bluuebunny/crossref_metadata_2025_split huggingface dataset:
DS04 A transcontinental qualitative comparison study of two Mohs external quality assurance programmes
Authors: Aslam Arif 
Published: June 2024

Abstract
Mohs micrographic surgery (MMS) has been shown to be an effective treatment for nonmelanoma skin cancer. It provides distinct advantages over traditional excisional surgery and its success rate is dependent on the accurate microscopic evaluation of carefully mapped specimens. The Mohs surgeon must be able to translate abnormal findings on the tissue map into appropriate sequential tumour removal. A critical component of this technique is the surgeon’s skill in interpreting histological specimens. Some studies have investigated the concordance of Mohs surgeons’ interpretation of frozen sections with that of dermatopathologists. The American College of Mohs Surgeons has successfully run an annual diagnostic quality control virtual exam. The Australasian College of Dermatologists (ACD) has a well-established external and independent quality assurance programme in conjunction with the Royal College of Pathologists Australia Quality Assurance Program. The British Society for Dermatological Surgery launched its own external quality assessment programme in 2022. This study compares the quality control programmes of both Australia and the UK and highlights key differences and lessons from both.
DS11 Buffering of lidocaine, time for a British Society for Dermatological Surgery position statement?
Authors: Nguyen Uyen , Habaluyas Katrina , Oliphant Thomas 
Published: June 2024

Abstract
Patients often experience pain or discomfort during local anaesthetic administration in Mohs surgery. Buffering local anaesthetics with sodium bicarbonate has been proven as a potential means to mitigate this pain in various research. However, despite the evidence, there are no standardized guidelines in the UK outlining the application of sodium bicarbonate buffering, which results in its limited application in practice and potential to improve patient comfort and quality of healthcare. This study investigates the usage of sodium bicarbonate-buffered Xylocaine solution in Mohs micrographic surgery as a simple, effective technique to reduce discomfort associated with the injection of local anaesthetic at a tertiary centre in the UK. Sodium bicarbonate (2 mL of 8.4% w/v) was mixed with 20 mL of Xylocaine 1% (lidocaine 1% with adrenaline 1 : 200 000) in a ratio of 1 : 10 to create a buffered solution. This buffered mixture was used for anaesthesia during Mohs surgery procedures on the head and neck. Pain assessment was conducted using a numerical rating scale ranging from 0 to 10, with 10 representing the worst pain. Pain scores were collected for each lesion injected in all patients receiving unbuffered Xylocaine and buffered Xylocaine. Unpaired t-tests were used for statistical analysis to compare the average pain score per lesion in both groups. The study included 62 patients, 28 receiving unbuffered Xylocaine and 34 receiving buffered Xylocaine. In total, 37 lesions were injected with buffered Xylocaine, and 47 lesions were injected with unbuffered Xylocaine. The average pain score for each lesion in the buffered Xylocaine group was lower than for the unbuffered Xylocaine group: 0.94 and 1.76, respectively (P = 0.03). For patients receiving injections to the nose (n = 16), 11 received buffered Xylocaine for 12 nose lesions, and five received unbuffered Xylocaine group for six nose lesions. The average pain score per nose lesion in the buffered Xylocaine group (0.75) was notably lower than that in the plain Xylocaine group (3.8) (P = 0.002). Additionally, 17 patients were surveyed regarding their previous experiences with unbuffered Xylocaine injections at the same anatomical location. Out of these, 16 patients reported that buffered Xylocaine injections were less painful, while only one patient perceived no difference in pain. No adverse effects related to sodium bicarbonate were reported. The study demonstrates that buffering Xylocaine 1% with sodium bicarbonate 8.4% is a simple and effective technique to reduce discomfort associated with the injection of local anaesthetic among patients undergoing Mohs micrographic surgery, potentially improving overall patient satisfaction. This highlights the need for comprehensive guidelines to guide its integration into practice with the goal of optimizing patient care.
DP08 Striking post COVID-19 vaccine aseptic pustular folliculitis, a follicular variant of acute generalized exanthematous pustulosis
Authors: Patel Nikesh , King-Stokes Natalie , Carter Jonathan , Carr Richard 
Published: June 2024

