Zoe , Laws Philip , Vital Edward
Published: June 2023

Cutaneous lupus erythematosus (CLE), particularly discoid lupus erythematosus (DLE), is frequently unresponsive to standard therapies, including antimalarial and immunosuppressive therapies. Recent evidence has identified the importance of type-1 interferon (IFN-1) in the pathogenesis of disease. Anifrolumab is a monoclonal antibody that targets IFN-1 and has been licensed for the treatment of systemic lupus erythematosus (SLE). It is unclear which clinical subtypes of CLE are associated with an IFN-1 signature and may be responsive to anifrolumab therapy. We sought to evaluate the efficacy of anifrolumab on (i) DLE and (ii) rituximab-refractory CLE; and (iii) to compare IFN-specific biomarkers and (iv) early and late immunophenotypic and clinical responses. Anifrolumab was available through an early access to medicines scheme. Patients with SLE for whom the phenotype was predominantly cutaneous were treated with anifrolumab 300 mg intravenously every 4 weeks. The Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) and Dermatology Life Quality Index (DLQI) were reported. Seven patients were enrolled (five with DLE, one with chilblain and one with subacute CLE). All patients were female (median age 46 years; median disease duration 17 years). The median number of failed therapies was six: rituximab in six, belimumab in two and thalidomide in four patients. Four patients required long-term oral prednisolone > 10 mg daily. Median baseline CLASI activity score was 17 and DLQI was 16/30. Median CLASI score reduced after 4 weeks to 6 (range 0–13; P = 0.016) with a median decrease from baseline of 60% (range 19–100%), which was maintained at 6 months. Clinical responses were associated with significant improvements in DLQI (P < 0.001) and EQ-5D visual analogue scale (P = 0.002) by 3 months. All patients had a marked suppression of IFN-stimulated genes at 4 weeks (mean difference 2.92; P < 0.01). Treatment was generally well tolerated with the exception of one patient who had shingles complicated by sensorineural hearing loss while on anifrolumab and prednisolone > 15 mg daily. This required prolonged aciclovir for effective management. This case series highlights the potential role for anifrolumab in managing treatment-resistant CLE with particular responses observed in DLE and chilblain lupus. The need for enhanced awareness of viral infections, particularly varicella-zoster virus, needs to be considered in higher-risk patients.
BI20 Generalized pustular psoriasis in a patient receiving pembrolizumab for metastatic lung adenocarcinoma
Authors: Cernova Jeva , Patel Majeeda , Dattani Jinesh , Goiriz Rebeca , Rashid Sukaina , Harwood Catherine
Published: June 2023

Skin toxicities are the most common immune-related adverse events (irAEs) associated with immune checkpoint inhibitor (ICI) treatment, an emerging field in dermatology. A wide spectrum of skin irAEs, including lichenoid reactions, vitiligo, bullous pemphigoid and other autoimmune skin diseases, have been reported. Psoriasiform irAEs may occur as an exacerbation of pre-existing disease or de novo and often occur later than other skin irAEs. Most cases reported to date are of chronic plaque and palmoplantar psoriasis. Generalized pustular psoriasis has been reported in fewer than 10 cases. We present a patient with mild pre-existing psoriasis who developed plaque psoriasis, evolving into severe pustular psoriasis after 4 months of pembrolizumab therapy for lung cancer. A 67-year-old man with stage 4 lung adenocarcinoma developed a widespread, itchy psoriasiform rash 3 months after starting pembrolizumab. He had a history of rheumatoid arthritis (RA) and pembrolizumab was started when he had progressed through chemotherapy. The RA was controlled on prednisolone, which was increased when methotrexate was discontinued shortly after diagnosis of lung cancer. He had a family history of psoriasis, and although he had previously been noted to have limited plaque and nail psoriasis, this had required minimal treatment. Within 2 months of starting pembrolizumab, he developed scaly, red plaques affecting more than 30% body surface area (BSA). The oncology team diagnosed a grade 3 skin toxicity and increased doses of oral steroids. Upon steroid tapering, the rash flared and was diagnosed in dermatology as consistent with exacerbation of pre-existing plaque psoriasis secondary to pembrolizumab and high-dose steroids. He partially responded to skin-directed treatment, but 2 months later following his sixth cycle of pembrolizumab, he progressed to generalized suberythrodermic pustular psoriasis. He was treated with acitretin and methotrexate. The incidence of ICI-mediated psoriasis and psoriasiform irAEs is approximately 4% of all skin toxicities. A cohort study by the European Network for Cutaneous Adverse Event to Oncologic Drugs group reported that 70% of 115 patients had no history of psoriasis. Ten per cent of psoriasiform irAEs were categorized as severe, involving more than 30% BSA. However, only eight (7%) had pustular involvement and 2% erythroderma. Treatment options include acitretin, methotrexate, apremilast and biologics. Guttate psoriasis and grade 2/3 disease were significant positive predictors for the antitumour response of ICIs. In summary, ICI-related psoriasis is an increasingly common problem with widespread use of immunotherapy. Early diagnosis and adequate management with agents that do not interfere with immunotherapy, or with the underlying malignancy, and close liaison with oncology are crucial.
BI21 The development of diffuse extragenital lichen sclerosus in a patient on palbociclib and fulvestrant for metastatic breast cancer
Authors: Johnston Sarah , Vatve Maneesha , Thomas Lianne
Published: June 2023

