tbuckley/cabot-search huggingface dataset:
P048 Immunosuppression and vaccination: a cross-specialty survey on current practices
Authors: Chris Puo Nen Lim, Akash Maliampurakal, Jayne Saunders, Elaine Paton, Angela Drummond
Journal: British Journal of Dermatology (2024)

Abstract According to the 2018 General Medical Services contract in Scotland, the responsibility for vaccination delivery has shifted from general practitioners to secondary care. Dermatologists working in NHS Scotland now have an active role in recommending vaccinations for their patients who are on immunosuppressants. This recommendation is outlined in the Green Book published by the UK Health Security Agency. Currently, dermatology patients on immunosuppressants are required to receive the pneumococcal vaccine before starting treatment and every 5 years thereafter. However, this requirement is not included in the patient group direction produced by Public Health Scotland. As a result, individual prescriptions for the vaccination are needed, which adds to the workload on the services. Our objective was to assess current vaccination practices for patients on systemic medications across multiple specialties (dermatology, rheumatology, gastroenterology) in our local health board. We developed an online questionnaire, which was iteratively refined and distributed between June and August 2023 to clinicians working in dermatology, rheumatology, and gastroenterology locally, as well as other dermatology units in Scotland through the Scottish Dermatological Society. The questionnaire aimed to gather information on clinicians’ recommendations regarding influenza, pneumococcal and COVID-19 vaccines for patients taking various immunosuppressants, including methotrexate, ciclosporin, azathioprine, mycophenolate mofetil, fumaric acid esters, apremilast, biologics, and Janus kinase inhibitors. In total 64 responses were obtained: from dermatology (44 of 64, 69%), rheumatology (8 of 64, 13%) and gastroenterology (12 of 64, 19%). Most respondents in dermatology (68%) and rheumatology (88%) were consultants or associate specialists, while 50% of the respondents in gastroenterology were specialist trainees. Almost all respondents across the three specialties recommended vaccinations routinely in their clinical practice. The majority of respondents recommended yearly vaccinations against influenza. There were mixed responses on recommendations regarding pneumococcal vaccinations, with varying frequencies between yearly and 5-year intervals. A significant proportion of respondents were unsure of the latest COVID-19 vaccine recommendations. Free-text comments revealed an interest in the project and the need for standardization of vaccination recommendations. A review of the Green Book highlighted the following recommendations for patients on immunosuppressants: annual influenza vaccine, one-off pneumococcal vaccine unless in high-risk groups (asplenia, splenic dysfunction, and chronic kidney disease) and booster COVID-19 vaccines during seasonal campaigns. In conclusion, we highlight the variations in vaccination practices among these three specialties, and the importance of standardization in vaccination recommendations.
BT40 A case of low-grade angiosarcoma of the face: is teledermatology effective in early diagnosis of rare skin tumours?
Authors: Faris Kubba, Pakiza Aliyeva-Derraz
Journal: British Journal of Dermatology (2024)

Abstract An 87-year-old White man presented with a gradual swelling of the right side of the face. This was clinically diagnosed by his general practitioner via teledermatology as erysipelas refractory to antibiotic treatment, with a clinical course of around 10 months. The differential diagnosis included rosacea. The lesion was gradually involving the cheek and spreading to the left side of the face. The patient was referred to the dermatology clinic and on examination the lesion was found to be indurated, tender and warm with a wet texture. The patient had a previous history of bladder cancer, which was treated 5 years earlier. A 4-mm punch biopsy from the right cheek was taken, which showed a permeative vasoformative tumour within the dermis composed of anastomosing vascular spaces lined by a single layer of plump endothelial cells. Mitotic figures were identified. ERG immunohistochemical stain highlighted the endothelial cells. Human herpesvirus 8 stain was negative. The diagnosis was a grade 1 angiosarcoma. This was also reviewed in the specialized unit and the patient was urgently referred to a sarcoma service. Computed tomography and positron emission tomography scans were performed and he was be referred for chemotherapy. The role of teledermatology for skin lesion assessment has been a recent development, particularly since the COVID-19 pandemic, and has impacted the ability to assess patients in person. In recent research, 22 studies were reviewed to include basal cell carcinoma, squamous cell carcinoma and melanoma. The authors stated that anxiety around missing early curable cases needs to be balanced against inappropriate referral and unnecessary excision of benign lesions. Their results suggest that teledermatology can correctly identify the majority of malignant lesions. In another recent review of 45 publications, the authors concluded that teledermatology offers a comparable standard of effectiveness to in-person assessment. It can save significant time in expediting advice and management. Image quality and inclusion of dermoscopy have a considerable bearing on the overall effectiveness. However, our case shows that the diagnostic accuracy of teledermatology in similar rare tumours needs to be carefully evaluated. Any clinical suspicion about lesions with diffuse growth patterns that mimic dermatoses refractory to medications should be taken seriously and an urgent referral to a dermatologist is to be recommended. In conclusion, we have presented a case of angiosarcoma of the face initially diagnosed as erysipelas, which needed further referral after being refractory to antibiotics. As primary cutaneous angiosarcoma is one of the most aggressive skin tumours and carries a very poor prognosis, further assessment of teledermatology as a reliable diagnostic method needs to be evaluated, and confusion with inflammatory dermatosis remains a serious diagnostic pitfall.
P018 Puzzling vesicles: a clinicopathological challenge
Authors: Sejal Jain, Anuradha Bishnoi, Anubha Dev, Debajyoti Chatterjee, Rahul Mahajan, Dipankar De, Sanjeev Handa
Journal: British Journal of Dermatology (2024)

