bluuebunny/crossref_metadata_2025_split huggingface dataset:
P17 Photosensitive rashes in the context of alcoholism: a diagnosis to remember
Authors: Davies Anna , Stone Natalie , Ponnambath Nabil 
Published: June 2023

Abstract
Pellagra is a disease defined by a deficiency in niacin and its precursor tryptophan. It is a clinical diagnosis characterized by the ‘four Ds’: dermatitis, dementia, diarrhoea and death (Badawy AA. Pellagra and alcoholism: a biochemical perspective. Alcohol 2014; 49:238–50; Pipili C. The diagnostic importance of photosensitivity dermatoses in chronic alcoholism. Dermatol Online J 2008; 14:15). It is predominantly a disease of non-Western countries with low niacin-containing diets, based on maize, with little meat or vegetables. In Western populations, the commonest causes of pellagra include alcoholism, gut malabsorption, some drugs and, rarely, carcinoid, which causes increased conversion of tryptophan to serotonin, depleting niacin precursor stores. The histopathological features of pellagra are nonspecific; however, pallor and keratinocyte ballooning in the upper third of the epidermis can be suggestive. We present two cases of pellagra in the context of alcoholism. Patient 1 was a 58-year-old woman who presented with a 6-week history of a rash on the dorsal hands which spread to the forearms and dorsum of both feet. Examination revealed a photodistributed erythematous rash with a prominent leading edge, wrinkling and hyperkeratosis. She described loss of appetite, diarrhoea and increasing confusion. A punch biopsy from the right forearm showed focal parakeratosis, perivascular inflammation and mild spongiosis with increased mucin in the superficial dermis. A clinical diagnosis of pellagra was suspected, and empirical niacin was prescribed. Patient 2 was a 60-year-old woman who presented with a 1-month history of a progressive itchy rash affecting her arms and legs. Examination revealed a striking photosensitive erythematous rash of her arms and legs, with complete sparing of the inner aspect of the arms. Skin biopsy showed mild keratosis, with subtle thickening of capillary walls. A diagnosis of pellagra was suspected and treatment with oral niacin commenced. Both patients drank alcohol to excess. Both had negative plasma porphyrins and had not started any new drugs and autoimmune screens were normal. The clinical appearance was identical in both cases. Patient 1 continued to drink excess alcohol, but the rash resolved with niacin supplementation. Patient 2 only took a short course of niacin due to significant flushing, but she managed to reduce her alcohol intake significantly and her rash fully resolved. Pellagra is a rare diagnosis in a Western population, but it is an important diagnosis to remember in patients presenting with a photosensitive rash, particularly in the context of alcohol abuse.
P19 Diagnostic conundrums in paraneoplastic pemphigus
Authors: Fleming Sarah , Setterfield Jane , Mee John , Barrett Helen , Eustace Karen 
Published: June 2023

Abstract
Paraneoplastic pemphigus (PNP) is a subset of pemphigus, a group of autoimmune blistering skin disorders. A 51-year-old man presented with paraneoplastic pemphigus associated with a hepatic neoplasm. He described an epigastric mass and associated mucositis affecting the orogenital mucosae, as well as the sclerae. Both computed tomography and magnetic resonance imaging demonstrated a 14-cm mass arising from the left lobe of the liver. A liver biopsy showed features of an atypical spindle-cell neoplasm, but a definite diagnosis was not possible. A diagnostic skin biopsy was taken from his outer lip mucosae. Histology showed surface ulceration with an acute inflammatory infiltrate, lichenoid lymphoplasmacytic infiltrate with focal basal vacuolar change, degenerate keratinocytes and adjacent suprabasal acantholysis and spongiosis. Perilesional direct immunofluorescence (DIF) was negative; however, indirect immunofluorescence (IIF) showed intercellular IgG antibodies on transitional epithelium with a high titre of 1 : 800 to rat bladder. These finding were consistent with the suspected clinical diagnosis of paraneoplastic pemphigus. The patient was commenced on oral prednisolone 1 mg kg−1 daily. Topical therapy included budesonide mixed with sweetener applied to the oral mucosae. Following this, a trial of 3 days of intravenous methylprednisolone along with 2% cocaine