A 59-year-old woman with skin phototype VI was commenced on palbociclib (cyclin-dependent kinase 4/6 inhibitor) and fulvestrant (oestrogen receptor antagonist) as chemotherapy agents for metastatic breast cancer. Two months later, she developed a new widespread rash. Past medical history included atopic dermatitis but no autoimmune conditions. Denosumab was her only other medication. On examination, she had hyperpigmented thickened plaques with purple hue and sclerotic plaques with cigarette wrinkling on her buttocks, arms, neck, abdomen and axillae. She also had widespread hypopigmentation. Biopsies showed hyperkeratosis and a lichenoid inflammatory reaction with pigmentary incontinence. Clinicopathological correlation supported the diagnosis of extragenital lichen sclerosus (EGLS). Palbociclib and fulvestrant were stopped and she noted improvement of her rash within 3 weeks. She was also managed with potent topical steroids, which eased her symptoms and further improved the appearance. Lichen sclerosus (LS) is a chronic inflammatory condition affecting the anogenital area. EGLS occurs in approximately 15–20% of those with LS, and only 6% of patients with EGLS do not have genital involvement at diagnosis. LS and EGLS are characterized by white papules, sclerosus and erosions with atrophic plaques. In the skin of colour, the presentation is varied, with hypo- or hyperpigmentation. Currently, the pathogenesis of EGLS is poorly understood, with studies suggesting an autoimmune aetiology, with possible genetic, infectious, hormonal, trauma and drug associations. In addition to specific autoantibodies, the absence of a suppressive function of regulatory T cells may contribute to the induction of autoimmunity. A recent association with immune checkpoint inhibitors (ICIs) further establishes this link. There are 12 case reports of ICIs and LS/EGLS, but cell cycle inhibitors associated with EGLS have not yet been reported (Silvestri M, Cristaudo A, Morrone A et al. Emerging skin toxicities in patients with breast cancer treated with new cyclin-dependent kinase 4/6 inhibitors: a systematic review. Drug Saf 2021; 44:725–32). Laboratory studies demonstrate increased T-cell activation with abemaciclib, a cell cycle inhibitor, which has been hypothesized to have other autoimmune drug associations (Truong K, Jones-Caballero M, Chou S et al. Lichen sclerosus and immune checkpoint inhibitors: a case and review of the literature. Australas J Dermatol 2023; 64:158–61). Other possible theories contributing to the development of EGLS include the Koebner effect of deep intramuscular injection of fulvestrant or subsequent low-oestrogen state. To the best of our knowledge, this is the first case of EGLS following these chemotherapy agents. This case hypothesizes the role of cell cycle inhibitors contributing to the aetiology in a mechanism similar to that of ICIs. It also demonstrates the difference in presentation of EGLS in skin of colour.
BI22 Successful treatment of antitumour necrosis factor-α-induced paradoxical palmoplantar pustulosis with tofacitinib
Authors: Murray Gregg , Barry Rory , Roche Muireann
Published: June 2023