Abstract
This case report documents the unique presentation of a 46-year-old woman who developed a widespread follicular pustular rash, prominently affecting her face, neck, upper chest and back, merely 4 days after receiving the Pfizer–BioNTech COVID-19 vaccine. Laboratory investigations revealed an elevated neutrophil count of 10.6 × 109 L−1 and an increased C-reactive protein level of 96 mg L−1. A skin biopsy showed a striking neutrophilic pustular folliculitis, characterized by the absence of viral inclusions and the presence of neutrophil exocytosis in the adjacent epidermis. A diagnosis of a follicular pustular variant of acute generalized exanthematous pustulosis was proposed. In response to the diagnosis, the patient was initiated on a therapeutic regimen, including prednisolone at 30 mg and topical applications of clobetasol propionate for her body and fusidic acid–betamethasone valerate for her face. The treatment approach aimed at alleviating the inflammatory response associated with the neutrophilic infiltration observed in the skin biopsy. The patient exhibited a slow yet progressive improvement in her rash, which transitioned from a pustular to a nonpustular presentation. This case contributes to the growing body of evidence regarding cutaneous manifestations following COVID-19 vaccination. The association between the patient’s symptoms and the Pfizer–BioNTech vaccine suggests a potential link, emphasizing the importance of vigilance in monitoring adverse events postvaccination. While the specific mechanisms underlying such reactions remain unclear, the prompt initiation of corticosteroid therapy, as demonstrated in this case, appears effective in managing the inflammatory cutaneous manifestations. The patient’s positive response to treatment underscores the clinical significance of recognizing and promptly addressing these rare dermatological side-effects associated with COVID-19 vaccination. In conclusion, this case report sheds light on a distinctive presentation of neutrophilic pustular folliculitis following COVID-19 vaccination, highlighting the importance of dermatological vigilance in the ongoing global vaccination efforts. Further research is warranted to elucidate the underlying pathophysiological mechanisms and establish optimal management strategies for these rare cutaneous reactions.
DP23 Stage presentation of melanomas arising in the back: a 20-year retrospective study of site-specific distribution and review of the literature
Authors: Kubba Faris , Hawkins Joanna , Alaani Haya 
Published: June 2024

Abstract
This is a study over 20 years to assess the pathological stage of presentation for melanomas arising in the back. We have reviewed studies for presentation of body-site-specific melanoma to compare against our findings and to see whether there has been any significant improvement in the rate of early detection. We extracted and analysed data from archived histopathology reports on the WinPath system by running a SNOMED code search on all melanomas reported from 2001 to 2011 and selected those affecting the back. The age of presentation varied from 29 to 94 years (mean 58.7). Twenty patients were male and seven female (male-to-female ratio 2.9 : 1). Most cases presented as American Joint Committee on Cancer 8th Edition stage pT1 (11 were 1a, 2 were 1b), pT2 (n = 2), pT3 (n = 4) and pT4 (n = 2). Six were in situ melanomas, mostly lentigo maligna or arising from severely dysplastic naevi. Breslow depth ranged from 0.1 to 6.5 mm (mean 1.6 mm). The cases were mostly from the upper back (n = 10). The melanoma types were superficial spreading (n = 14), nodular (n = 2), lentigo maligna (n = 3) and melanoma in situ from dysplastic naevi (n = 3). On reviewing the literature, we found one study suggesting that melanomas in visible areas present earlier. Another concluded that a melanoma is more often self-detected in female patients, explained by the high proportion of lesions in men presenting on the back. Further research suggests that older patients recognize melanomas at a lower rate than younger patients. Older men frequently have lesions in difficult-to-see areas such as the scalp and the back, and therefore also may be limited to self-notice new or changing lesions. The role of family members is as important in early detection as that of trained health professionals. As a delay in diagnosis may be responsible for the thicker melanomas in hidden areas, preventive and screening programmes should stress the importance of not neglecting these locations in self-examination. Special attention should be given to educating older men. To conclude, we have presented a laboratory-based study on the presenting pathological stage of melanoma of the back in patients aged &gt; 20 years. Half of our patients presented as stage pT1, while the other half of the tumours included in situ melanoma to stage pT4. Men predominated over women (ratio 2.9 : 1). There is no screening programme for melanoma, and providing education that raises awareness of the early signs and patient self-examination with opportunistic screening is the current standard. As the back area is not routinely inspected by patients, we believe that late presentation should be avoidable by recommending whole-body examination in general practice and dermatology clinics to ensure early detection and better prognosis of melanomas arising in the back and other hidden anatomical sites.
BG03 A case of nasal tip necrosis secondary to giant cell arteritis and a review of the cutaneous manifestations reported in large-vessel vasculitis
Authors: Binns Hannah , Steuer Alan , Zacharias Hannah 
Published: June 2024

