bluuebunny/crossref_metadata_2025 huggingface dataset:
CD03 Watch out! Allergic contact dermatitis to acrylates in a smart watch
Authors: Davies Anna , Stone Natalie
Published: June 2024

A 15-year-old girl with long-standing atopic dermatitis and hay fever presented to the patch test clinic with an atypical distribution of eczema over the trunk, elbows and perioral skin. Close examination additionally revealed a well-defined patch on the dorsal left wrist, at the exact site of her Apple smart Watch. She was a competitive swimmer and gym user. Her medications were tranexamic acid, topical steroids and emollients. Testing to the British Society for Cutaneous Allergy standard, medicaments, facial, oral, metals and acrylate series (applied on day 2) showed positive reactions to methylisothiazolinone (day 2+, day 4++), methylchloroisothiazolinone/methylisothiazolinone (MCI/MI) (day 2+, day 4++), benzophenone-3 (day 2−, day 4+), benzophenone-4 (day 2−, day 4+), sodium benzoate (day 2−, day 4+), benzoyl peroxide (day 2−, day 4+), isobornyl acrylate (day 2+), ethylene glycol dimethacrylate (day 2+) and hexanediol diacrylate (day 2+). The benzophenones were of current relevance to her sun protection factor-containing emollient. Sodium benzoate was present in her shower gel and shampoo, as well as her favourite Vimto squash. Benzoyl peroxide was of unknown relevance and MI/MCI was thought to be of past relevance. The acrylates, in particular isobornyl acrylate, were postulated to be of current relevance to her Apple Watch. Since avoiding the allergens, including the Apple Watch, her eczema has significantly improved, specifically clearing at the wrist and perioral skin. Our patient had no known previous acrylate exposure, in particular no history of using gel or acrylic nails. The Apple product website declares that many of their products contain trace amounts of acrylates and methacrylates. Knowledge that acrylates are a common cause of allergic contact dermatitis (ACD) in diabetic devices, and strong clinical suspicion about the watch, prompted us to test with the acrylate series. There are two previous reported cases of Apple Watch ACD, both attributed to nickel (Levian B, Chan GC, Adler BL. Out of REACH: allergic contact dermatitis to nickel in an Apple Watch. Contact Dermatitis 2024; 90: 99–101; Ko WC, Yu J. Nickel allergy elicited by an Apple Watch. Dermatitis 2022; 33: e11–12). Nickel is mentioned on the Apple product website, but that states that release levels are low. Interestingly in one case the dimethylglyoxime spot test was negative (Levian et al.) and the acrylate series was not tested. Our patient tested negative to nickel. There are many reported cases of ‘irritancy’ caused by smart watches; however, most have not been patch tested to the acrylate series. To our knowledge this is the first case suggesting acrylate ACD caused by a smart watch. We encourage others to test with the acrylate series in similar future cases.
CD04 The dermal–dental nexus
Authors: Hussain Fazleenah Ajmul , Williams Jeremy , Godwin Alison , Yesudian Paul Devakar
Published: June 2024

Allergic contact dermatitis (ACD) from acrylates is frequently observed in occupational settings, particularly among dental workers, nail technicians and beauticians. In the last 2 decades, there has been a shift in the types of products causing ACD related to acrylates, transitioning from conventional sources like dental materials, glues, sealants, adhesives, paints and printing inks, to increasing prevalence in nail cosmetics. Recent studies indicate that 64% to > 80% of reactions to acrylates were related to cosmetic nail products. In dermatological practice, patients undergo patch testing for oral reactions following dental procedures involving acrylates. In these patients, previous nail acrylate sensitization is thought to play a role. Systemic contact dermatitis (SCD) refers to a condition where sensitization via the skin leads to subsequent reactions to the same or crossreacting allergens systemically. Recognizing the significance of this phenomenon, we conducted a survey among dental workers in the UK to gauge their awareness of this association. We received 49 responses, of which 39 (80%) were from general dental practitioners. Our cohort was highly experienced, with 21 (43%) having > 20 years’ experience. Most respondents (31, 63%) were from Wales, and 30 (61%) spent > 75% of their time working with the NHS. Overall, 26 (53%) responders reported that 5 to 10 patients a day required acrylate as part of their treatment, while 14 (29%) stated that they use it in fewer than 5 patients a day seeking dental treatment. In total, 34 (69%) did not routinely enquire about patients’ past allergy or sensitivities to nail acrylates before undertaking acrylate-related dental procedures. One responder asked this routinely and two (4%) responders felt that there was no evidence for this. Nineteen (39%) expressed uncertainly about encountering oral reactions following exposure to dental acrylates in patients with nail acrylate allergy as they were not aware of this association. Seventeen (35%) did not experience any such reaction, while eight (16%) encountered this, albeit rarely. In total, 32 (65%) were unaware that nail acrylate sensitization could lead to oral reactions following dental acrylate exposure, and a significant majority (47, 96%) had never received education on this association. The survey underscores a lack of awareness among dental practitioners regarding the potential for SCD causing oral reactions after nail acrylate sensitization. Given the relevance of these findings, it is imperative to incorporate this knowledge into dental undergraduate curricula.
CD05 Consort allergic contact dermatitis to occupational acrylates
Authors: Khan Yasmin , Latheef Faheem
Published: June 2024