Palmoplantar pustulosis (PPP) is an inflammatory skin condition characterized by eruptions of sterile pustules on the palms and/or soles. These eruptions cause significant discomfort and have a major impact on a patient’s quality of life. The exact cause of PPP remains unknown; several theories have been hypothesized. These theories include genetic factors, including mutations in IL36RN, associations with autoimmune/autoinflammatory disorders and drug-induced aetiologies. Tumour necrosis factor (TNF)-α inhibitors are widely used in the treatment of autoimmune conditions such as psoriasis, psoriatic arthritis, rheumatoid arthritis and inflammatory bowel disease. An unusual side-effect of these treatments is their ability to induce paradoxical reactions. It is reported in the literature that this can occur in 2–5% of patients receiving TNF-α inhibition. We report a case of anti-TNF-α-induced paradoxical PPP in a 52-year-old woman with rheumatoid arthritis (RA). Three months after commencing adalimumab for her RA, the patient developed painful sterile pustules on her palms and soles. She was a smoker with no previous history of psoriasis. Her adalimumab treatment was discontinued, and her hands and feet were treated with clobetasol propionate. Despite 3 months of topical treatment and discontinuation of adalimumab, her PPP deteriorated. Interleukin (IL)-17 or IL-23 inhibition was considered but is not indicated for the treatment of RA. To gain control of both her RA and PPP, she was started on tofacitinib 5 mg twice daily, a partial and reversible JAK1 and JAK3 inhibitor. Within 4 days, the pustulosis on her hands and feet improved, and within 3 months, she had total disease clearance with a complete response. Her Dermatology Life Quality Index improved from 23/30 to 0/30. The patient developed a dental abscess on treatment. During this infection, her tofacitinib was withheld for 2 weeks and was treated with metronidazole. During this period, she had an acute flare of her PPP, which quickly resolved once recommencing tofacitinib. In a recent systematic review, a total of 155 patients with biologic-associated paradoxical PPP were identified, with the most common cause being TNF-α inhibition, with female sex, smoking and concomitant autoimmune disorders being major risk factors. To date, only five case reports have described the successful treatment of PPP with tofacitinib. We found that tofacitinib is an effective and rapid treatment for paradoxical PPP.
BI23 Erythrodermic eczematous reactions to immunoglobulins
Authors: Gold Adam , Hussain Fazleenah , Yesudian Paul , Popli Urvi
Published: June 2023

Intravenous immunoglobulins (IVIg) have been used in clinical practice for more than 50 years. They are used for dermatological indications such as dermatomyositis, pemphigus and Kawasaki disease. Although this is regarded as a safe treatment modality, it can produce adverse reactions in the skin. We report two patients with IVIg-induced skin changes. A 71-year-old man with no preceding skin disease was under neurology care for the treatment of chronic inflammatory demyelinating neuropathy (CIDP) with IVIg. He presented with an erythrodermic eczematous rash and was symptomatic with pain and pruritus. The rash started on the hands and had spread to the rest of the body 3 days after completion of his third course of IVIg. He was treated with topical clobetasol propionate. His skin settled over the course of a few weeks. The patient was keen to resume IVIg for CIDP; unfortunately, he developed a more severe and rapid reaction on retrial and IVIg had to be stopped. An 82-year-old man was given IVIg for CIDP. He denied any previous skin conditions or atopy. He received a 5-day course of IVIg followed by intravenous methylprednisolone 1 g once daily for 6 days. Four weeks later, he developed pompholyx on the palms and thereafter a widespread eczematous rash over the arms, abdomen, back and face. He was treated with topical clobetasol propionate to the trunk and limbs and clobetasone butyrate to the face. His rash and symptoms settled with topical treatment. Eczematous immunoglobulin reactions are often under-recognized. Reactions preferentially affect middle-aged men and those being treated for neurological disease. The clinical presentation is peculiar and distinctive, almost always involving the palmoplantar aspects with a dyshydrotic element. The reaction pattern starts within a few days to weeks of exposure to immunoglobulins and can become erythrodermic. Histology shows a spongiotic dermatitis and is not diagnostic. Immunoglobulin-associated eczema can persist even after the discontinuation of immunoglobulins. Recommended treatment depends on severity. If mild, continuing immunoglobulins with topical steroids should be considered. If the reaction persists or worsens, up to two switches of the immunoglobulin brand can be considered. In severe or persistent cases, methotrexate may be beneficial. The mechanism of an IVIg-induced skin reaction is not fully understood. The diagnosis of eczematous IVIg reaction is clinical, with a high index of suspicion required. The care of these patients requires collaboration between dermatologists and the physician prescribing the immunoglobulin, who may be unfamiliar with this adverse event.
BI25 Immunotherapy-associated Sweet syndrome in a patient with metastatic melanoma
Authors: Barry Rory , Murray Gregg , Eustace Karen
Published: June 2023

