tbuckley/cabot-search huggingface dataset:
CPC04 An atypical case of vasculitis: when immunosuppression is not the answer
Authors: Perin Celebi, Hannah Sherlock, Rand Hawari, Maaz Abid
Journal: British Journal of Dermatology (2024)

Abstract Cutaneous vasculitis has a wide range of recognized causes, including drugs, autoimmune diseases, infection and malignancy. The management depends on the underlying cause, but the mainstay of treatment for severe disease is typically immunosuppressive agents such as corticosteroids. This case report discusses an unusual presentation and cause of small vessel vasculitis, and the challenges faced in diagnosis. A 53-year-old woman with a background history of renal sarcoidosis presented to dermatology with a 6-month history of a painful nodular and nonblanching purpuric rash on her lower legs. The clinical impression of cutaneous sarcoid was managed by increasing her prednisolone and later her azathioprine. However, despite this, her rash progressed into a bullous and necrotic ulcerating vasculitic eruption. An incisional biopsy was performed due to the atypical appearance of the rash, and the level of pain, which was not in keeping with cutaneous sarcoid or a usual vasculitic eruption. Sections of skin showed prominent epidermal necrosis, with focal blisters containing numerous dead keratinocytes. There were occasional viable keratinocytes showing intranuclear viral inclusions most in keeping with herpes infection. The underlying dermis showed prominent perivascular inflammation and fibrinoid necrosis of the superficial and deep blood vessels, even extending into the subcutaneous fat with areas of fat necrosis. Occasional leucocytoclastic debris was seen in the superficial blood vessels with numerous extravasated red blood cells. These histological features are in keeping with fulminant leucocytoclastic vasculitis with atypical herpes infection. Varicella zoster serology was positive, confirming the rare diagnosis of atypical fulminant herpes vasculitis. The patient improved on intravenous aciclovir 5 mg kg−1 and continues on a longer-term prophylactic oral dose. Atypical presentations of vasculitis are challenging to diagnose, resulting in delayed management and increasing the risk of postherpetic neuralgia. We aim to discuss this and other cases in the literature to improve awareness of this rare but important presentation, which, contrary to other vasculitides, should not be treated with immunosuppression.
O06 Abatacept efficacy in severe refractory morphoea: experience from a specialized centre
Authors: Sophia Watts, Emma Gardette, Catherine Orteu
Journal: British Journal of Dermatology (2024)

Abstract Our aim was to evaluate the efficacy and safety of abatacept in the treatment of severe refractory morphoea. We conducted a single-centre prospective cohort study at a national specialized scleroderma centre treating adult patients with morphoea. The patients included had severe disabling generalized plaque, pansclerotic or linear morphoea. Abatacept was started after failure of at least two standard systemic immune-modifying therapies (SIMTs), including intravenous and/or oral corticosteroids and methotrexate (MTX), mycophenolate mofetil (MMF), ciclosporin and hydroxychloroquine. Patients on abatacept were assessed at baseline and 6 and 12 months, employing validated scores: the Localized Scleroderma Cutaneous Assessment Tool (particularly the modified Localized Scleroderma Skin Severity Index, mLoSSI) to assess disease activity, and Dermatology Life Quality Index (DLQI) and Hospital Anxiety and Depression Scale (HADS) to assess disease impact. In total 30 patients, all female, with a median age of 57 years (range 22–84) are currently receiving abatacept: 18 patients for ≥ 6 months and 16 for ≥ 12 months. Of these, 57% have pansclerotic morphoea. Patients had not responded to oral and/or intravenous corticosteroids in all cases, and an average of 2.4 other SIMTs, most frequently MTX (93%) and MMF (70%). At abatacept initiation, 47% of patients continued on oral prednisolone, and 13% received intravenous pulsed prednisolone. Most patients (29 of 30) continued a maintenance SIMT, 23% of patients received concomitant MMF, 37% received MTX and 20% received both MTX and MMF. At 6 months, 15 of 18 patients had available data and the median improvement in mLoSSI was 37.7%; at 12 months, all patients had available data and the median improvement was 49.1%. The mean DLQI was 17.4 at baseline, 15.1 at 6 months and 12.4 at 12 months. The mean HADS anxiety score was 10.1 at baseline, 9.3 at 6 months and 8.2 at 12 months; the mean depression score was 9.6 at baseline, 9.3 at 6 months and 10 at 12 months. Three patients (10%) discontinued abatacept: two due to early side-effects in the first 3 months and one due to plateauing of response in very severe disease. There were no serious adverse events. Abatacept appears to be an effective and safe option for severe refractory morphoea. The high DLQI and HADS scores reflect the significant psychosocial impact of the disease and tend to remain high despite significant clinical improvement. A 2-year follow-up is now needed as the disease is slow to reverse and continuing improvement was observed at 1 year.
P069 Familial malignant melanoma: <i>CDKN2A</i> mutation-positive family tree
Authors: Sarah Winter, Sally Ashton, Hannah Davies, Avad Mughal
Journal: British Journal of Dermatology (2024)