A 52-year-old woman presented to dermatology with severe widespread dermatitis, characterized by spongiosis on a recent skin biopsy. Despite thorough investigation, a definitive cause remained elusive. The patient underwent patch testing with the baseline, photopatch, anti-infective, excipient, cosmetic, textile, fragrance and acrylate series. Patch testing revealed multiple positive 3+ blistering reactions to various acrylates: 2-hydroxyethyl methacrylate, 2-hydroxypropyl methacrylate, ethylene glycol dimethacrylate, 1,4-butanediol dimethacrylate, 1,6-hexanediol diacrylate, tetrahydrofurfuryl methacrylate, tetraethylene glycol dimethacrylate, butyl acrylate, ethyl acrylate, 2-hydroxyethyl acrylate and triethylene glycol diacrylate. The patient lacked any direct exposure to acrylates through common sources such as gel, shellac or acrylic nails; dental materials; dressings or bone cement. Further inquiry revealed that the husband’s profession was in windscreen repairs, where he routinely handled resins containing acrylates, which he would wipe on to his work overall. It emerged that the transfer of resin onto his clothing, subsequently laundered alongside the patient’s own clothes, likely facilitated sensitization. Analysis of the husband’s work-related resin products confirmed the presence of several acrylates implicated in the patient’s patch test reactions. Given the severity of her symptoms, including blistering reactions, a consort allergic contact dermatitis (CACD) to occupational acrylates was strongly suspected. Following counselling on allergen avoidance strategies, the patient consciously avoided close contact with her partner’s work clothing and began laundering her garments separately. Remarkably, this intervention led to complete resolution of her symptoms. CACD, also referred to as connubial contact dermatitis, is a recognized phenomenon wherein one develops allergic reactions to allergens originating from another individual. A recent systematic review reported a female predominance (62.8%) in cases of CACD, with partners or spouses being the most common consorts (50.0%) (Lee J, Guo S, Dinalo J et al. Consort allergic contact dermatitis: a systematic review. Dermatitis 2022; 33: 181–6). Exposure from a partner’s occupation was noted in a subset of cases (14.6%), underscoring the relevance of occupational history in such presentations. A caregiving relationship was also frequently involved. This case represents the one of the first documented instances of CACD attributed to occupational acrylates. It highlights the need for comprehensive social and occupational history taking in dermatology settings. It underscores the importance of considering potential sources of allergen exposure from partners or dependants, particularly in cases with unusual clinical presentations.
CD06 Beryllium is back: a case of culinary contact dermatitis
Authors: Lee Pui Chi , Thompson Donna
Published: June 2024

Beryllium is a metal with physical properties including a great strength-to-weight ratio, making it stronger than steel. It is a useful material in many industries and is used in metal alloys. It is found in tools, dental and medical prostheses, and the aerospace industry. We report an unusual case of occupational hand dermatitis in a chef secondary to beryllium-containing tools. A 23-year-old woman with hand dermatitis was seen in our cutaneous allergy clinic for patch testing. She is right-handed and reported a 3-year history of blistering, erythema and cracking of the palms of both hands. A suspected source was the professional chef’s knives that she had purchased over 7 years ago and had been using daily. There was no past medical or surgical history of note, and no history of dental work. Patch testing was performed to the standard, cosmetics, rubber, metals, plants and woods series, with a positive reaction to only diallyl disulfide (1% in petrolatum) on day 2 (48 h). However, she later developed a new positive reaction on day 9 (216 h), confirmed to be beryllium sulfate tetrahydrate (1% in petrolatum). Her hand dermatitis improved with garlic avoidance, and the discontinued use of the utensils, often made with beryllium-containing alloys. At our centre, we have patch tested a total of 731 patients to beryllium in our extended metal series in the past 20 years. There were four other patients who patch tested positive to beryllium with association to occupation and medical prostheses. In one case it was felt that the copper beryllium alloy wires used in the flexible leads of their pacemaker were relevant. Beryllium is an uncommon cause of allergic contact dermatitis, with published case reports notably highlighting the tendency to late reactions, particularly occurring between day 7 and day 10 (Toledo F, Silvestre JF, Cuesta L et al. Contact allergy to beryllium chloride: report of 12 cases. Contact Dermatitis 2011; 64: 104–9). Such delayed reactions are often under-reported, as routine patch test readings are not performed after day 4 or day 7. Toledo et al. published a case series of 12 patients with positive reactions to beryllium chloride and suggested that readings between day 7 and day 10 can be useful whenever beryllium is patch tested. Our case reinforces the value of taking patch test readings beyond day 4 when specific metal allergies are suspected. It also demonstrates beryllium-containing utensils as a cause of culinary contact dermatitis and highlights these as an additional source of occupational exposure.
CD08 ‘If it’s not the hair maybe it’s in the air?’ A case of allergic contact dermatitis from airborne exposure to acrylates
Authors: Khan Yasmin , Latheef Faheem
Published: June 2024