mouthwash, triple mouthwash (betamethasone, doxycycline and nystatin) and Dermovate® ointment was commenced, with improvement noted in pain, haemorrhage and ulceration. Intravenous immunoglobulin was administered preoperatively. The patient was subsequently transferred to a specialist centre for hepatobiliary surgery and listed for debulking of the liver mass. Postoperatively, he had plasmapheresis, with a noted reduction in mucosal ulceration and significant improvement in pain. Chemotherapy with doxorubicin and ifosfamide was initiated thereafter. PNP is a severe autoimmune blistering disorder characterized clinically by flaccid blisters and erosions. Although much is yet to be understood regarding the pathophysiology of PNP, studies show that the development of autoantibodies to the plakin family and desmogleins 1 and 3 play a particular role in its pathogenesis. In addition to autoantibodies, CD8+ T cells have also been shown to contribute to the development of PNP. In adults, the majority of cases are associated with an underlying haematological malignancy and, rarely, a solid-organ tumour. DIF findings include IgG and C3 deposition along the intercellular and basement membrane zones, while IIF detects autoantibodies to proteins found in transitional or stratified squamous epithelium. As in our case, reports have shown that the DIF can be negative, with one study showing a positive DIF in only 41% of cases. This case highlights the complex diagnostic and treatment challenges practitioners face when dealing with PNP and the patients it affects.
P21 Facial papules in an immunocompromised patient
Authors: Carty Kieran , Eustace Karen , de Barra Eoghan 
Published: June 2023

Abstract
A 29-year-old man presented with a 6-week history of clustered facial papules. Of note, he had a diagnosis of HIV 5 months previously and was on maintenance antiretroviral treatment. His initial CD4 count was 5, which increased to 38, and his viral load was now no longer detectable. He had also been treated for cytomegalovirus reactivation, pneumocystis pneumonia and suspected mycobacterium infection for the previous 3 months. He had ongoing symptoms of malaise, fevers, weight loss and nausea, along with abnormal liver function tests and a raised C-reactive protein. A bone marrow trephine showed noncaseating discrete small granulomas; Grocott and periodic acid–Schiff (PAS) stains were negative. Prior to his dermatology review, the papules were initially perioral and he had been treated with empiric valaciclovir for suspected herpes simplex virus (HSV) but with no resolution. Testing for HSV DNA and syphilis was negative. On examination, there were clusters of small nontender, well-circumscribed papules (some umbilicated), distributed on the forehead, cheeks, and cutaneous and mucosal lips. A diagnostic punch biopsy was taken of one of the characteristic papules. Histological examination demonstrated a dense dermal infiltrate of histiocytes with focal non-necrotizing granuloma formation. Interspersed neutrophilic microabscesses and occasional eosinophils were present. PAS stain for fungi confirmed the presence of numerous thick-walled spherules, many with a single distinct nucleus, with some showing binucleation, consistent with fungal organisms located within the histiocytes in the dermis. Differential diagnosis included histoplasmosis, cryptococcosis, blastomycosis and coccidiomycosis. He was commenced on intravenous liposomal amphotericin B for disseminated endemic mycosis while awaiting definitive diagnosis. Formal identification by panfungal polymerase chain reaction of skin tissue was positive for Histoplasma capsulatum and itraconazole was added. The diagnosis was consistent with disseminated histoplasmosis with cutaneous involvement. The lesions resolved completely over 4 weeks, with some residual hyperpigmentation remaining. Histoplasma capsulatum is a dimorphic fungus found in soil and the droppings of bats and birds. Infection is through spore inhalation, with most patients being asymptomatic. It is more prevalent in temperate and tropical climates. Disseminated histoplasmosis occurs mostly in immunocompromised individuals and can be fatal if left untreated. Although endemic to specific world regions, disseminated histoplasmosis should be considered in immunocompromised patients presenting with atypical cutaneous findings, even in regions of low prevalence.