Abstract The most common cause of inherited melanoma is mutations in the CDKN2A gene, which is a gene regulator of cell division. The risk of melanoma in carriers of this gene is 30% by 50 years and 67% by 80 years (Goldstein AM, Fraser MC, Struewing JP et al. Increased risk of pancreatic cancer in melanoma-prone kindreds with p16INK4 mutations. N Engl J Med 1995; 333: 970–5). Fortunately, germline mutation in the CDKN2A gene is believed to be rare in the population (Harland M, Cust AE, Badenas C et al. Prevalence and predictors of germline CDKN2A mutations for melanoma cases from Australia, Spain and the United Kingdom. Hered Cancer Clin Pract 2014; 12: 20). Those positive with the CDKN2A gene have associated risks of developing other malignancies such as lung, breast, brain and, in particular, pancreatic carcinoma. Pancreatic cancer is associated with smoking and alcohol-induced pancreatitis. To the best of our knowledge no study has mapped out an extensive CDKN2A mutation-positive family tree including second-degree relatives. We have mapped a family tree including first- and second-degree relatives, stemming from our index patient. She was the first in her family to be diagnosed with malignant melanoma, at the age of 33 years. She tested positive for the CDKN2A gene mutation, BRAF wildtype. Our patient had 10 first-degree relatives. To date, four of these relatives have been diagnosed with malignant melanoma. Her son was diagnosed with malignant melanoma at the age of 12 years and was also found to be positive for the CDKN2A mutation. Four of her other first-degree relatives have been diagnosed with other malignancies: lung adenocarcinoma, squamous cell carcinoma, breast cancer and chordoma. No diagnosis of pancreatic carcinoma has been made in a first-degree relative. There are 21 second-degree relatives, with only one confirmed malignant melanoma. Not all family members have been tested for the CDKN2A mutation, and confounding factors include lifestyle and sun exposure. However, this family tree clearly shows the spread of the condition through a family, with the mutation present in a non-Mendelian pattern. More cohorts need to be collected to accurately predict the risk of malignancy and correction of preventable factors. Being genetically tested for the CDKN2A mutation is beneficial for patients and their families as appropriate counselling can be provided. Patients would be better informed in continued skin self-examination, sun protection and risk of other malignancies.
BC03 Assessment of atrophic and hypertrophic photoageing in patients with basal cell carcinoma
Authors: Aine Kelly, Libin Mathew, Catherine Stefanato, Faisal Ali, Jean Ayer, Emma Craythorne
Journal: British Journal of Dermatology (2024)