A 38-year-old auditor was referred for patch testing for a suspected hair dye reaction following development of a florid eczematous reaction on her face after a hair dye appointment. This reaction predominantly affected her cheeks, with the left more so than the right, extending to just below her eye. She also had mild eye swelling. The description and photographs taken at the time were atypical for a hair dye reaction, and on further questioning she revealed she had been sat in close proximity to someone undergoing acrylic nail treatment during the aforementioned hair appointment. We undertook patch testing to our baseline, anti-infective, excipient, hairdressing, fragrance, acrylic nail, cosmetic, photopatch and perianal series. Positive results were observed for 14 acrylates found in acrylic nails, namely methyl methacrylate, 2-hydroxypropyl methacrylate, ethylene glycol dimethacrylate, triethylene glycol dimethacrylate, urethane dimethacrylate, bisphenol A dimethacrylate 2%, bisphenol A glycidyl dimethacrylate 2%, 1,6-hexanediol diacrylate, tetrahydrofurfuryl methacrylate, tetraethylene glycol dimethacrylate, butyl acrylate, ethyl acrylate, 2-hydroxyethyl acrylate, and triethylene glycol diacrylate. No reactions were observed to any hair dyes on patch testing. Skin prick testing for para-phenylenediamine (PPD) was also negative, excluding a type 1 allergy to PPD. She reported prior but infrequent use of acrylic nails, the last instance being over a year ago. It is therefore likely that the patient became sensitized through these exposures, leading to a pronounced reaction following subsequent airborne exposure to acrylates. An increasing incidence of allergic contact dermatitis (ACD) to acrylates has been noted, particularly among nail technicians and consumers. Although airborne contact dermatitis to acrylates is rare, it has been reported in occupational settings involving nail technicians and dental nurses, and in manufacturing. Facial dermatitis or dermatitis in exposed areas without direct allergen contact has been documented. Additionally, four cases of respiratory sensitization with acrylate-induced occupational asthma have been reported in conjunction with ACD. Respiratory problems were often alleviated with mask usage, but airborne contact dermatitis posed greater challenges, prompting job changes. Efforts to collect sensitizers using air pumps for vapours and filters for airborne aerosols have seen limited success. This unusual case underscores the diverse clinical presentations of acrylate sensitivity and emphasizes the importance of promptly detecting the allergen to prevent further exposure. Awareness of airborne allergic contact dermatitis to acrylates is useful in occupational disease reviews. Additionally, efforts should be made to minimize airborne methacrylate concentrations to reduce sensitization risk.
CD15 The role of lipid-metabolizing enzymes in CD1a-associated cutaneous inflammation
Authors: Ye John , Ng Jessica , Singh Randeep , Nahler Janina , Naidoo Karmella , Hardman Clare , Gao Fei , Gileadi Uzi , Chen Yi-Ling , Ogg Graham
Published: June 2024

Atopic dermatitis (AD) is a common, relapsing–remitting inflammatory skin disease that is associated with other disorders such as food allergy, allergic asthma and rhinitis, leading to increased rates of morbidity and mortality. The discovery of CD1a involvement in AD pathogenesis through the presentation of permissive neolipid antigens generated by house dust mite phospholipase A2 (PLA2) enhanced our understanding of the complex network of T-cell targets that contribute to disease development. As well as defining agonist lipids, it is now known that very long-chain sphingomyelins can act as natural lipid antagonists of CD1a–T-cell receptor (TCR) engagement. We sought to determine whether bacterial sphingomyelinases (SMases) could also activate CD1a-reactive T cells and help explain the known bacterial infection-associated manifestations of AD. An isoelectric focusing system was used to evaluate the hydrolytic capacity of bacterial SMases on very long-chain CD1a-preferred sphingomyelins. Additionally, this approach permitted examination of the impact of cobalt and nickel ions on bacterial SMase activity. Furthermore, using primary human T-cell clones and TCR transfer with CRISPR Homology Directed Repair, we evaluated SMase-reactive CD1a-dependent T-cell responses. Moreover, we examined both lesional and nonlesional skin from patients with AD, patients with psoriasis and healthy controls using RNA-Seq. Bacterial SMases were able to digest CD1a-selected sphingomyelins, and the enzymatic activity was potentiated by the presence of divalent metal ions, which are known contact dermatitis allergens. Furthermore, bacterial SMase-reactive CD1a-dependent T-cell responses were identified through markedly increased detection of AD-associated inflammatory cytokines and elevated activation marker expression. Consistency of responses between the primary T-cell clones and HDR T cells confirmed that these responses were indeed TCR specific. Skin transcriptomic changes included altered lipid processing pathways, in particular, mammalian SMase and PLA2-mediated pathways, activated in lesional tissue. We showed that bacterial SMases can effectively degrade very long-chain antagonist sphingomyelins and potentiate CD1a-reactive T-cell responses. In addition, our bioinformatics analysis revealed enhanced expression of mammalian SMases in lesional AD and psoriasis, suggesting potential broad involvement of this enzyme class in skin inflammation. This study extends our understanding of the role of lipid-metabolizing enzymes to CD1a-dependent T-cell activation in AD pathology, as well as defining a hitherto unknown pathway of contact dermatitis. The mechanisms provide insights towards novel targets for therapeutic intervention. The principal investigator has received relevant research collaboration support from UCB and Janssen. The principal investigator and some members of the group are on patents filed on CD1a.
DS15 Lentigo maligna: mapping using confocal microscopy and the impact of multiple facial surgeries on patient quality of life
Authors: Leahy Marion , Laing Mary
Published: June 2024