P25 Considering the burden of scabies alongside a mass drug administration treatment programme in an indigenous community in northern Australia
Authors: Cox Victoria , Dowden Michelle , Williams Crystal , Engelman Daniel , Yan Jennifer , Ralph Anna , Currie Bart , Francis Joshua 
Published: June 2023

Abstract
Scabies is estimated to affect 455 million people worldwide and is one of 20 neglected tropical diseases recognized by the World Health Organization (WHO). It is caused by a parasitic mite infestation that is hyperendemic in low-resource regions, and the disease burden in northern Australia is believed to be among the highest in the world. However, few recent prevalence assessments have been conducted in northern Australia and it is not known whether historical assessments are still representative of the disease burden. Therefore, it is difficult to advocate for the allocation of government funding and resources without accurate information on the burden of disease. Considering the effectiveness of an ivermectin-based mass drug administration (MDA) treatment programme in northern Australia is important to explore a control strategy, following successful large trials conducted in the Pacific and recommendations from the WHO. The aim was to consider the burden of scabies and other skin conditions in an indigenous community in northern Australia, from undertaking a simplified skin assessment of all consenting community residents. An observational cross-sectional study design was used for this purpose. Five field teams covered different regions in Maningrida. The teams were comprised of a medical practitioner from the investigative team who worked alongside a local healthcare worker and an Aboriginal healthcare worker. All community residents who gave verbal consent were administered ivermectin, or topical permethrin cream if ivermectin was contraindicated, as part of a MDA programme, which was locally developed and implemented by the Mala’la Health Service. Simplified skin examinations (n = 1306) were conducted in Maningrida during Healthy Skin Week from 14 to 18 November 2022, with verbal consent from 99% of community residents approached for recruitment to undergo a simplified skin assessment and administration of ivermectin as part of the MDA treatment programme. The point prevalence for scabies was 25.2% (330 individuals). Ninety-three people (7.1%) were diagnosed with impetigo, and approximately 40% of community residents had evidence of skin disease. No study participants were diagnosed with crusted scabies. Scabies is endemic in indigenous communities in northern Australia. This was the first prevalence assessment to be conducted in the Northern Territory since the East Arnhem Healthy Skin Project, which concluded in 2007, and the first MDA treatment programme conducted by an aboriginal medical service as a local health intervention. The consideration of effective rapid mapping and regional control strategies is essential to tailor a public health response that addresses the high burden of skin disease in northern Australia.
