tbuckley/cabot-search huggingface dataset:
O01 Survey of Scottish Dermatology Society members on the new Medicines and Healthcare products Regulatory Agency isotretinoin recommendations
Authors: Faisal Dubash, Robert Dawe, Andrew Affleck
Journal: British Journal of Dermatology (2024)

Abstract Recent Medicines and Healthcare products Regulatory Agency (MHRA) isotretinoin legislation includes significant changes that will affect clinical practice (Medicines and Healthcare products Regulatory Agency. Drug Safety Update volume 16, issue 9: April 2023: 4). We obtained opinions from members of the Scottish Dermatological Society (SDS) on these recommendations. Five questions were circulated to members using a Microsoft Forms e-survey, and responders were anonymous. In total, 77 of 180 members responded in a 1-week period, with a 43% response rate. Open comments were also captured in a free-text box. The results included the following. Question 1: 95% (73 of 77) of responders stated that the new MHRA legislation is more likely to harm people with severe acne, while 3% (2 of 77) believed the recommendations would help patients with acne. Another 3% (2 of 77) answered ‘other’, with one stating ‘there are some improvements and some issues with this guidance’ and ‘people with severe acne will have to wait longer to start isotretinoin and suffer harm’. Question 2: 92% (71 of 77) felt that the views of people with severe acne were not considered. Question 3: 99% (76 of 77) of SDS members agreed that the new recommendations were not based on good evidence. Question 4: 90% (69 of 77) were against the requirement for two separate healthcare practitioners to approve isotretinoin prescribing in patients aged &amp;lt; 18 years. Question 5: 87% (67 of 77) agreed that clinicians should not need to ask about sexual dysfunction at every consultation, while 13% (10 of 77) believe we should. Open comments highlighted common themes such as ‘significant delays in patient access to isotretinoin, additional staff required for decisions, legislation being a barrier to prescribing effective treatment, additional patient harm such as scarring, effect on quality of life and concerns of worsening mental health due to the guidance’. ‘Further damage to the doctor–patient relationship’ was raised as ‘patients would be victim to a nocebo effect’. There was frustration expressed about the creation of more meaningless tick-box exercises and it was widely perceived that the legislation was authoritarian and disproportionately represented a minority opinion over an ‘unheard’ patient majority. There was also a feeling that there had been a ‘lack of expert dermatological opinion involved in the process of developing the guidance’. Overall, an overwhelming response from SDS members highlighted many concerns with the MHRA guidance and its impact on patient care. Isotretinoin appears to have been demonized without any scientific basis. The results of this survey question the credibility of the MHRA and their recommendations. We propose the creation of an objective working group, with no conflicts of interest, to re-evaluate the MHRA recommend­ations and accurately reflect the current evidence base.
DS16 Incidence and management of pregnancy-associated melanoma in a district general hospital in the Southeast of England
Authors: Nicholas Pearson, Sara O’Kelly, Andrew Birnie
Journal: British Journal of Dermatology (2024)

Abstract Melanoma is the most common malignancy during pregnancy (Driscoll MS, Martires K, Bieber AK et al. Pregnancy and melanoma. J Am Acad Dermatol 2016; 75: 669–78). Pregnancy-associated melanoma (PAM) is defined as any melanoma diagnosed during pregnancy or up to 1 year postpartum. PAM appears to have poorer outcomes than other melanomas (Byrom L, Olsen C, Knight L et al. Increased mortality for pregnancy-associated melanoma: systemic review and meta-analysis. J Eur Acad Dermatol Venereol 2015; 29: 1457–66). The pathophysiology of why this could be is incompletely understood. There are currently no guidelines on the management of PAM in the UK. This is part of a project to collect data nationally to identify features of PAM, and to determine potential diagnostic challenges due to pregnancy. Patients were identified from the paper notes of the skin cancer multidisciplinary meetings from a district general hospital in the south-east of England. This covered a catchment area of approximately 800 000 patients. To identify patients who were diagnosed with PAM, we investigated the cohort of patients who were registered as female and aged between 20 and 50 years, a commonly used definition in the literature. Details on the pregnancies and melanoma were obtained from the electronic medical records. Four years of data from multidisciplinary meetings were processed, from December 2019 to November 2023. During this period, there were 85 female patients of childbearing age who were diagnosed with melanoma. Six patients had PAM, five of whom were diagnosed postpartum. The Breslow thicknesses ranged from 0.3 to 2.2 mm. The patient who was identified perinatally did not have her treatment delayed due to the pregnancy, and there was no record of the placenta being sent for histology or the baby being given a full-skin examination. Regarding the outcome for these patients, when the data were collected in December 2023, five were currently under follow-up and one had completed follow-up. PAM is a relatively rare condition, but with maternal ages rising in the developed world, the incidence could be expected to increase. National data collection is therefore required to identify trends and associations to gain consensus on its management.
DS14 Not all dimples are simples
Authors: Sana Sankey, Elena Ailenei, Chalani Amarasena, Suraj Thomas, Dhulsan Preena, Daya Gahir, Manju Paul
Journal: British Journal of Dermatology (2024)