Abstract Two contrasting forms of clinically evident photoageing have been described – hypertrophic and atrophic. Recent studies postulate that hypertrophic photoageing, described as a leathery appearance with coarse wrinkles, may be protective and mitigate skin cancer. Conversely, atrophic skin ageing is described as translucent skin with telangiectasia and skin thinning and is thought to be associated with actinic damage and an increased incidence of skin cancer. Full-face photographs of 102 patients who underwent Mohs surgery for basal cell carcinomas of the cheek during 2018–2023 were selected, and their hypertrophic and atrophic photodamage scored by two dermatologists and a nonmedic independently (score of 0–8, in increasing severity). All histopathology from 102 patients was reviewed. Two of the 102 patients were omitted due to poor-quality slides. Solar elastosis was scored based on the percentage of dermis affected (grade 1 &amp;lt; 50%, grade 2 50–90%, grade 3 100%). Epidermal thickness was measured from an inter-rete ridge region halfway along each specimen. In total, 53% of patients were female and 47% were male; 49% had Fitzpatrick skin type I, 49% type II, and 2% type III. Overall, 89% of patients did not smoke, 9% currently smoked and 2% formerly smoked. Only 3% of patients were immunosuppressed. Five patients (5%) had an atrophic score of 2, 29% of 4, 49% of 6, and 17% of 8. Overall, 22% of patients had a hypertrophic score of 0, 58% of 2, 18% of 4, and 1% of 6. Eighty-eight patients (88%) had a solar elastosis score of 3. Of the patients with severe solar elastosis 70% had an atrophic photoageing score graded as severe (6 or 8). There was no association between sex and atrophic photoageing score. There was an association between solar elastosis grade and atrophic photoageing score. The mean epidermal thickness was lower in patients with a higher atrophic photoageing score (sum of squares 43.6, P = 0.002). The mean epidermal thickness was lower in patients with higher hypertrophic photoageing scores; however, this result was not statistically significant. There was a discrepancy between atrophic scoring and a concordance for hypertrophic scoring between the dermatologist and nonmedical personnel. Epidermal thickness was reduced regardless of sex in both atrophic and hypertrophic photodamaged skin. Most patients in our study had significant solar elastosis in their dermis, although this appeared to be more severe in those with higher atrophic photoageing scores. We postulate that photoageing changes are complex but can be depicted clinically. It is unclear whether dividing patients into atrophic and hypertrophic categories can distinguish histological changes and overall skin cancer risk.
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: Yasmin Khan, Faheem Latheef
Journal: British Journal of Dermatology (2024)

Abstract 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.
BC06 A systematic review of social media and Melanotan, the ‘Barbie drug’
Authors: Sarah O’Mahony, Archie Connolly, Aoibhin Collins, Talal Alhunay, Katie Edgar, Madeline Hynes, Anne Marie Tobin
Journal: British Journal of Dermatology (2024)

Abstract Melanotan, a term referring to both Melanotan I (MT1) and Melanotan II (MT2), is a synthetic analogue of the endogenous hormone, α-melanocyte-stimulating hormone (α-MSH). Although the compound is unregulated and unlicensed, it is commonly exploited for its ability to produce a sunless tan. Melanotan has recently regained notoriety through social media platforms such as TikTok, a video-sharing online platform. The substance gained traction on TikTok, where the hormone is known as the ‘vacation peptide’. MT2 is an illicit substance sold on websites such as www.trutan.net, in gyms and in aesthetic clinics. The ‘Barbie drug’, MT2 promises to suppress appetite and thus induce weight loss, increase libido and produce an artificial tan that does not wash off. Recent increases in social media use have demonstrated positive correlations with body dissatisfaction. As a result, one can see how, in a world where social media has been demonstrated to cultivate body dissatisfaction, a seemingly quick-fix solution may prove attractive. MT2 is injected subcutaneously or administered intranasally via nasal sprays to produce increased skin pigmentation in the user via stimulation of melanocytes. From baking in the sun, to messy applications of temporary tans, and the now declining popularity of sunbed use, this new method of achieving a darker complexion surfaced incidentally. Initially researched for their photoprotective properties and their potential to reduce skin cancer, these synthetic hormones were found to have the desirable effects that are now sought after by self-proclaimed Instagram ‘influencers’ and fitness models. Despite being structurally different compounds, both are α-MSH analogues; α-MSH is a nonselective full agonist that targets melanocortin receptors. MT1 and MT2, in turn, act as relatively nonspecific agonists at melanocortin receptors. MT1 is more structurally like α-MSH and maintains its high affinity for the melanocortin 1 receptor (MCR1), while MT2 has an increased affinity for melanocortin 4 receptors (MCR4). This explains the increased pigmentation effects of both analogues, while MT2 also has additional sexual effects due to the role of MCR4 in sexual behaviour and erectile function. This systematic review aims to explore the impact of social media on Melanotan consumer perception through qualitative analysis. Four relevant studies were included in this systematic review. The results revealed that social media is a driving force in unlicensed Melanotan sales. Additionally, it was made clear that very few social media posts show Melanotan in a negative light, despite its deleterious adverse effects. From a perspective of safety, the results of this study outline a need for increased awareness of the negative aspects of Melanotan throughout social media platforms.
P078 Establishing diagnostic criteria for vulval lichen sclerosus (SHELLS): an international electronic-Delphi consensus study
Authors: Rosalind Simpson, Mike Birchall, Jane Daniels, Sonia Gran, Gudula Kirtschig, Kim Thomas
Journal: British Journal of Dermatology (2024)