P31 Trial design to improve inclusion of patients from ethnic minority backgrounds
Authors: Bishop Liam , Smith Isabelle , Gilberts Rachael , Nixon Jane , Wittmann Miriam 
Published: June 2023

Abstract
The ALPHA trial was a UK National Institute for Health and Care Research-funded, multicentre, prospective, adaptive, two-arm parallel group randomized controlled trial. Consenting participants with severe chronic hand eczema (CHE) were randomized on a 1 : 1 basis to receive either alitretinoin or immersion psoralen + ultraviolet A in conjunction with concomitant topical corticosteroids, emollients and patient education. Different skin types might respond differently to phototherapy due to different pigmentation, so it was important to recruit an ethnically diverse patient group. This was reflected in the design and analysis of the trial. ALPHA included a substudy where photographs were taken in a subgroup of randomly selected consenting participants and used as a disease-assessment quality-assurance check. Following a discussion with the Trial Steering Committee patient representative, a protocol amendment was implemented so that all consenting participants of an ethnic minority background would be selected for the substudy to assess any differences by skin type. The minimization algorithm was amended to incorporate the skin type as a minimization factor to ensure balance between the treatment groups in terms of skin colour and incorporated as a covariate in the primary analysis. ALPHA recruited 441 participants between October 2015 and June 2021, of which 49 (11.1%) were participants from ethnic minority background (13% was the national average in 2011, and 18% was the national average in 2021). In total, 95.2% (n = 373/392) of White participants and 92% (n = 45/49) of participants from ethnic minority backgrounds provided consent to have photographs taken as part of ALPHA. A total of 113 (30.3%) consenting White participants were selected for the photographic substudy, and 36 (80%) ethnic minority participants were selected. The presentation will report on the agreement between assessors in terms of photographs by skin type. Details of disagreement between photographs will be explored through the use of other disease-assessment measures that provide extra detail on the clinical symptoms that may not be visible on a photograph. Through increased awareness of the importance of different skin types, the trial was adapted to ensure ALPHA recruited a proportion of participants from ethnic minorities similar to the proportion of people from ethnic minority backgrounds in the UK. As a result, the trial was an example of adapting trial design to acknowledge the differences across ethnic groups, and to lead to improved research outcomes for patients from ethnic minority backgrounds. We will conclude the presentation with some practical recommendations for equality, diversity and inclusion in dermatological clinical trials.
P32 Impact of the COVID-19 pandemic on health equality in malignant melanoma diagnosis
Authors: Lau Kenny , Cheng Huan , Hussain Rima 
Published: June 2023

Abstract
Difficult access to care during the COVID-19 pandemic has led to a delay in some disease diagnoses. The pandemic has exacerbated pre-existing health inequalities, and the most deprived population has often been the most disproportionately affected. In this study, we investigated the impact of COVID-19 on the volume and pattern of melanoma diagnosis, to evaluate whether there is an association with the socioeconomic status of the population. Cases with newly diagnosed cutaneous melanoma from January 2019 to December 2021 were identified in a specialist multidisciplinary team-held database. Breslow thickness, pathological disease stage, patient demographics and postcodes were reviewed. In the 3-year study period, there was a total of 1910 cases. Compared with 2019 prepandemic data, there was a 31% reduction (P = 0.03) in melanoma cases diagnosed in 2020 and a 10% reduction (P = 0.09) in 2021. In 2020, stage 4 cases had a 46% increase (P = 0.031). In 2019, 7% of the most deprived population had stage 4 disease at diagnosis, which increased to 21% in 2020 (P = 0.02). COVID-19 has caused a dramatic reduction in the volume of melanoma diagnoses and an accompanying upstage of disease. Among the most deprived population in our region, they are three times more likely to receive a stage 4 diagnosis vs. before the pandemic. This suggests that the barrier to health care secondary to the pandemic is most apparent to the deprived population and probably caused a delay in cancer diagnosis among this group of patients. Health policy needs to be put in place urgently to address this health inequality, to minimize the prognostic impact on the population.