Abstract We discuss four cases of orofacial fistulas presenting via the skin cancer pathway over 12 months. The predominant morphological presentation of the lesions was dimpling on the skin. The time to presentation ranged from 6 to 24 months. All patients required surgical input from the maxillofacial team. Case 1 is a 76-year-old man referred with a 2-year history of a lesion under the left submandibular area. Computed tomography (CT) of the neck revealed a dental apical cyst. The patient underwent a tooth extraction, leading to sinus resolution. Case 2 is a 58-year-old man who presented with a ruptured lesion on the left cheek, leading to recurrent discharges. The ultrasound scan (USS) revealed a sinus tract from a dental infection that had tracked to the skin. The sinus resolved after tooth extraction. Case 3 is a 54-year-old woman referred with a chronic, indented papule above the left nasolabial groove. USS examination revealed a heterogeneous lesion tracking deep into the subcutaneous tissue. An orthopantomogram identified a periapical infection of the upper-left third tooth. She underwent root canal treatment with resolution of the sinus. Case 4 is a 79-year-old woman with a 6-month history of a nonhealing discharging lesion in the left submental area. CT revealed soft-tissue thickening along the left mandible alveolar margin involving the buccal aspect, extending as a sinus to the skin surface and extensive osteoradionecrosis. Unfortunately, she succumbed to an unrelated illness and did not complete her treatment. An orofacial fistula, or sinus, is an abnormal connection between the oral cavity and the face’s surface. Despite its rarity, anyone can be affected regardless of age, sex or race. Dental issues cause most oral cutaneous fistulas and are often accompanied by inflammation. Chronic dental periapical infections and dentoalveolar abscesses are the most common culprits of intraoral and extraoral fistulas. The discharging points on the skin depend on the relationship between the muscle attachment and the site of the infection. These lesions may be mistaken for more severe conditions like squamous cell carcinoma or cysts, especially if ulcerated. Thus, careful examination of the oral cavity and dental history is crucial in diagnosis. Imaging tests like USS or CT can confirm the diagnosis. Treatment options involve antibiotics and dental treatment. Usually, fistulas present to dentists or surgeons, but occasionally they can be referred to the skin cancer clinics. A high level of suspicion is essential to achieve an early diagnosis and prompt treatment.
DS18 Pre-Mohs biopsy survey (related specifically to basal cell carcinoma and biopsy prior to Mohs surgery)
Authors: Omar Nassar, Dev Shah
Journal: British Journal of Dermatology (2024)

Abstract Mohs micrographic surgery (MMS) is a specialized surgical technique for removing locally invasive, high-risk skin cancers. MMS provides high cure rates with maximal preservation of unaffected tissue (Hanke CW. Frederic Mohs tribute. History of Mohs micrographic surgery. J Drugs Dermatol 2002; 1: 169–74; Brodland DG, Amonette R, Hanke CW, Robins P. The history and evolution of Mohs micrographic surgery. Dermatol Surg 2000; 26: 303–7). In contrast to standard excision, in which only a small portion of the margins is evaluated, in MMS, specimens are cut in horizontal sections that allow the evaluation of the entire peripheral and deep margins of the tumour. This survey was conducted to gather different opinions about type of biopsies used before Mohs surgery specifically for basal cell carcinoma (BCC). The survey was sent to British Society for Dermatological Surgery members all over the UK. The survey aimed to investigate participants’ opinions in doing biopsies before Mohs surgery specifically for BCC. This includes the types of the biopsy they prefer, and how it affects the Mohs procedure, for example whether there is a specific type of biopsy that results in the need to take more deep levels during the Mohs procedure. Of the responses received, 60% were from dermatology consultants, about half of whom are Mohs surgeons. Overall, we found that about 50% do routine biopsy before Mohs, 65% prefer scoop biopsy or shave biopsy and only 10% do punch biopsy, while 15% do not mind the type of the biopsy. We were interested that 50% routinely do biopsies prior to Mohs, and of these at least 10% are punch biopsies, which we feel should be limited as they can induce a deep scar and result in more layers being taken during the Mohs surgery procedure in order to clear the scar.
Poster presentationsDS12 A rare ophthalmological consequence of cutaneous malignant melanoma
Authors: Thushika Mahendiran, Stephen Orpin, Ajay Patil
Journal: British Journal of Dermatology (2024)