Ipilimumab, an anti-CTLA-4 monoclonal antibody, is used in the treatment of metastatic melanoma. As with other immune checkpoint inhibitors, it can cause a spectrum of immune-related adverse events (irAEs), including a cutaneous pathology, in 25% of patients. To date, there have been five case reports of Sweet syndrome solely due to ipilimumab therapy. We present a suspected further case in a patient with metastatic melanoma of unknown primary origin, who concurrently developed vitiligo. A 65-year-old man presented to the dermatology department with a 2-week history of a mildly tender, erythematous papulonodular rash localized to the right forearm. He had also developed extensive vitiligo on all limbs over a similar period of time. Histology from a skin punch biopsy demonstrated a predominantly neutrophilic dermal inflammatory infiltrate without features of vasculitis, confirming Sweet syndrome. There were no recent medication changes or disease recurrence on repeat imaging. Nine months prior, the patient had been diagnosed with cerebral and pulmonary metastatic melanoma of unknown primary origin (BRAF V600 mutation positive). He underwent an evacuation of a left temporal cortical mass and subsequent stereotactic radiosurgery. The oncology team then commenced ipilimumab (3 mg kg–1) and nivolumab (1 mg kg–1) every 21 days. Four cycles were completed until discontinuation after 3 months due to multiple severe irAEs, namely, panhypopituitarism and liver toxicity. He was commenced on 80 mg (1 mg kg–1) oral prednisolone, which was slowly reduced over subsequent months and completed a few weeks prior to the development of Sweet syndrome and vitiligo. We prescribed topical clobetasol propionate 0.05% once daily, with resolution of Sweet syndrome after 2 months. The oncology team elected to withhold further immunotherapy due to the multiple irAEs, instead monitoring for melanoma recurrence by serial radiological imaging. The five previously documented cases of ipilimumab-associated Sweet syndrome report an average time to clinical presentation of 8.9 weeks. Our case differs as the patient developed Sweet syndrome 5 months after the discontinuation of immunotherapy. However, the development of any cutaneous adverse effect may have been masked by high-dose steroids for the other systemic irAEs soon after the fourth cycle of treatment. Despite a lack of temporality between immunotherapy and Sweet syndrome in our case, the addition of vitiligo at the same presentation suggests an irAE. This case highlights the importance of monitoring patients on immunotherapy for dermatological side-effects and working closely with oncology colleagues to manage these complex cases.
BI26 Treatment-induced scleroderma in a patient with metastatic melanoma
Authors: Yiu Daniel , Heelan Kara , Aguilar-Duran Silvia , Terlizzo Monica , Furness Andrew
Published: June 2023

We present a 71-year-old woman who presented with sclerodermoid plaques affecting the abdomen and lower limbs, following a single cycle of nivolumab and ipilimumab 20 months prior for BRAF-mutant metastatic melanoma (pulmonary and hepatic metastases). Immunotherapy was discontinued owing to iatrogenic colitis, confirmed on flexible sigmoidoscopy, and requiring oral prednisolone, infliximab and, later, modified-release beclomethasone dipropionate. Owing to the progression of hepatic disease, she was commenced on targeted therapy with dabrafenib and trametinib. A lesional punch biopsy was performed; histological analysis demonstrated a dense dermis with mild chronic inflammatory infiltrate, in keeping with a diagnosis of scleroderma. Treatment with a combination of topical corticosteroids and vitamin D analogues improved disease from 15% body surface area (BSA) to 3% after 4 months. We performed a literature search in PubMed for articles on immunotherapy-related scleroderma published up to August 2022 and identified 18 articles that met our inclusion criteria. Scleroderma was reported in patients with melanoma, non-small-cell lung cancer, renal cell carcinoma, rectal adenocarcinoma, adenocarcinoma of the lung and large-cell neuroendocrine lung cancer treated with pembrolizumab, nivolumab, atezolizumab and ipilimumab. Latency of onset ranged from 0 to 18 months, and treatment included topical and systemic corticosteroids, mycophenolate mofetil, hydroxychloroquine, cyclophosphamide, infliximab and immunoglobulins, with varying treatment outcomes. There was no clear relationship between cancer subtype, duration of treatment and response to treatment. Furthermore, the lack of documented quantitative or semiquantitative measurements for improvement such as BSA and modified Rodnan skin score is limiting. Our case report is important in promoting the awareness of localized scleroderma as a rare side-effect of immunotherapy and highlights the various treatment options available.
BI27 Strongyloides stercoralis screening in dermatology
Authors: Oldham Jaimie , Lambourne Jonathan , O’Toole Edel
Published: June 2023