Abstract An 8-year-old male child presented with a history of multiple vesicles and bullae on the ear, nose, upper trunk, lower legs and feet for the past 4 years. There was no history of photosensitivity. There was no history of similar conditions in family members. On examination, the child had erosions with haemorrhagic crusting on the above-mentioned sites. The lesions were healing with hypopigmentation and scarring. A few milia-like lesions were seen on the nose and ears. Superficial tiny erosions with haemorrhagic crusting were present on the lip mucosa and tongue. Dystrophy of the left great toe was also noted. Differential diagnoses of Kindler syndrome, porphyria cutanea tarda, bullous pemphigoid and chronic bullous dermatosis of childhood were considered. A 3-mm punch biopsy from the vesicle revealed epidermis with psoriasiform hyperplasia and hyperkeratosis. The upper dermis showed a perivascular and perifollicular lymphomononuclear infiltrate with multiple eosinophils. A perilesional 3-mm punch biopsy was sent for direct immunofluorescence, which revealed at least three IgG linear deposits along the dermoepidermal junction in an N-serration pattern. There were no IgA or IgM deposits. A genetic analysis showed no mutation in the FERMT1 gene. Porphyrin levels in the blood, urine and stool were normal. Based on the histopathology and direct immunofluorescence findings, the patient was diagnosed with childhood bullous pemphigoid. Weight-based azathioprine was started and there was improvement in the lesions within 2 months of initiation of therapy. Bullous pemphigoid is a subepidermal blistering disorder that commonly affects older patients (60–80 years), but it can rarely affect children. It demonstrates considerable clinical and histopathological overlap with other acquired and/or congenital blistering disorders. A high index of suspicion coupled with appropriate investigations are imperative for diagnosis. Histopathology and direct immunofluorescence are more cost-effective. In a limited-resource setting, this can eliminate the need for more expensive tests, such as genetic analysis.
BT31 The dermatology department without walls: how teledermatology unmasks unmet need in coastal ‘deserts of provision’
Authors: Roopa Farooki, Saul Halpern
Journal: British Journal of Dermatology (2024)

Abstract Dermatology departments actively use digital solutions to provide services remotely, particularly to supplement overbooked face-to-face clinics. In coastal areas, there are additional challenges regarding provision of access to dermatology, with few centres offering dermatology appointments, and with patients not always having the means to travel. This paper discusses how the teledermatology service in one of the coastal ‘deserts of provision’ both widens access to secondary care and unmasks unmet need in these communities. The methods used involve direct comparison of the number of dermatology referrals from primary care, both before the establishment of the teledermatology service and afterwards. The teledermatology service examined has been established in coastal locations, offering photography and dermoscopic images of lesions, submitted with a standardized patient history form. The main focus of the service is to identify skin cancers and provide reassurance of benign lesions, without recourse to 2-week-wait appointments, although other skin conditions suitable for general clinics are also referred. Interestingly, the results show that the teledermatology service has had no impact on mitigating traditional referrals to routine or 2-week-wait clinics, which have continued to increase, on average by 18% in the 2-year period ending January 2024, across 24 surgeries in the region. For one surgery located in one of the most isolated areas, weekly referrals have increased by 142%, representing an increase from three to seven referrals per week. This centre also made an additional eight referrals to teledermatology per week, mainly for single lesions that general practitioners felt did not merit the 2 week wait, but that required timely dermatological opinion. Of 97 referrals examined across a 12-week period (November 2023 to January 2024), five lesions were listed directly for surgical excision, eight for biopsy and eight for further clinical evaluation. It seems evident that in providing this additional path of access, the teledermatology service has unmasked an unmet need in the coastal community. It offers a ‘dermatology department without walls’, where expert secondary care advice with consultant insight can be obtained locally, and surgical follow-up or further clinical management can be organized directly by the advising dermatology team. Further study is needed to confirm that this increased access also leads to improved patient outcomes, which is predicated on appropriate referrals to teledermatology by primary care, and assessment of the diagnostic accuracy of teledermatology compared with traditional in-person clinics. The hope is that effective dermatology specialty care is being brought to the patient more directly in coastal communities than has previously been possible.
BT36 A cross-sectional study of social media content relating to cutaneous lupus
Authors: Lisa Murphy, Bairbre Wynne
Journal: British Journal of Dermatology (2024)