Abstract A 66-year-old man was referred urgently to dermatology from ophthalmology with a short history of developing multiple pigmented lesions on the trunk and in the axillae, the concern being that he had developed a malignant melanoma. He had been under their care for almost a year with a history of a subacute decline in vision in both eyes leading to ‘tunnel vision’. His medical history was complex and included acute myeloid leukaemia secondary to myelodysplastic syndrome treated with fludarabine, melphalan and alemtuzumab (FMA) reduced-intensity sibling allograft. Following bone marrow transplant and chemotherapy, he had post-transplant complications including cytomegalovirus reactivation, cytopenia secondary to splenomegaly, and possible graft-versus-host disease (bronchiolitis obliterans and brachial plexitis). He had presented to ophthalmology with his vision at 6/12 and 6/9 in the right and left eye, respectively. On examination, there were poorly reactive pupils with normal pupil reflexes and normal colour vision in both eyes. The visual field to confrontation was significantly constricted. Optical coherence tomography scans demonstrated outer retinal loss in the parafoveal region with macular oedema in both eyes. An autoimmune retinopathy was suspected due to these findings. Electrodiagnostic tests were consistent with this. A secondary survey was undertaken, and a positron emission tomography scan showed no evidence of active acute myeloid leukaemia or other malignancy. Neuroimaging demonstrated generalized cortical atrophy with no acute intracranial abnormalities. He was treated for a presumed nonparaneoplastic autoimmune retinopathy. He was commenced on dexamethasone intravitreal implants and mycophenolate mofetil 1 g twice a day. At review, as well as him having multiple seborrhoeic keratoses, there was an atypical melanocytic lesion on the back, which was excised urgently. This proved to be a malignant melanoma in situ with extensive regression; subsequent re-excision revealed no residual tumour. Therefore, he was diagnosed with presumed melanoma-associated retinopathy (MAR) and commenced on monthly intravenous immunoglobulin 1.5g kg−1. On subsequent visits he subjectively felt his vision had remained stable with no further deterioration. MAR is a rare paraneoplastic ocular condition. This is an autoimmune retinopathy, where a molecular mimicry occurs between the neuroectodermally derived melanocytes and the retinal proteins. MAR can precede the diagnosis of malignant melanoma, with other initial investigations being negative. This case highlights the importance of referring patients for a thorough dermatology examination for an individual presenting with an autoimmune retinopathy. With early detection and treatment, irreversible immune-related retinal damage and associated visual loss can be mitigated.
DP19 Intraepithelial metastatic melanoma mimicking gastric signet ring adenocarcinoma <i>in situ</i>
Authors: Jo-Yve Wong, Jonathan Carless, Kristofer Holte, Joe Houghton, Paul Kelly
Journal: British Journal of Dermatology (2024)