Strongyloidiasis is a major neglected tropical disease and chronic parasitic infection caused by Strongyloides stercoralis. An estimated 30–100 million people are infected worldwide, with acquisition via contact with contaminated soil. Accurate data for the UK are unavailable, but there is a prevalence of > 20% in certain immigrant populations. Many cases are asymptomatic; without therapy, the infection may be lifelong. Testing is more common in dermatology since the advent of dupilumab as infection can be life-threatening in the immunocompromised. Symptoms reported with strongyloidiasis include not only pruritus and urticaria but also abdominal and respiratory issues. Standard diagnostic testing of strongyloidiasis relies on demonstration of the parasite in faeces, body fluids or tissue samples, although serology is most often used in dermatology. The aim of our study was to assess why dermatologists are ordering Strongyloides serology and whether the results could identify features of infection. All Strongyloides serology tests sent by dermatology from two centres from January 2021 to December 2022 were analysed. Data collected included demographics, reason for testing, symptoms, foreign travel, test results and treatment. In total, 187 tests were sent. Patient demographics are provided in Table 1. The reasons for testing were before starting dupilumab in 57.2% (n = 107), pruritus in 13.4% (n = 25) and urticaria in 3.2% (n = 6/187). There was a recorded history of other symptoms of strongyloidiasis in five patients, and a recorded history of foreign travel in four. Twelve per cent of results were positive (n = 23/187), 6.9% (n = 13) were borderline and 80.7% (n = 151) were negative. There was no major skew toward a reason for testing in those who were positive/borderline. Eight per cent (n = 3/36) of those with positive/borderline results had other recorded symptoms. Of the positive/borderline results, 31% (n = 11/36) were not treated (mostly because they did not go on to have immunosuppression), 28% (n = 10) were treated with a single dose of ivermectin, 31% (n = 11) with two doses and 8% (n = 3) with four doses. The main reason for Strongyloides testing in dermatology is before starting dupilumab. A low proportion of the patients with positive/borderline results had symptoms, although often this was not recorded. A higher proportion of individuals of Asian or African ancestry had positive/borderline results. We shall also discuss evidence behind the methods of and reasons for Strongyloides testing.Table 1Patient demographicsDemographicAll tests (n = 187)Positive/borderline tests (n = 36)Male115 (61.5)22 (61)Female72 (38.5)14 (39)White52 (27.8)5 (14)Asian95 (50.8)22 (61)Black21 (11.2)5 (14)Other/not stated19 (10.2)5 (14)Data are presented as n (%).
CD01 Sodium benzoate: an important allergen to patch test to — is 5% in petrolatum too irritant?
Authors: Lawrance Nicholas , Gaikwad Sophie , Holden Catherine
Published: June 2023

Sodium benzoate is a naturally occurring preservative present in substances including cinnamon and apples. It is used as a food preservative and increasingly in leave-on and wash-off personal care products (PCPs), including moisturizers, hand washes, shampoos, mouthwash, toothpaste and baby wipes. Increased use results, in part, from European Union legislation regulating other preservatives, notably methylchloroisothiazolinone and methylisothiazolinone, which are banned in leave-on PCPs and are required to be used in reduced concentrations in wash-off products. Sodium benzoate was recently recommended for consideration for inclusion in the British Society for Cutaneous Allergy facial series after a national audit demonstrated that 1.5% of patients tested positive on patch testing when tested to sodium benzoate 5% in petrolatum (pet.) (Rolls S, Owen E, Bertram CG et al. What is in? What is out? Updating the British Society for Cutaneous Allergy facial series. Br J Dermatol 2021; 184:151–5). In our institution, 3229 patients were patch tested to sodium benzoate 5% in pet. from Chemotechnique Diagnostics™ from 2008 to 2022. It was tested in targeted series, bakery and cheilitis (2008–2022), and variably in fragrance (2012–2018) and cosmetic (2015–2018 and 2021–2022) series. We noted many irritant reactions to sodium benzoate 5% pet. and undertook an audit. Fifty-seven (1.8%) patients had positive reactions (+/++), 52 (1.6%) had doubtful reactions (? +), and 133 (4.1%) had irritant reactions. Of the positive reactions, 38 (66.7%) were of current relevance and 19 (33.3%) were of unknown relevance. The frequency of positive (+/++) reactions in the different targeted series was as follows: bakery and cheilitis 1.5%, cosmetic 1.7% and fragrance 2.1%. Concerningly, over three times more patients had irritant or doubtful reactions (5.7%) than those who tested positive (1.8%). When concentrations of a patch test preparation are decreased, the rate of irritancy on patch testing usually also decreases (Johansen J, Aalto-Korte K, Agner T et al. European Society of Contact Dermatitis guideline for diagnostic patch testing – recommendations on best practice. Contact Dermatitis 2015; 73:195–221). Given that sodium benzoate is a known allergen with increasing frequency of use, it is important that the optimum concentration and vehicle are used for patch testing to ensure adequate sensitivity but low irritancy. Decreasing the patch test concentration of sodium benzoate to 2% in pet., which is commercially available, may reduce irritant reactions and the risk of false positives. We recommend that dilutional studies should be performed comparing 5% with 2% in pet. with the hope that the latter is comparatively a nonirritant preparation without loss of sensitivity.
CD02 A retrospective comparison of Chemotechnique Cosmetic series–positive contact allergens with the British Society for Cutaneous Allergy facial series
Authors: McFeely Orla , Byrne Emma , Storan Eoin
Published: June 2023