Lentigo maligna (LM) can present with subclinical extension that may be difficult to define preoperatively and lead to incomplete excision and potential recurrence. Preliminary studies have used reflectance confocal microscopy (RCM) to assess LM margins. Knowing the margin prior to surgery allows for forward planning and enables the doctor to discuss the plan with the patient. The objectives of this study were (i) to evaluate the correlation of subclinical extension of LM defined by RCM compared with the gold standard of histopathology, and (ii) to assess the impact of multiple surgical excisions on a patient’s mental health and quality of life. This was a prospective study of patients with LM referred for surgery. RCM was performed at the clinically defined initial surgical scar, followed by staged RCM imaging of the ‘normal’ skin to define the exact margin of the lesion. Punch biopsies were then completed along the negative margin to ensure the accuracy of the results. Patients then completed a questionnaire detailing their knowledge of LM and the impact that multiple surgeries had on their life. Ten patients were included: five male and five female. All patients had undergone multiple surgeries without obtaining a negative margin. Ninety per cent had a facial lesion and 10% had a chest lesion. The mean largest diameter was 2.8 cm (range 0.8–5). Diagnostic accuracy for detection of residual LM using RCM was 97%. Histopathology correlation revealed that 96% of biopsies matched the RCM findings. All participants reported a negative impact on their quality of life. Eighty per cent of patients thought LM was melanoma. Fifty per cent of patients were not informed of the nonsurgical options. Twenty-five per cent of patients would not have opted for surgical excision if they had understood the extent of the surgery. In conclusion, providing optimal care for patients with LM requires a multidisciplinary approach. RCM is an useful tool to aid surgical planning and for managing patient expectations in LM.
DS18 Pre-Mohs biopsy survey (related specifically to basal cell carcinoma and biopsy prior to Mohs surgery)
Authors: Nassar Omar , Shah Dev
Published: June 2024

Mohs micrographic surgery (MMS) is a specialized surgical technique for removing locally invasive, high-risk skin cancers. MMS provides high cure rates with maximal preservation of unaffected tissue (Hanke CW. Frederic Mohs tribute. History of Mohs micrographic surgery. J Drugs Dermatol 2002; 1: 169–74; Brodland DG, Amonette R, Hanke CW, Robins P. The history and evolution of Mohs micrographic surgery. Dermatol Surg 2000; 26: 303–7). In contrast to standard excision, in which only a small portion of the margins is evaluated, in MMS, specimens are cut in horizontal sections that allow the evaluation of the entire peripheral and deep margins of the tumour. This survey was conducted to gather different opinions about type of biopsies used before Mohs surgery specifically for basal cell carcinoma (BCC). The survey was sent to British Society for Dermatological Surgery members all over the UK. The survey aimed to investigate participants’ opinions in doing biopsies before Mohs surgery specifically for BCC. This includes the types of the biopsy they prefer, and how it affects the Mohs procedure, for example whether there is a specific type of biopsy that results in the need to take more deep levels during the Mohs procedure. Of the responses received, 60% were from dermatology consultants, about half of whom are Mohs surgeons. Overall, we found that about 50% do routine biopsy before Mohs, 65% prefer scoop biopsy or shave biopsy and only 10% do punch biopsy, while 15% do not mind the type of the biopsy. We were interested that 50% routinely do biopsies prior to Mohs, and of these at least 10% are punch biopsies, which we feel should be limited as they can induce a deep scar and result in more layers being taken during the Mohs surgery procedure in order to clear the scar.
DS21 Perils of a 3-mm punch biopsy
Authors: Victory Liana , Brady Ronan , Quigley Claire , Kevane Barry , Moloney Fergal
Published: June 2024

An 83-year-old woman underwent a 3-mm diagnostic punch biopsy from a Bowenoid patch on her right cheek. Her medical background was significant for invasive cholangiocarcinoma and she was on active treatment with gemcitabine under the care of oncology. In terms of anticoagulation she was on aspirin 75 mg as a preventative measure. Unfortunately, the patient developed ongoing bleeding from the biopsy site and presented to the emergency department. She was reviewed in the emergency department, the wound was sutured and haemostasis was noted. Over the next few days, she had progressive bleeding from the biopsy site. A plastic surgeon was consulted and the site was examined, cauterized and resutured. During the procedure haemostasis was achieved. The patient was discussed with haematology, and tranexamic acid for 3 days was recommended and aspirin was held. Routine bloods and a coagulation screen were sent. It was noted there was an isolated prolongation of the activated partial thromboplastin time. A diagnosis of acquired factor VIII deficiency was made following a coagulation screen in the department. She was transferred to the National Coagulation Centre for management and replacement of factor VIII. She was commenced on prophylactic FEIBA (anti-inhibitor coagulant complex) intravenous three times per week. Acquired haemophilia A is a rare but severe autoimmune bleeding disorder caused by circulating autoantibodies that inhibit the coagulant activity of factor VIII. It is more frequent in older patients and is associated with several conditions such as malignancies, the postpartum period, autoimmune diseases and drug exposure. This is a rare presentation; however, it highlights the risks involved with even minor dermatological surgical procedures and the importance of consenting patients for these possible complications.
DS27 Laser hair depilation therapy for pilonidal sinus disease: a 5-year, retrospective experience in a university teaching hospital in the UK, 2017–2023
Authors: Andrew Kashini , Dyson Maya , Lee Pui Chi , Patel Pooja , Applewaite Rona , Thomson Michelle , Nevill Alan M
Published: June 2024