Abstract Lichen sclerosus (LS) is a chronic inflammatory condition mainly affecting genital skin. It causes distressing symptoms that impact daily quality of life, results in progressive anatomical changes and has a potential risk of cancer. There is no defined set of diagnostic criteria for vulval LS. As a result, vulval LS is often misdiagnosed and improperly treated. The objectives of this study were to reach international expert consensus on clinical diagnostic criteria for vulval LS. Between March and May 2023, a four-stage electronic-Delphi consensus exercise was conducted. In the first three rounds, participants were asked to rate the importance of a list of clinical criteria. Responses from round one were summarized and presented in rounds two and three, along with additional criteria suggested by participants. Any items that met the definition of consensus as ‘very important/critical’ or ‘not important’ were not voted on again in subsequent rounds. In round four, items that met agreement for ‘important but not critical’ were ranked in order of their importance. Consensus was defined a priori, and all rounds were conducted anonymously. In total 47 participants from 14 countries completed round one, with 42 (89%) retained by round three when consensus was determined. Round four was completed by 36 (77%) participants. Participants completing all four rounds predominantly included healthcare professionals (78%, n = 28) and patient support group representatives (19%, n = 7). In round one, 21 diagnostic features were voted on. Participants suggested an additional 10 features that were subsequently added to the round two survey. After three rounds, consensus was achieved for five diagnostic features: whiteness, itch, changes in anatomy, burying of the clitoral area, and improvement in response to topical steroids. There were also 12 features voted as ‘important but not critical’, and participants subsequently ranked them in the fourth round. Experts have agreed on five critical diagnostic features for vulval LS in adults, and an additional 12 features that may also be important. Future research should assess these features for diagnostic validity through a multicentre diagnostic test accuracy study.
P076 Risk of psoriatic arthritis and uveitis among patients with psoriasis after COVID-19 infection: a nationwide cohort study
Authors: Tai-Li Chen, Chen-Yi Wu, Wei-Chuen Chang, Chih-Chiang Chen
Journal: British Journal of Dermatology (2024)

Abstract Psoriasis is a chronic, inflammatory, immune-mediated dermatosis associated with multiple comorbidities, such as psoriatic arthritis and uveitis. Systemic inflammation contributes to the pathophysiology of psoriatic complications. Nevertheless, whether patients with psoriasis have a higher risk of developing psoriatic arthritis and uveitis after COVID-19 infection, a disease known to boost inflammatory cytokines, was largely unknown. Therefore, we aimed to investigate the risk of incident psoriatic arthritis and uveitis among patients with psoriasis after COVID-19 infection using real-world data. In this retrospective nationwide study, we analysed data from the US Collaborative Network of the TriNetX Research Database. Adults aged ≥ 18 years diagnosed with psoriasis were eligible for inclusion. Two study cohorts were established: a COVID-19 cohort and a non-COVID-19 cohort. Patients with a diagnosis of COVID-19 between 2020 and 2022 contributed to the COVID-19 cohort. Patients without COVID-19 were matched to construct the non-COVID-19 cohort using 1 : 1 propensity score matching. Multiple covariates, such as age, sex, race, ethnicity, comorbidities, baseline steroid use, systemic immunosuppressant use, and use of biologics, were included to calculate the propensity score. We excluded participants with a history of psoriatic arthritis or uveitis. A Cox regression model was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for psoriatic arthritis and uveitis. Stratified analyses according to age, sex, race and ethnicity were also performed. In total 21 186 participants were included. Overall, 1083 patients with COVID-19 and 495 control patients developed psoriatic arthritis during the follow-up. Patients with psoriasis after COVID-19 infection had an increased risk of incident psoriatic arthritis (HR 2.16, 95% CI 2.07–2.25) compared with those without COVID-19. Moreover, 748 patients with COVID-19 and 401 control patients developed uveitis. Patients with psoriasis with COVID-19 had an increased risk of incident uveitis (HR 1.83, 95% CI 1.70–1.97) compared with those without COVID-19. The increased risk of psoriatic arthritis and uveitis remained significant among men, White patients, and those aged &amp;gt; 45 years. In conclusion, patients with psoriasis after COVID-19 infection have an associated increased risk of psoriatic arthritis and uveitis. Long-term follow-up of complications such as psoriatic arthritis and uveitis may be considered for patients with psoriasis after COVID-19 infection. Future research is warranted to elucidate the pathophysiology linking psoriasis, COVID-19 and psoriatic comorbidities.