Patch testing is an important tool in the assessment of facial dermatitis. The cosmetic or facial series of haptens are highly relevant in facial dermatitis. The British Society for Cutaneous Allergy has recently updated the facial series to include the reduced number of 24 haptens. We compared positive allergens found in the Chemotechnique Cosmetic series (60 haptens) with that of the British Society for Cutaneous Allergy (BSCA) facial series. We conducted a retrospective review of patients who were patch tested to the Chemotechnique Cosmetic series over a 30-month period. We recorded and compared positive contact allergens in this series with that of the BSCA facial series. Sixty-three patients were patch tested to the Chemotechnique Cosmetic series over a 30-month period. Twenty-one patients were diagnosed with at least one positive contact allergen. In total, 35 contact allergies were diagnosed. Contact allergen positivity was seen to sorbitan oleate (Span 80; positive rate 4.7%), thimerosal (Merthiolate; positive rate 4.7%), chloroacetamide (positive rate 4.7%), hexahyrdo-1,3,5-tris(2-hydroxyethyl) triazine (Groton BK; positive rate 4.7%), abitol (hydroabietyl alcohol; positive rate 9.5%), benzophenon-3 (Eusolex® 4360, EscalolTM 567, oxybenzone; positive rate 4.7%), sorbitan sesquioleate (positive rate 14.2%), benzyl salicylate (positive rate 9.5%), tert-butyl hydroquinone (positive rate 14.2%), tea tree oil oxidized (positive rate 4.7%), 3-(dimethylamino)-1-propylamine (positive rate 4.7%), Amerchol (positive rate 4.7%), quaternium (positive rate 4.7%), methyldibromo glutaronitrile (MDBGN; positive rate 9.5%), methylisothiazolinone (MI; positive rate 4.7%), sodium metabisulfite (positive rate 28.5%) and gallate mix (positive rate 28.5%). Nine patients (43%) were found to have more than one contact allergy. Five of the positive haptens (Amerchol, quaternium, MDBGN, MI and sodium metabisulfite) are captured within the BSCA standard series but are not found within the BSCA facial series. Benzophenone 3 is captured within the BSCA extra facial series. Five further haptens [sorbitan oleate (Span 80), thimerosal (Merthiolate), chloroacetamide, hexahyrdo-1,3,5-tris(2-hydroxyethyl) triazine (Groton BK) and benzyl salicylate] were captured with the Chemotechnique series. However, these five are not included in the BSCA facial series and would not otherwise have been identified. Seventeen per cent of contact allergies would not have been diagnosed in this study if the BSCA facial series had been applied. This study highlights the variation in positivity seen between the Chemotechnique and BSCA facial series and the potential for missed diagnoses.
CD03 Contact sensitization to shellac: a possible marker of fragrance allergy
Authors: Ghadiri Sina , Sambi Pavan , Wilkinson Mark , Whitehouse Heather
Published: June 2023

Shellac, the purified resin produced from the female lac bug (Kerria lacca), has its application within a wide range of industries, including healthcare, food, wood treatments and cosmetics. Shellac 20% alcohol is included in the British Society for Cutaneous Allergy/European Society of Contact Dermatitis extended facial series based on frequency of reactions exceeding the 0.3% threshold. However, the source of primary sensitization remains difficult to characterize through patch testing as relevance is not always clear and the test preparation has an irritant potential. We present a series of 28 patients from 2013 to 2022 with positive or irritant reactions to shellac, to elucidate its reaction pattern and relevance within our outpatient population. Cases with confirmed shellac positivity (‘+’ reactions and higher) or irritant reactions using a test preparation with alcohol 20% (Chemotechnique MB Diagnostics, Vellinge, Sweden) on days 2 and 4 of patch testing in a cosmetic series were retrieved between 2013 and 2022 from a total of 5458 people tested. Data collected from records included degree of positivity, irritancy, relevance, coexisting allergens, primary anatomical site and previous history of atopy. Data were processed using Microsoft Excel. We report 21 positive reactions, 14 (67%) of which were weak. Eleven (52%) positive reactions were deemed of current relevance, seven (33%) of doubtful relevance, one (5%) of past relevance and one (5%) a crossreaction to fragrance. Seven (25%) patients had documented irritant reaction to shellac. Nickel and colophony were the most common coexisting allergens in shellac-positive patients (positive in five and four cases, respectively). Nine (43%) cases with positive reaction had coexisting positivity of fragrance markers (which included one or more of geraniol, citral, Evernia furfuracea, turpentine, propolis, colophony, abitol, isoeugenol, cinnamyl alcohol, Jasminum officinale, jasmine absolute, majantole or benzaldehyde), indicating a higher prevalence than existing rates from studies in the general population. Fourteen (67%) positive cases documented the face as the primary site of disease, and 16 (76%) had a personal history of atopy. Our results indicate a significant association between shellac positivity and coexisting fragrance allergy, suggesting a role as a marker of fragrance allergy due to cross-reaction. When comparing irritant reactions to the proportion of positive reactions, this was higher than in previous US population-based reports (five irritant cases vs. 64 positive cases of a total cohort of 612 cases) but significantly lower than in a recent German population-based study (90 irritant cases vs. 76 positive cases of a total cohort of 2167), in all instances using the alcohol 20% preparation.
CD04 An unusual case of menorrhagia and an episodic rash
Authors: Latheef Faheem
Published: June 2023