Pilonidal sinus disease (PSD) is a chronic debilitating condition affecting young adults. Laser hair depilation is an established adjunct to surgical treatment for PSD and can lead to reduced rates of recurrence and postsurgical interventions (Harries RL, Alqallaf A, Torkington J, Harding KG. Management of sacrococcygeal pilonidal sinus disease. Int Wound J 2019; 16: 370–8). This study aimed to assess the outcome of laser hair depilation therapy on disease progression in patients with PSD at the Birmingham Skin Centre, Birmingham, UK. We report retrospective data of 97 patients with PSD referred for laser hair depilation therapy. We collected the patient demographics, clinical stage of PSD, laser types utilized, number of laser sessions, and surgical interventions by reviewing electronic medical records. Most patients affected were male, with a male-to-female ratio of 3.5 : 1. The average age of the patients was 22 years. Most patients had mild PSD in this cohort. Of the 51 patients who completed the treatment, most required between eight and nine laser treatment sessions; 32 had completely healed PSD at the end of their treatment. Patients with early disease required fewer laser treatment sessions than patients with advanced disease, even though it was not statistically significant (P < 0.01). Most of the patients treated were referred for laser hair depilation treatment after having surgical interventions. No complications were reported in this cohort. This study shows that laser hair depilation is a safe and cost-effective adjunct to surgical treatments for PSD, and increasing access to this outpatient noninvasive procedure would be of significant benefit to patients with PSD, as we have demonstrated in our centre.
DP16 Nicolau syndrome (embolia cutis medicamentosa) due to glatiramer acetate (Copaxone) injection: a case report
Authors: Mukhtar Sadaf , Rashid Sahrish , Hawari Rand
Published: June 2024

Nicolau syndrome (NS) is a rare cutaneous drug reaction that occurs at the site of an intramuscular drug or intra-articular injection. NS has been reported with the administration of various other drugs such as penicillins {Modzelewska I, Dawidowicz-Szczepanowska A. [Nicolau syndrome following administration of procaine penicillin]. Wiad Lek 1980; 33: 231–3 (in Polish)}, local anaesthetics, corticosteroids (Cherasse A, Kahn MF, Mistrih R et al. Nicolau’s syndrome after local glucocorticoid injection. Joint Bone Spine 2003; 70: 390–2) and nonsteroidal anti-inflammatory drugs. Patients experience extremely severe pain around the injection site of the drug immediately after injection, followed by rapid development of erythema, a livedoid reticular patch or a haemorrhagic patch. It may result in necrosis and ulceration of the skin. We report the case of 50-year-old woman who presented with areas of skin discoloration over her left axilla and left arm after an injection of Copaxone (glatiramer acetate) for her multiple sclerosis. It was painful and swollen. She has a past medical history of multiple sclerosis, epilepsy and an underactive thyroid. She has been on glatiramer acetate injections for multiple sclerosis for more than 3 years but has never had any reaction. Drug history included glatiramer acetate, levothyroxine, pregabalin, udenafil, propranolol, levetiracetam and docusate. There was no known drug allergy. She was seen by an on-call dermatologist. On examination there were bruise-like patches on her left lateral arm and left axilla, with some livedoid pattern. Bloods and medical photographs were taken. Incisional biopsy was done. On review after a few days, the swelling had decreased but the skin discoloration persisted and the skin was tender. Skin bacteriology swab was taken. Blood showed a slightly deranged clotting profile and raised creatinine kinase. Autoimmune screen was negative. Skin biopsy showed necrosis of the squamous epithelium, fibrinoid thrombi in superficial and mid-dermal blood vessels, and occasional eosinophils. This was suggestive of NS. Over time the rash evolved into indurated ulcerated plaques with a necrotic surface. Oral doxycycline 100 mg once daily was started, as a swab showed a heavy growth of Staphylococcus aureus. Glatiramer acetate injection was discontinued. She was treated with AQUACEL (silver-containing) dressing, clobetasol propionate cream for the surrounding skin, and surgical debridement. The skin healed completely within 20 weeks with scarring. NS is an important cause for morbidity and also of mortality in severe cases. There is no specific therapy. Conservative treatment with debridement, pain control and dressings are the mainstays of therapy. This case highlights the need for awareness about this rare condition.
DP22 An unusual presentation of acquired perforating dermatosis
Authors: Murphy Lisa , Hackett Caitriona
Published: June 2024

Granulomatosis with polyangiitis (formerly known as Wegener granulomatosis) is a rare condition that can affect people of all ages and ethnicities. We present the case of a patient who presented with a rash consistent with vasculitis on his fingers and nose, and a number of keratotic papular lesions on his elbows. These lesions were pruritic and were clinically consistent with perforating dermatosis. Biopsy of a lesion on his left elbow showed skin with central dome-shaped epidermal ulceration in the epidermis with abundant cellular debris and collagen fibres. The features were in keeping with a perforating dermatosis. Initially, he was commenced on methylprednisolone, before being switched to rituximab infusions. His rash resolved, and he developed no further new lesions. Perforating dermatoses are characterized by the transepithelial elimination of dermal connective tissue through the epidermis. The acquired form is more common and typically presents in patients with diabetes mellitus and chronic renal disease. The lesions usually present as umbilicated, keratotic papules on the extremities. The histology of acquired perforating dermatoses typically demonstrates epidermal invagination with a keratotic plug consisting of collagen, keratin or elastic fibres. Perforating dermatosis in patients with granulomatosis with polyangiitis is very rare. Treatment for acquired perforating dermatosis is primarily centred on treating the underlying disease. Options include antihistamines, topical corticosteroids and keratolytic agents such as salicylic acid.
PA08 Extensive congenital epidermal skin loss with sparing of the palms, soles and head: strikingly similar appearances in four patients with neonatal herpes simplex infection
Authors: Vaughan Emily , Balboa Pablo Lopez , Martinez Anna , Ravenscroft Jane
Published: June 2024