Abstract
A 90-year-old woman presented to the emergency department with a 6-week history of a nasal tip lesion associated with left-sided headache, and scalp and facial tenderness. Visual symptoms, jaw claudication and systemic upset were absent. On physical examination, an 8 × 8-mm annular ulcerated and necrotic lesion was present on the nasal tip. Pain was elicited on palpation of the left superficial temporal artery. At presentation inflammatory markers were elevated, with C-reactive protein (CRP) 310 mg L−1 and erythrocyte sedimentation rate (ESR) 131 mm h−1. The white cell count was 13.6 × 109 L−1 and platelets were 410 × 109 L−1 and estimated glomerular filtration rate 31 mL min−1 1.73 m−2. Computed tomography of the head showed no acute abnormality. A subsequent ultrasound doppler scan of the left superficial temporal artery demonstrated changes typical of giant cell arteritis (GCA). Prednisolone (40 mg once daily) was initiated. Two weeks later the patient reported complete resolution of the headache, the necrotic area of nasal tip skin was healing, and the temporal arteries were pulsatile and nontender. CRP and ESR had reduced to 13 mg L−1 and 57 mm h−1, respectively. While GCA commonly affects the branches of the external carotid artery, any artery can be affected. Necrosis in this case was thought to be a direct result of inflammation of the distal branches of the facial artery, a branch of the external carotid artery that supplies superficial facial structures. The nasal tip area is supplied predominantly by the superior labial and angular vessels. The diagnosis of GCA was established due to the classical presentation of acute-onset headache, scalp tenderness and raised inflammatory markers, combined with the left temporal artery ultrasound Doppler findings and in association with rapid response to steroid therapy. Temporal artery biopsy was not performed. Cutaneous manifestations of GCA and other large-vessel vasculitides are rare, and as a presenting complaint are exceptional. Necrosis of the scalp and tongue is a well-recognized ischaemic complication of GCC. However, nonischaemic manifestations such as panniculitis-like lesions and acute inflammatory nodules have also been reported in the context of GCA and Takayasu arteritis. GCA presenting with necrosis of the nasal tip has rarely been reported. An older person with such a lesion could forcibly present to a 2-week-wait dermatology clinic and clinicians should consider GCA as a differential, if other suggestive features are present. Older people are more likely to be referred with suspected skin cancers, and given that GCA is the most common vasculitis among this population group, dermatologists should have a good working knowledge of the disease’s clinical features, namely headache, scalp tenderness, visual manifestations and claudication of the tongue and jaw.
BG07 Once in a blue moon?
Authors: Madhwapathi Vidya , Tso Simon 
Published: June 2024

Abstract
An 80-year-old woman with a background of Hodgkin disease, hypertension and arthritis was diagnosed with bullous pemphigoid (BP) following skin biopsy. She was managed as a dermatology outpatient with skin-directed therapies (clobetasol propionate ointment and emollients) and doxycycline 100 mg once daily (due to renal function). Following a flare of BP, the accident and emergency department added oral prednisolone 40 mg once daily with proton pump inhibitor cover, which was gradually weaned down, but disease control remained suboptimal at prednisolone 20 mg once daily. She was later admitted as an inpatient due to new-onset delirium and acute chronic renal impairment attributable to hyponatraemia and steroid-induced delirium. Despite supervised weaning of oral prednisolone (with cortisol monitored to avoid Addisonian crisis) and commencement of oral dapsone 50 mg once daily (on a background of normal glucose-6-phosphate dehydrogenase level and baseline methaemoglobin level), the delirium persisted. Full-body computed tomography was performed, showing small-vessel ischaemia. A methaemoglobin level performed after dermatology review showed an increased level of 14.2%. Methylene blue was commenced and dapsone stopped. The patient continued to deteriorate despite ward-based care. She was discharged for palliation and passed away a few weeks later. Dapsone is a drug with immunosuppressive properties, used in a wide variety of dermatological conditions including BP, pyoderma gangrenosum and vasculitis. Methaemoglobinaemia is a well-known, but uncommon side-effect. Attributing causation for this patient’s symptoms to prednisolone alone is difficult, as her symptoms started 4 weeks after, at a dose of 20 mg. Fully attributing them to dapsone is also difficult, as the symptoms had started before its initiation. However, it is likely multifactorial. BP itself, addition of immunosuppressive BP treatment, polypharmacy and subsequent methaemoglobinaemia tipped the delicate balance in a patient of advancing age, with known small-vessel ischaemia and other comorbidities. This difficult case highlights the challenges and complexities of managing dermatological conditions and the use of immunosuppression in an increasingly older population. The number of people aged ≥ 85 years in the UK was estimated to be 1.7 million in 2020 (2.5% of the UK population) and this is projected to almost double to 3.1 million by 2045 (4.3% of the UK population). The issues arising in this case will become more commonplace for dermatologists. This case emphasizes the need for working closely with colleagues caring for older patients, and for consideration of rare side-effects of medications as a contributor to delirium.
BG08 Boosting the cutaneous chronicle of the COVID-19 vaccine: it’s not over yet
Authors: Moon Emily , Peng Chenjing , Abdullah Anthony 
Published: June 2024