Abstract Social media is now a well-recognized entity when it comes to accessing information quickly and at minimal cost. If patients could be directed towards reputable social media pages, they could have greater access to reliable information, as well as a forum to reach out to other patients with similar conditions. Systemic lupus erythematosus is a complex disease that can affect a number of organs. Some patients may become overwhelmed with the wealth of information being provided to them at diagnosis. Social media could play a key role in providing patients with more user-friendly information, while equally introducing a more interactive component to information sharing. As a result, the aim of this study was to establish the nature of the content available to patients on popular social media websites. Three popular social media sites were identified and included in this study: Instagram, X (formerly known as Twitter) and Facebook. The search words ‘cutaneous lupus’ were used on all three websites and the top 30 posts were included in data analysis. The content breakdown on Instagram could be stratified into the sharing of patients’ personal photographs, infographics, and the sharing of cutaneous lupus events and resources. Overall, 30% of the posts consisted of infographics with factual medical information for viewers, while 23% of patients posted personal photographs of their cutaneous lupus manifestations. The average number of people who had engaged with posts on Instagram was 1541. In terms of the site X, 47% of posts shared were to disseminate article links and publications in medical journals. Six posts were statements that contained factual medical knowledge, eight posts were images and two posts were infographics. The average number of views for these posts on X was 9797 people. Of the analysed posts on Facebook, 10 were links to article publications, 5 were statements, 5 were members seeking advice, 3 were infographics, 5 were images and 2 were videos. In total, 73% of posts on Facebook contained factual medical information regarding lupus. The average number of people to have engaged with posts on Facebook was 29. Social media has the potential to provide patients with increased access to healthcare information, medical developments, and support from other patients. This study highlights that social media may prove to be a useful adjunct for clinicians to direct their patients towards for further information. While it is important to warn patients of the potential for misinformation, if patients could be counselled on how to use social media sites appropriately, this could be an effective method for patients to garner support and knowledge about cutaneous lupus.
P016 A case of poikilodermatous plaque-like haemangioma
Authors: Hannah Ross, Luisa Motta, Liezel Griffin
Journal: British Journal of Dermatology (2024)

Abstract An 89-year-old man was found to have an incidental asymptomatic, erythematous, scaly, slightly atrophic plaque on the left hip, measuring 5 × 2.5 cm. The patient reported that it had been present for several years and attributed it to previous radiotherapy for prostate cancer. An incisional biopsy showed histological features of hyperkeratosis, focal parakeratosis and acanthosis, with mild focal spongiosis and scattered intraepidermal lymphocytes with focal Langerhans cell vesicles. Additionally, there was remodelling of collagen in the dermis with proliferation of blood vessels, and perivascular and interstitial infiltrates of lymphoid cells in the superficial dermis. There was no evidence of neoplastic activity, and a reactive or inflammatory process was favoured. Several treatments were trialled including moderate and potent topical corticosteroids under occlusion and pressure-relieving foam dressings, but with no resulting change to the appearance of the plaque. A repeat biopsy was undertaken, which again showed hyperkeratosis, patchy parakeratosis and mild spongiosis. The main abnormality was the presence of a plaque and bandlike proliferation of small thin-walled blood vessels in the upper dermis and upper reticular dermis, which had morphological features reminiscent of postcapillary venules. The findings in the initial biopsy were similar, but much more subtle; subsequently a diagnosis of poikilodermatous plaque-like haemangioma was suggested. Poikilodermatous plaque-like haemangioma was proposed as a newly defined clinical entity by Semkova et al. in 2019 (Semkova K, Carr R, Grainger M et al. Poikilodermatous plaque-like hemangioma: case series of a newly defined entity. J Am Acad Dermatol 2019; 81: 1257–70). This case series identified 16 patients presenting with a solitary atrophic erythematous or violaceous plaque occurring on the extremities or buttocks with an indolent clinical course. The mean age of patients was 72 years, with a male predominance. Duration of lesion, available for 13 patients, confirmed a mean of 2.5 years, and the mean diameter was 5.8 cm. All lesions were asymptomatic. Histology demonstrated a distinctive bandlike proliferation of vascular channels suggestive of postcapillary venules within the superficial dermis. There was also evidence of background fibrosis, oedema and loss of elastic fibres. Awareness of poikilodermatous plaque-like haemangioma is important in differentiation from other dermatological conditions including mycosis fungoides, inflammatory dermatoses, Bowen disease and necrobiosis lipoidica. Histological examination is essential in diagnosis and may prevent unnecessary investigation and treatment.
BT30 Artificial intelligence triage is of greater benefit for screening suspected melanoma referrals than squamous cell carcinoma referrals
Authors: Nor Ismail, Maryam Barfei, Hannah McLaughlin, Elizabeth Jane Roberts
Journal: British Journal of Dermatology (2024)