A 24-year-old female university student from Hong Kong was referred with a 4-month history of a vesicular rash on her lips, eyes and oral mucosa that always appeared around the same time of her menstrual cycle. She would also get similar lesions on her neck, arms and legs. She was seen in dermatology and given a provisional diagnosis of erythema multiforme/recurrent herpes simplex and started on treatment, as well as prophylactic dose aciclovir for a few months. Despite this, there was no improvement in symptoms and her viral swabs also came back negative. She was referred for a second opinion, and, on reviewing her history, she volunteered that she suffers from menorrhagia. On questioning regarding any use of painkillers, she took out a packet of 60-mg etoricoxib that she had been getting from Hong Kong over the counter (OTC) and which was not on her records in the UK. She was taking this on day 1 of her period, and the vesicular eruption appeared the following day; it also became apparent that it would occur at the same sites on her body each time. A fixed drug eruption (FDE) to etoricoxib was suspected, and patch testing was undertaken to our baseline, facial and photopatch series (which includes a number of nonsteroidal anti-inflammatory drugs), to the medication crushed in paraffin applied to the back as standard and also to the specific sites at which the eruptions occur on the neck, arms and legs (lesional skin) under occlusion. No reactions were seen at 48 h, but at 72 h, we noted vesicular eruptions morphologically identical to the very dramatic photos she had on her phone but only in the areas where she had previously reacted (lesional skin); no reaction was seen on the nonlesional skin on the back where the standard patch testing was performed. Her rash fully resolved after stopping the etoricoxib. This case highlights the importance of enquiring about OTC medications when seeing patients with unusual or recalcitrant presentations as the flare with the menstrual cycle was a red herring and also highlights the importance of patch testing lesional skin with the culprit medication to avoid false negatives when considering FDE. This is a rare presentation of a FDE to etoricoxib, with only eight other cases reported in the literature, but this should be considered as a differential diagnosis in someone presenting with an erythema multiforme-like eruption.
CD06 Delving in to Disperse Orange 1
Authors: Butt Sanaa , Thompson Donna
Published: June 2023

Disperse Orange 1, colour index 11080, is an azo dye. Collectively, azo dyes are a common cause of textile-related allergic contact dermatitis (ACD). A 2006 European Union (EU) directive restricts the sale of any articles or dyed items that have direct and prolonged contact with the skin or the oral cavity and contain more than 30-ppm azo dyes. These include a wide range of items such clothing, bedding, furniture, toys and yarn. Despite clear regulation set out by the directive, these dyes have been detected within garments produced and sold within the EU (https://echa.europa.eu/regulations/reach/legislation). In our cutaneous allergy clinic, we have patch tested a total of 547 patients to the clothing and dye series. Only seven (1.3%) have tested positive to Disperse Orange 1. We present a series of cases and highlight the suspected sources of exposure. We identified a total of seven patients, four of whom were male. Their ages ranged between 20 and 78 years. Aside from Disperse Orange 1, all patients developed positive patch test results to other disperse dyes. Three patients also reacted to paraphenylenediamine. Sites affected included the head and neck (n = 4), hands (n = 2), chest (n = 1) and leg (n = 1). Other series patients tested positive to included fragrances, metals, rubber, acrylates and local anaesthetics. Suspected sources of Disperse Orange 1 included hair dyes, clothing, wound dressings and a thyroid shield. Few cases of ACD have been published on Disperse Orange 1. One report noted a textile necklace as a source of a severe localized ACD (Nygaard U, Kralund HH, Sommerlund M. Allergic contact dermatitis induced by textile necklace. Case Rep Dermatol 2013; 5:336–9). We wish to raise awareness of the presence of problems with Disperse Orange 1, despite the EU directive. Members should consider a variety of sources, including traditional items such as clothing and hair dyes and also newer items such as dressings and thyroid shields, as suspected in our cases.
DP03 (P23) Primary penile melanoma and penile lichen sclerosus
Authors: Dear Kate , Kravvas George , Sim Sharmaine , James Mariel , Watchorn Richard , Haider Aiman , Ellery Peter , Freeman Alex , Alnajjar Hussain , Muneer Asif , Bunker Chris
Published: June 2023