Abstract
The initial UK rollout of the SARS-CoV-2 COVID-19 vaccine in 2020 sparked concerns regarding vaccine-related adverse reactions. Cutaneous pustular eruptions subsequent to COVID-19 vaccination have primarily manifested after the first to third doses, with the second dose being the norm [Karampinis E, Gravani A, Gidarokosta P et al. Pustular eruption following COVID-19 vaccination: a narrative case-based review. Vaccines (Basel) 2023; 11: 1298]. We report a distinctive case of new-onset generalized pustular psoriasis (GPP) following the sixth dose of a COVID-19 vaccine in a 77-year-old woman. Our patient presented with a widespread pustular eruption affecting 80% of her body, 3 days after receiving her COVID-19 VidPrevtyn Beta monovalent B.1.351 vaccine (Sanofi). This marked her sixth dose of a COVID-19 vaccine since 2021, with no history of allergy or reactions. Her vaccination history revealed exposure to five different types of vaccines from four different pharmaceutical companies. Notably, this was her first encounter with VidPrevtyn by Sanofi. A clinical diagnosis of GPP secondary to the COVID-19 booster was made, which was supported by histological findings on a punch biopsy. She was commenced on acitretin (10 mg daily) and intravenous piperacillin–tazobactam to cover for skin impetiginization. Initial skin improvement was slow, but antibiotic-induced pancytopenia and renal impairment precluded a switch to ciclosporin. Full-skin clearance was eventually achieved after a few months of acitretin 20 mg, but discontinuation resulted in a recurrence of symptoms. Consequently, the patient continues acitretin 10 mg daily, which is proving effective for control and is well tolerated. The patient was advised against future COVID-19 vaccination and to consider early antiviral treatment for COVID-19 infection if indicated. This case serves as a poignant reminder that despite a cumulative vaccination history, significant cutaneous adverse reactions following the COVID-19 vaccine persist. The Joint Committee on Vaccination and Immunisation advocates for 6-monthly COVID-19 booster vaccines in adults aged ≥ 75 years, with a seasonal booster recommended for those aged ≥ 65 years [UK Health Security Agency. COVID-19: the green book, chapter 14a. Available at: https://www.gov.uk/government/publications/covid-19-the-green-book-­chapter-14a (last accessed 19 April 2024)]. As the landscape evolves with new variants and booster vaccines, there is an escalating potential for reactions, particularly after the first or second dose of the new booster vaccine. Furthermore, our case demonstrated a notable achievement in the effective management of vaccine-induced GPP with acitretin. It is imperative for clinicians to remain vigilant, recognizing that COVID-19 vaccination, while increasingly common, should not falsely reassure based on a negative history of numerous COVID vaccines in the past. Thoroughly assessing vaccination history is essential in clinical practice.
PA06 A cross-sectional study to evaluate the clinical and allergenic differences between intrinsic and extrinsic forms of atopic dermatitis
Authors: Garg Divya , Mahajan Rahul , Sharma Vinod Kumar , De Dipankar , Handa Sanjeev 
Published: June 2024

Abstract
Atopic dermatitis (AD) is now recognized as a condition comprising various endotypes, rather than being a homogeneous disease. One of these distinctions lies in the intrinsic and extrinsic forms of AD, which are pathogenetically different but exhibit subtle clinical differences. Limited knowledge is available regarding the comparison of clinical features between the two endotypes in paediatric populations and individuals with skin of colour. The aim of this study was to compare the frequency of occurrence of different demographic parameters and clinical features of AD between intrinsic and extrinsic AD. Consecutive children with AD, all under the age of 18 years, were enrolled. A comprehensive examination of their medical history and clinical assessment was conducted. Serum IgE levels were utilized to distinguish between extrinsic AD (characterized by high IgE) and intrinsic AD (associated with normal IgE levels). Additionally, assessments for food-allergen-specific IgE (with seven food allergens) and skin prick tests were performed. Out of the 200 children who were recruited, 181 (90.5%) had high IgE levels. The group with extrinsic AD showed a positive association with a personal history of atopy (P = 0.005), involvement of the dorsum of the hands and feet (P = 0.01), orbital darkening (P = 0.01), and prurigo-like lesions (P = 0.02). Conversely, the group with intrinsic AD exhibited a significant association with the presence of ichthyosis (P = 0.01). A moderate correlation (correlation coefficient, r = 0.48) between Scoring Atopic Dermatitis and IgE was observed, which was statistically significant (P &lt; 0.001). According to the radioallergosorbent test, the most common food allergen was wheat (46.4%), followed by peanut (39.7%). In skin prick tests, the most common allergens were house dust mites, specifically Dermatophagoides pteronyssinus (52.4%) and Dermatophagoides farina (38.1%), followed by wheat dust (23.8%), whole egg (19%) and Blomia mites (19%). However, no significant association was found between either endotype and allergen testing. The findings highlight the clinical differences, disease course and associated factors between these subtypes, which can aid in accurate diagnosis, management, and personalized care for individuals with AD.