We present a case series of four preterm neonates from two tertiary centres in the UK. All presented at birth with 90% epidermal skin loss. In all four neonates, there was a strikingly similar presentation, with skin spared on the palms, soles, and areas on either the face or scalp. Three of the neonates tested positive for herpes simplex virus (HSV) type 1 and one tested positive for HSV type 2 on skin swabs taken soon after birth. None of the mothers gave a history of genital HSV infection. In the past, this pattern of skin loss has been attributed to severe congenital erosive and vesicular dermatosis, with a differential diagnosis of aplasia cutis or epidermolysis bullosa. HSV has been recognized in a few cases but there is limited literature available discussing widespread skin loss secondary to HSV infection. In utero HSV is rare in neonates and accounts for 5% of all neonatal herpes infections. Intrauterine HSV has an increased risk of preterm labour and has been reported to occur in asymptomatic mothers with no history of genital herpes. HSV contracted in utero commonly presents with cutaneous lesions in the context of an unwell neonate and carries a high risk of eye involvement, mouth disease and neurological complications such as encephalitis, meningitis and neurodisability. Babies with this suspected diagnosis need urgent skin swabs for viral polymerase chain reaction and bacterial culture. Early treatment with high-dose intravenous antivirals prior to swab results is essential. Full neonatal intensive care support is needed, as well as analgesia, gentle handling and antibiotics. Neonates are best managed in a tertiary neonatal intensive care setting with input from the national epidermolysis bullosa team, due to the extensive nature of the skin loss. Two of our cases healed with severe reticulated scarring and contractures, requiring multiple procedures and extensive physiotherapy. The other two did not survive the neonatal period despite early diagnosis and a multidisciplinary approach. Management of HSV in future pregnancies must be discussed with the obstetric team. This is the first case series describing a characteristic pattern of severe skin loss among neonates with congenital HSV. We recommend early recognition and empirical treatment of HSV, while swabs are awaited.
PA15 Paediatric lupus vulgaris masquerading as an unusual facial lesion: a diagnostic dilemma
Authors: Chandran Ashima R
Published: June 2024

We present a rare case of lupus vulgaris in a 9-year-old boy with an asymptomatic raised lesion on the left cheek, initially posing a diagnostic challenge due to its atypical presentation. Clinical and investigative findings were analysed, including the patient’s medical history, physical examination, routine investigations, Mantoux test, differential diagnoses, histopathological examination and response to treatment. The patient presented with a progressively enlarging, single, well-defined erythematous plaque (1 × 1 cm) on the left cheek over 2 months. Notably, a bacille Calmette–Guérin scar was present, and routine investigations, including chest X-ray, were normal. The Mantoux test yielded a positive result (18 mm). Differential diagnoses considered were borderline tuberculoid Hansen disease, lupus vulgaris, sarcoidosis, and granuloma annulare. Histopathological examination revealed mild flattening of the epidermis with elongated rete ridges, accompanied by numerous epithelioid granulomas in the dermis and epidermal junction, surrounded by inflammatory infiltrate. A 20% acid-fast bacilli (AFB) staining for Mycobacterium tuberculosis was positive. However, sputum smear for AFB was negative. The final diagnosis was lupus vulgaris, a rare form of cutaneous tuberculosis. This case highlights the importance of considering lupus vulgaris in the differential diagnosis of facial lesions, even in paediatric patients. The positive Mantoux test and histopathological findings supported the diagnosis, emphasizing the need for a multidisciplinary approach in challenging cases. Treatment involved a 6-month course of category 1 antitubercular therapy. This case underscores the significance of early diagnosis and prompt initiation of appropriate therapy to prevent complications and ensure a favourable outcome. This report contributes to the limited literature on lupus vulgaris in paediatric patients, emphasizing the necessity of vigilance among dermatologists in recognizing atypical presentations of cutaneous tuberculosis, particularly in regions with a high prevalence of tuberculosis.
PA16 Isotretinoin under the lens
Authors: Long Amy , O’Malley Sean , Quigley Claire , Collins Sinead
Published: June 2024