P36 A cross-sectional patient survey in a tertiary hidradenitis suppurativa clinic
Authors: Mathew Libin , Aziz Sally , Kattach Leila , Shah Aadarsh , Rashidghamat Ellie 
Published: June 2023

Abstract
Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease that affects approximately 0.8% of the UK population. A survey was carried out among patients attending a tertiary HS clinic with the aim of better understanding the management of HS in primary care, and identifying the prevalence of associated risk factors. A total of 212 of the 552 patients (38.4%) invited chose to participate. The length of time patients had experienced symptoms before consulting their general practitioner (GP) was variable with 33.8% (n = 63) of participants reporting symptoms for 3–10 years and 26.3% (n = 49) experiencing symptoms for &gt; 10 years. The majority of patients were given a diagnosis in secondary care (n = 103; 55.4%) and 28.5% (n = 53) by their GP. In primary care, treatments prescribed included topical treatment and antimicrobial washes (n = 107; 65.2%). Just over half (n = 84; 51.2%) were prescribed short and extended courses of antibiotics. Looking at lifestyle factors, 31.5% (n = 52) were current and 27.9% ex-smokers (n = 46). The majority (n = 108; 65.5%) identified themselves as being overweight, with 67.8% (n = 112) wanting to lose weight. Almost a third of patients (n = 107; 64.5%) did not carry out exercise regularly (defined as cardiovascular exercise three times weekly). Eighty per cent (n = 132) of patients reported that they had not received any psychological support for HS, either from primary or from secondary care. This study highlights that only a small proportion of patients with HS were diagnosed by their GP, with the majority receiving a diagnosis from their secondary care physician. A self-reported lack of confidence by GPs in diagnosing HS has historically been highlighted. Despite this lack of confidence, this study demonstrates good adherence to existing UK recommendations for the initial treatment of HS when the diagnosis is made. The negative effects of lifestyle factors on HS, such as smoking and obesity, are well recognized. Despite this, over half of patients in this study who were current smokers had not been offered referral to a smoking cessation service. This study underscores the need to screen for depression and anxiety in patients with HS and improve access to psychology services. This patient self-reported study gives an insight into the importance of providing holistic care for patients with HS. As GPs gain confidence in the diagnosis and initial management of HS, an awareness of associated lifestyle changes and comorbidities can further enhance the holistic care of patients with HS in primary care.
P43 Patient tolerability of adalimumab biosimilar therapy in dermatology and rheumatology: real-world experience from a large tertiary centre
Authors: McGuire Arlene , Guard Sarah , Topping Karen , Smith Catherine , Mahil Satveer , Barker Jonathan , McGrath Conn , Fox Hannah , Moorhead Lucy 
Published: June 2023

Abstract
Adalimumab is widely used in the treatment of immune-mediated inflammatory diseases. It is the highest-spend drug in the National Health Service, costing more than £400 million annually. In 2018, adalimumab biosimilars became available, leading to substantial cost savings. However, patient tolerability of biosimilars remains underexplored. We evaluated the tolerability of adalimumab biosimilar therapy (Idacio®) in patients who were switched from Humira® in a large dermatology and rheumatology tertiary centre. We identified all patients issued with a prescription of Humira by dermatology [psoriasis and hidradenitis suppurativa (HS)] or rheumatology (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and Behçet disease) and analysed the number who switched to Idacio between January 2021 and March 2022. Patient electronic records were reviewed up to October 2022 to identify patients who switched back to the originator product and the documented reason for the switch. The primary outcome was the numbers of patients who were switched back from the biosimilar to the originator product. Of 769 patients issued with a prescription of Humira, 694 were switched to Idacio during the study period. Of these, 134 (19.3%) switched back to the originator product, 102 of whom (76.1%) remained on this during follow-up. The highest proportion of individuals switching back to the originator product was observed in the HS population (26.7%). The most common reasons for switching back were patient-reported loss of disease control (n = 63; 47.0%), injection pain (n = 51; 38.1%) or both (n = 10; 7.5%). The median time to switch back was 197 days (interquartile range 138–280). Of 694 patients prescribed Idacio, 32 (4.6%) were switched to an alternative biologic agent during the study period. Our experience with previous biosimilar switches within rheumatology and dermatology (etanercept, rituximab and infliximab) has resulted in few patients requiring a switch back to the originator. Our data indicate that around one in five patients in our study population switched back to the originator product. The higher proportion of patients citing injection pain may relate to the citrate excipient content or larger injection volume of the biosimilar Idacio. Loss of efficacy with time is well established with adalimumab, in part due to antidrug antibodies, and cannot be specifically attributed to the biosimilar. Switching may alter a patient’s confidence in the drug, which is particularly important when it may be a first-line therapy or the only approved biologic for a condition. Data on switch-back rates for other adalimumab biosimilars is required to understand how generalizable our findings are and the potential economic implications.