Abstract There has been a rapid expansion in the use of artificial intelligence (AI) models to aid in diagnosis and triage of skin cancer in the UK in the last few years. This has been driven by a need to manage an increasing number of urgent referrals for suspected skin cancer. Our service has been using one such platform to screen out benign lesions, thus reducing the number of patients subsequently requiring a face-to-face appointment with a trust dermatologist. The AI platform assesses the features of a single dermoscopic image to categorize the lesion into benign or malignant. Information from patient history and macroscopic images are not involved. As dermatologists, we recognize the importance of history (pain, rapid growth) and clinical examination (induration, tenderness) as well as dermoscopic assessment in reaching a diagnosis. We suspected that the use of dermoscopy in clinical practice is of greater value for distinguishing benign from malignant pigmented lesions compared with keratotic lesions. When a suspected skin cancer is referred into our service, the general practitioner is required to state whether they suspect melanoma or squamous cell carcinoma (SCC). (Basal cell carcinomas are referred on a separate, routine pathway). We sought to use this information to assess for any differences in outcomes. A retrospective review of patients assessed by the AI platform was conducted between August 2023 and November 2023. In total 800 patients were included in the study (396 melanoma pathway, 404 squamous cell carcinoma pathway). In total 116 referrals were discharged by the AI platform on the melanoma pathway (29.2%) and 32 referrals were discharged by DERM on the SCC pathway (7.9%). These results support our hypothesis that AI is better at recognizing benign pigmented lesions, as 92% of patients referred on the SCC pathway required further assessment by a trust dermatologist compared with 70% of those referred on a melanoma pathway. This information is of importance to commissioners planning to implement skin cancer AI triage models.
P015 Acne: clues to the mechanism of disease
Authors: Sarah Fleming, Helen Enright, Kevin Molloy, Caitrionna Hackett
Journal: British Journal of Dermatology (2024)

Abstract Acne vulgaris continues to result in a significant psychological and physical burden on patients, mostly occurring at an important time of psychosocial development. We would like to highlight the novel case of a 19-year-old male patient who attended the dermatology department for treatment of nodulocystic acne. On presentation, he had large cystic lesions affecting the forehead, cheeks and neck and abutting the left medial canthus. He had a background history of aplastic anaemia, treated with eltrombopag, antithymocyte globulin and ciclosporin. Unfortunately, the patient developed idiopathic intracranial hypertension (IIH) secondary to treatment with ciclosporin. Due to the severity of his IIH, treatment with isotretinoin was contraindicated. He was commenced on erythromycin 500 mg twice daily along with adapalene gel topically but had a suboptimal therapeutic response. During his care, he was admitted under the haematology team with diffuse abdominal pain and a raised lactate dehydrogenase. He was subsequently diagnosed with paroxysmal nocturnal haemoglobinuria (PNH) and was commenced on biweekly eculizumab infusions. Within 1 month, he noticed a significant improvement in his acne. He was reviewed 3 months later, and his acne was clear, with only a few scattered pustules. The patient continues to report that scattered papules and pustules appear 1–2 days before his biweekly infusions; however, these quickly resolve after infusion. Eculizumab was first approved for treating PNH in 2007 and is a recombinant humanized monoclonal antibody inhibiting complement component C5. In vitro studies investigating the role of the complement pathway were carried out in the 1970s, at which time it was thought that colonizing bacteria can activate the complement pathway through stimulation of the reticuloendothelial system. Both acne and hidradenitis suppurativa (HS) are disorders of follicular occlusion; 23–70% of patients with HS report concomitant acne. Phase IIa/IIb clinical trials of C5a inhibition have shown promise in the treatment of HS. Although the pathogeneses of both acne and HS remain distinct, there have been studies showing positive response to C5 inhibition in patients with acne, supporting the theory that perhaps complement does pay a role in acne development. The authors present this case to highlight the complement pathway as a possible alternative therapeutic target in severe nodulocystic acne.