bluuebunny/crossref_metadata_2025_split huggingface dataset:
BI20 Generalized pustular psoriasis in a patient receiving pembrolizumab for metastatic lung adenocarcinoma
Authors: Cernova Jeva , Patel Majeeda , Dattani Jinesh , Goiriz Rebeca , Rashid Sukaina , Harwood Catherine 
Published: June 2023

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

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

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

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

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

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

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

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