Isotretinoin has been a widely prescribed medication in the field of dermatology for almost 50 years. It has been heavily scrutinized because of its teratogenicity, association with mood disturbance, and now its potential for sexual dysfunction. Ophthalmic adverse sequelae, although frequent, are the subject of less scrutiny. A 22-year-old woman was referred urgently to dermatology with a 6-month history of severe nodulocystic facial acne and extensive ice pick scarring. She had not responded to a combination retinoid and benzyl peroxide cream and an oral tetracycline antibiotic. She had an intrauterine device for contraception, and her medical history was otherwise unremarkable. Her most recent eye exam was 4 years previously for a mild convergent squint. Low-dose isotretinoin was commenced in conjunction with oral erythromycin. Her dose of isotretinoin was uptitrated until control of her acne was achieved. Six weeks into treatment, a routine ocular exam revealed bilateral early cataracts. Congenital cataracts could be excluded, and no other associated risk factors could be determined. In view of the temporal relationship a potential causal association with isotretinoin was postulated. She remained on isotretinoin after a discussion regarding the risk and benefit was had. She completed a further 4 months of therapy, averaging 0.25 mg kg−1 daily, with full clearance of her acne. She had no progression of the cataracts at a 6-month ophthalmological follow-up. Despite many ocular side-effects being generally reversible and mild, there is potential for significant harm and ocular morbidity to be caused by isotretinoin. Adverse events range from surface evaporative disease and blepharoconjunctivitis more commonly, to reports of rarer events such as cataracts. Data on cataracts in the context of isotretinoin are scant and largely historical. With the added pharmacovigilance accompanying the new UK Medicines and Healthcare products Regulatory Agency’s guidance on isotretinoin, there may be an opportunity to record the impact of the ocular and mucocutaneous adverse events that have been less well studied [Commission in Human Medicines. Report of the Commission on Human Medicines Isotretinoin Implementation Advisory Expert Working Group. Available at: https://www.gov.uk/government/publications/report-of-the-commission-on-human-medicines-isotretinoin-implementation-advisory-expert-working-group (last accessed 19 April 2024)]. Our case serves to remind prescribers of isotretinoin of potential serious ocular toxicity associated with this common drug, and to include ocular symptoms in our checklist of adverse events.
PA18 Audit of direct booking of urgent dermatology slots by the emergency department
Authors: Carter-Hurst Jonathan , Nadeem Muna , Goodyear Helen
Published: June 2024

Children with skin disorders frequently present to emergency departments (EDs) with onward referral to dermatology. Recognizing the urgency of some presentations, and to minimize requests from ED for an immediate dermatology opinion, we created one dedicated ED slot on all consultant dermatology clinics, which was directly bookable by the ED. If the slot was unfilled it could be used for other urgent referrals. This system worked well over many years, but recently clinicians have noted long waits by ED patients. To analyse slot use, we undertook a retrospective audit from 1 April 2022 to 31 March 2023. We identified 219 appointments for 210 individuals. Twelve episodes, none of which were ED referrals, were excluded from analysis due to inadequate or erroneous data. The remaining 207 referrals were from ED (85, 41.1%), general practitioners (92, 44.4%), internal specialties (15, 7.2%), external hospitals (9, 4.3%) or our own department (6, 2.9%). The commonest non-ED referrals were melanocytic naevi (34, 27.9%), infantile haemangiomas (21, 17.2%) and eczema (18, 14.8%). The most frequent ED referrals were eczema flares (29%), infected eczema (15%) and ‘nonspecific rashes’ (12%). The median symptom duration was 4 weeks (range 1 day to several years). Treatment given in ED was considered appropriate in most cases (56%) but could not be assessed in 28% because of ED clinician diagnostic uncertainty. In 11% of cases, ED sought on-call dermatology advice before booking appointments. The median wait from referral to appointment was 2 weeks (range 0–7), with an attendance rate of 84.7%. In 20% of attendances, the problem had already resolved. The audit team’s assessment of referrals was that most were warranted, with further treatment commenced in 74.1% and ongoing clinic follow-up in nearly 75%. In conclusion, our work highlights that these outpatient slots designed for ED use were being utilized for other referrals, resulting in excessive waits by ED patients with urgent needs. This reflects outpatient waiting list pressures including 2-week-wait referrals. We propose to reinforce booking rules to the call centre and to reinstate regular dermatology teaching in ED to optimize urgent first-line management.
BI05 Successful treatment with upadacitinib for severe atopic dermatitis in a patient with primary immunodeficiency (CARD11)
Authors: Iqbal Mishal , O’Driscoll Daniel , Ardern-Jones Michael R
Published: June 2024

A 42-year-old woman with a history of multiple severe allergies, asthma, urticaria, atopic dermatitis and recurrent bacterial and viral infections was diagnosed with CARD11 deficiency (heterozygous missense mutation dominant-negative) through whole-genome sequencing in 2017. Since adolescence, she had been treated with multiple systemic therapies for atopic dermatitis, including systemic corticosteroids, omalizumab, dupilumab and tralokinumab, which were eventually withdrawn due to treatment failure or intolerable adverse effects. On examination she had widespread severe eczema [Eczema Area and Severity Index (EASI) 24, Patient-Oriented Eczema Measure (POEM) 28, Dermatology Life Quality Index (DLQI) 16]. After discussion with immunology colleagues, the patient was offered treatment with upada­citinib 15 mg once daily. At follow-up 8 weeks later, there was a marked improvement in her eczema with complete resolution of itch (EASI 4, POEM 6, DLQI 2). After 5 months, she developed an episode of shingles, which responded to a 7-day course of high-dose oral aciclovir. She was able to restart treatment on alternate-day dosing of upadacitinib 15 mg. Her eczema remains well controlled. The CARD11 gene encodes a scaffold protein required for nuclear factor-κB activation in response to lymphocyte receptor binding. Homozygous null mutations in CARD11 lead to severe combined immune deficiency, while gain-of-function mutations are associated with lymphoproliferative disease. As in our patient, recently described dominant-negative mutations in CARD11 have been shown to be associated with a severe atopic phenotype, multiple allergies and variable predisposition to infection (Ma C, Stinson J, Zhang Y et al. Germline hypomorphic CARD11 mutations in severe atopic disease. Nat Genet 2017; 49: 1192–201). It is postulated that aberrant CARD11-dependent T-cell receptor signalling results in deficiencies in T-cell proliferation and a T helper (Th)2 bias in immune responses. Upadacitinib is an oral small-molecule Janus kinase (JAK) inhibitor that preferentially binds JAK1, inhibiting multiple cytokines associated with Th2 signalling. Given the reported increase in infectious adverse events compared with placebo in clinical trials, the use of JAK inhibitors in patients with inborn errors of immunity must be approached with great caution. However, in our patient with a severe atopic phenotype, recalcitrant to multiple systemic therapies, targeting the JAK1 pathway has provided a dramatic clinical benefit.
BI17 Impact of an annual multidisciplinary clinic on patient care and experience in cutaneous T-cell lymphoma
Authors: Greenish Huw , Heath Harry , Marsh Rainy , Furtado Michelle , Dunnill Giles , Bailey Claire
Published: June 2024