Abstract Melanoma is the most common tumour to metastasize to the gastrointestinal tract. We present an exceptionally rare case of metastatic melanoma presenting as a gastric metastasis with atypical endoscopic findings and subtle histological findings mimicking signet ring adenocarcinoma in situ and neuroendocrine cell hyperplasia. A 78-year-old patient with a remote past history of pT2b acral lentiginous melanoma of the great toe was referred to gastroenterology with weight loss and anorexia. An oesophagogastroduodenoscopy (OGD) demonstrated focal thickening of the gastric folds. Biopsy from the thickened area demonstrated a focally confluent, lentiginous intraepithelial proliferation of cytologically bland, amelanotic, small cells that was confined to gastric glands. These cells were suspected to be melanocytic in nature because of the presence of periglandular mild melanin incontinence. The melanocytes stained strongly with SOX10, S100, HMB45, melan-A and PRAME immunohistochemistry. Despite examination at levels there was no lamina propria invasion or nodule formation. Given the patient’s clinical history a diagnosis of metastatic melanoma was favoured over a primary gastric melanoma. Soon after OGD the patient developed dyspnoea. A computed tomography (CT) scan demonstrated bilateral pulmonary emboli with thrombus extending from the renal vein into the vena cava. This also demonstrated lytic lesions in the T12 and L1 vertebra and para-aortic lymphadenopathy, both of which were fluorodeoxyglucose avid on positive emission tomography (PET) CT. No gastric lesion was identified on PET CT. Metastatic melanoma presenting as a gastric intraepithelial lesion is incredibly rare, and to our knowledge this is only the second such reported case. However, this is the first case to be examined with a negative PET CT scan, demonstrating a lack of sensitivity of radiological investigations in identifying metastatic melanoma with this growth pattern. This in situ pattern of metastasis to the stomach is potentially more common than previously recognized and is deserving of wider attention.
DS17 Two cases of traumatic pseudoaneurysm of the superficial temporal artery
Authors: Chris Phillips, Kirsty Smith, Matthew Potter, Richard Turner
Journal: British Journal of Dermatology (2024)

Abstract We present two cases of traumatic pseudoaneurysm of the superficial temporal artery (STA). An 87-year-old woman was referred to the dermatology 2-week-wait clinic with a 4-cm painless nodule on the left forehead. Three weeks prior she sustained a fall at home, and computed tomography revealed a subgaleal haematoma over the left forehead. She was on warfarin for deep vein thromboses (international normalized ratio 4.2). The nodule was compressible and had a purple hue. A diagnosis of haematoma was made and incision and drainage was booked. On the day of surgery her procedure was cancelled as clinical re-examination revealed the mass was pulsatile and overlying the STA. The diagnosis was revised to STA pseudoaneurysm. She was referred to plastic surgery and underwent ligation of the artery and excision of the pseudoaneurysm. A 51-year-old man presented to dermatology with a 1-month history of a 1-cm painless, pulsatile subcutaneous mass on the right forehead continuous with the STA. Further questioning revealed a cycling accident 3 months prior with polytrauma. STA pseudoaneurysm was diagnosed clinically. He underwent ligation of the artery and resection of the pseudoaneurysm under local anaesthetic in dermatology theatres successfully, with no complications or recurrence. STA pseudoaneurysm is a rare presentation of an enlarging nodule on the forehead or temple, which typically occurs following blunt head trauma. However, cases have been reported following Botox injections, hair transplants and other procedures. The interval between the causative trauma and the onset of the lump can vary (reported range 2–6 weeks to 10 years), and therefore it may not be obvious or volunteered by the patient. Although STA pseudoaneurysm is usually asymptomatic, ear pain, headache and facial nerve palsies have been described. Examination reveals a typically spherical subcutaneous lesion, continuous with the course of the STA. Unless thrombosed, palpation should reveal a characteristic pulse or thrill and a bruit on auscultation. Diagnosis is usually clinical. Doppler ultrasound (demonstrating vessel dilatation and turbulent flow), magnetic resonance imaging, computed tomography (CT), and CT angiography can confirm the diagnosis and are useful to investigate other post-traumatic injuries. Treatment is usually surgical ligation of the artery and resection of the pseudoaneurysm. Embolization is an alternative if surgery cannot easily be performed. In summary, STA pseudoaneurysm is a rare but important clinical diagnosis to consider in a subcutaneous mass on the forehead, before biopsy or aspiration is performed. A history of trauma does not always directly precede its onset despite it being the likely causative factor. Although the clinical history can be suggestive, examination to identify the pulsatile nature is important, so the diagnosis may be missed on reviewing teledermatology images only.
CPC05 A case of adult-onset en coup de sabre responsive to abatacept
Authors: Sophie Diong, Bairbre Wynne, Mairin McMenamin
Journal: British Journal of Dermatology (2024)