The association between squamous cell malignancies and genital lichen sclerosus (GLSc) is well established. There is an increasing literature regarding the relationship of GLSc with genital malignant melanoma (MM). While there have been several reported cases of vulvar melanoma associated with lichen sclerosus (LSc), there have been fewer cases published with regard to male genital (M)GLSc and penile (Pe)MM. The aims of this study were to explore the relationship between PeMM and MGLSc by reviewing all cases managed by our multidisciplinary service over a period of 11 years. All patients known to our tertiary urology and male genital dermatology service with a diagnosis of penile MM and where histology was available for review were identified over an 11-year period (2011–2022). Two independent dermatologists reviewed the clinical records and photographs where available. Two independent mutually blinded histopathologists reviewed the histology and recorded features of GLSc where present. In cases of discordance between histopathologists, a third independent histopathologist reviewed the cases. Eleven patients were identified for inclusion in the study. Overall, GLSc was present on histopathology in nine of 11 cases (82%). Findings were concordantly positive in five cases and concordantly negative in one case. In cases of discordant findings (n = 5), the third histopathologist determined GLSc to be present in four cases and absent in one case. Clinical photographs were available for three cases, and clinical features of GLSc were seen in all of them; they also all had positive histopathological findings. Clinical notes, including electronic notes and letters, were available for review in eight cases. Symptoms in keeping with GLSc were mentioned in only one case, and signs suggestive of GLSc were documented in three cases. Penile MM is a rare entity accounting for 0.7% of penile cancer and 0.1% of MM cases. Like other malignancies, MM is a multifactorial disease caused by a combination of environmental factors and altered host responses contributing to an alteration of regulatory processes. Although ultraviolet exposure is important in the pathogenesis of extragenital MM, this cannot be a factor for genital disease. However, specific risk factors for genital MM have not yet been elucidated. To our knowledge, there have only been three previously documented cases (all from our group) of PeMM coexisting with GLSc. In this present study, finding of GLSc in nine of 11 men with PeMM is suggestive of a causative relationship. We postulate that this is related to chronic melanocytic distress created by chronic inflammation secondary to LSc.
DP11 Dermal plexiform spindle cell lipoma: a perplexing entity
Authors: Byrne Tiarna , McDonald Louise , Holte Kristofer
Published: June 2023

We present a 66-year-old man who presented to dermatology with an unusual lesion. An outdoor worker with prior history of melanoma, the patient was referred with a new pigmented lesion adjacent to his melanoma scar. This was identified as a seborrhoeic keratosis and the patient was reassured. Following a full body examination, an incidental lesion was identified on the left anterior shoulder. The lesion measured 9 × 7 mm, was dermal-based, dome-shaped, soft to palpation and skin coloured with light peripheral pigmentation. The lesion was featureless upon dermoscopic examination. The clinical differential diagnosis included neurofibroma and an intradermal naevus. The lesion was narrowly excised. Histological examination revealed an ill-defined, wedge-shaped dermal lesion with tumour fascicles with a vaguely plexiform arrangement. The widely separated fascicles comprised loosely arranged spindle cells, mature adipocytes and scant collagen fibres with a myxoid stroma. The spindle cells were stained diffusely with CD34 immunohistochemistry. The adipocytes and a proportion of spindle cells (around 20–30%) were stained with S100. The features were in keeping with a dermal plexiform spindle cell lipoma. Spindle cell lipoma is an uncommon benign, histologically distinct tumour, accounting for 1.5% of all adipocytic neoplasms. More common within the subcutis, it is rare for these lesions to present with a purely intradermal location. Dermal spindle cell lipomas tend to be less cellular than their subcutaneous counterpart. This coupled with the variable representation of the three constituent lesion components (spindle cells, mature adipocytes and fibromucinous stroma) results in a wide range of possible differential diagnoses. The plexiform variant of spindle cell lipoma (PSCL) is a poorly recognized form with even greater potential for misdiagnosis, particularly with plexiform neurofibroma—­leading to an erroneous diagnosis of neurofibromatosis. Dermal PSCL is an exceptionally rare diagnosis with only eight cases reported in the literature thus far. Here, we report a further case of dermal plexiform spindle cell lipoma, with, for the first-time, corresponding clinical images. In our summary, we discuss in detail the potential diagnostic pitfalls of this rare tumour and how to best employ immunohistochemical staining to avoid them.