Cutaneous T-cell lymphomas (CTCLs) are a group of rare conditions with diagnostic and management challenges and reduced patient quality of life (QoL). Optimal management requires haematology, dermatology and referral to a local skin specialist multidisciplinary team (MDT), with further referrals to a regional supranetwork skin MDT for some patients. An annual CTCL clinic day was established to bring the MDT to the patient and address the challenges of CTCL. Objectives included establishing a local database of patients with CTCL including staging, adjusting treatment as appropriate, upskilling local clinicians, educating patients and initiating annual QoL assessments. Currently two annual clinics have taken place with a third planned. Patients with both known and suspected CTCL were invited. The clinics included nurse-led patient education and a 30-min dermatology-led consultation with access to a specialist haematology consultant and regional CTCL expert. On-the-day blood tests and diagnostic biopsies were performed if needed. Patients completed pre- and postclinic questionnaires for feedback, itch visual analogue scale and Dermatology Life Quality Index and mycosis fungoides (MF)-QoL assessments, and clinician feedback was sought. A total of 31 patients attended one (n = 17) or both (n = 14) clinics following an average 28% late-cancellation/no-show rate. Across the two clinics, it was determined that a total of eight patients did not have CTCL. All patients with CTCL were appropriately staged. Of those attending both annual clinics only 1 patient had a stage progression (IA to IB) and the majority had stable or improved QoL (9 of 13, MF-QoL). Four patients had unplanned hospital visits between clinics, all due to symptom or disease progression. Of the 23 patients with CTCL, 10 had their treatment type changed at one or both of the clinics, 3 had the frequency changed, 3 stopped treatment and 7 had no change in treatment. Patient feedback regarding the clinic was positive with 93% rating the outcome of the clinic as excellent or very good, and 97% responding that they would attend a similar clinic in the future. Some patients retained knowledge from the first clinic education session, whereas others did not and these patients benefited from repeat education. Clinician feedback also reported high value. The outcome of the first two annual CTCL MDT clinic days demonstrated the value patients placed on the service and the need to tailor education frequency to individual needs. In summary, the annual clinic efficiently delivers patient-centred management and care, and education to both patients and clinical teams, and ensures close working relationships between departments within the Trust. This project was a joint working partnership between the Trust and Recordati Rare Diseases UK.
BI21 Lues maligna mimicking pyoderma gangrenosum and cutaneous lymphoma
Authors: McKenzie Ning , Hickey Matthew , de la Sancha Carlo , Coates Sarah , Leslie Kieron
Published: June 2024

A 44-year-old man was referred for 2 months of erythematous ulcerative papules and plaques on the scalp, face and lower legs. The lesions started as painful ‘pimples’. He also reported fever and chills. He had a 5-year history of well-controlled HIV on antiretroviral therapy since diagnosis and a prior history of recurrent syphilis. Exam showed a large violaceous plaque on the right cheek with surrounding erythematous papules and an additional erythematous papule on the left ear. On the bilateral ankles and calves were four ulcers with necrotic centres and purple borders. The differential diagnoses included pyoderma gangrenosum and cutaneous lymphoma. A punch biopsy of the right zygomatic area showed dermatitis with a dense, diffuse plasma cell infiltrate suggestive of syphilis. The acid-fast bacteria (AFB), periodic acid–Schiff with diastase (PAS-D), and spirochete stains were all negative. Rapid plasma regain (RPR) was reactive at 1 : 4096. HIV was detected at < 30 copies per mL. Absolute CD4 T-cell count was 529 cells per μL. AFB and fungal cultures were negative, and bacterial culture showed rare Staphylococcus aureus. Although the spirochete stain was negative, it is only 70% sensitive and the positive RPR with histopathology supportive of syphilis in a patient who was positive for HIV confirmed the diagnosis of lues maligna. The patient received one dose of 2.4 million units of intramuscular penicillin G benzathine. He continued empiric doxycycline 200 mg daily, which had previously been initiated, and continued doxycycline postexposure prophylaxis after diagnosis. The patient reported healing with no new lesions 3 weeks after treatment. A new question brought on by this case is whether prior history of recurrent syphilis infection has a role in developing lues maligna. This patient in particular required syphilis treatment four times in the 3 years leading up to his presentation. Current literature describes a patient who was treated for secondary syphilis, then reinfected with malignant syphilis. However, further research is needed to elicit whether recurrent syphilis infections increase the chances of severe infection or malignant syphilis.