Abstract En coup de sabre (ECDS) is a rare subtype of linear morphoea, located on the forehead or frontoparietal scalp. It is typically seen in children, with &amp;lt; 100 cases of adult-onset ECDS reported. The name derives from the characteristic scar that indents the skin and underlying structures. It can involve the dermis, subcutaneous tissue, muscle, bone and underlying structures, with resulting extracutaneous manifestations including neurological, ocular and oral complications. A 70-year-old female patient presented with a progressive, year-long history of forehead linear atrophy and induration manifesting along a decade-long vertical rhytid. Examination revealed a right paramedian linear atrophic depression with a violaceous rim. This extended posteriorly into her frontal scalp, with associated linear cicatricial alopecia, and inferiorly towards her orbital rim. Histopathology highlighted scarring alongside lymphocytic inflammation and focal subtle vacuolar interface change. Given both the clinical and pathological features, a diagnosis of ECDS was made. Magnetic resonance imaging of her brain revealed no skeletal or parenchymal abnormalities. Ophthalmology examination was normal. Given a history of progression, and the clinical appearance of active disease, immunosuppressive therapy was warranted. Abatacept 125 mg subcutaneously weekly was chosen over methotrexate given the presence of comorbid liver disease. An 8-month course was completed, improving the appearance of the lesion. No further activity has been noted 1 year off treatment. ECDS is a chronic autoimmune fibrosing condition of the skin and underlying tissue with the potential for significant disease-associated morbidity. There is currently no universal diagnostic test for ECDS and no pathological marker that correlates with disease activity. Histology often highlights a perivascular and periappendageal lymphocytic infiltrate, with vacuolar interface changes. All patients should undergo brain imaging to determine the extent of disease. While its aetiopathogenesis remains unknown, there is evidence to suggest that the early inflammatory stages are driven by the T helper (Th)1/Th17 pathway, while the Th2 pathway may be responsible for the fibrosis and damage observed later in the disease. This concept underpins the efficacy seen with abatacept, which inhibits T-lymphocyte activation. Abatacept is a lesser-recognized but important therapeutic option in our armamentarium for managing ECDS. Studies have shown a latency period of &amp;gt; 2 years between symptom onset and diagnosis, likely due to the rarity of this condition and reduced knowledge of adult-onset ECDS. Given the cutaneous and extracutaneous manifestation of this condition, this can have disastrous consequences. Increased awareness of adult-onset ECDS is important to allow for prompt diagnosis, investigation and management.
DS15 Lentigo maligna: mapping using confocal microscopy and the impact of multiple facial surgeries on patient quality of life
Authors: Marion Leahy, Mary Laing
Journal: British Journal of Dermatology (2024)

Abstract Lentigo maligna (LM) can present with subclinical extension that may be difficult to define preoperatively and lead to incomplete excision and potential recurrence. Preliminary studies have used reflectance confocal microscopy (RCM) to assess LM margins. Knowing the margin prior to surgery allows for forward planning and enables the doctor to discuss the plan with the patient. The objectives of this study were (i) to evaluate the correlation of subclinical extension of LM defined by RCM compared with the gold standard of histopathology, and (ii) to assess the impact of multiple surgical excisions on a patient’s mental health and quality of life. This was a prospective study of patients with LM referred for surgery. RCM was performed at the clinically defined initial surgical scar, followed by staged RCM imaging of the ‘normal’ skin to define the exact margin of the lesion. Punch biopsies were then completed along the negative margin to ensure the accuracy of the results. Patients then completed a questionnaire detailing their knowledge of LM and the impact that multiple surgeries had on their life. Ten patients were included: five male and five female. All patients had undergone multiple surgeries without obtaining a negative margin. Ninety per cent had a facial lesion and 10% had a chest lesion. The mean largest diameter was 2.8 cm (range 0.8–5). Diagnostic accuracy for detection of residual LM using RCM was 97%. Histopathology correlation revealed that 96% of biopsies matched the RCM findings. All participants reported a negative impact on their quality of life. Eighty per cent of patients thought LM was melanoma. Fifty per cent of patients were not informed of the nonsurgical options. Twenty-five per cent of patients would not have opted for surgical excision if they had understood the extent of the surgery. In conclusion, providing optimal care for patients with LM requires a multidisciplinary approach. RCM is an useful tool to aid surgical planning and for managing patient expectations in LM.