tbuckley/cabot-search huggingface dataset:
Historical H01 A published case of delusional parasitosis in an entomologist
Authors: Serena Altaf Merchant, Syed Fazal Hussein Shah
Journal: British Journal of Dermatology (2024)

Abstract Delusional parasitosis describes an individual’s false yet firmly held belief that they are infested with parasites crawling or burrowing under their skin. This can result in self-inflicted dermatoses as patients attempt to remove the ‘parasites’. A notable case of delusional parasitosis is that of Jay R. Traver (1894–1974), an entomologist who published her personal account of living with a ‘mite infestation’ (Traver JR. Unusual scalp dermatitis in humans caused by the mite Dermatophagoides. Proc Entomol Soc Washington 1951; 53: 1–25). Traver’s account, written alternatingly in first and third person, describes her condition as beginning with pruritic red papules of the scalp that progressed to nocturnal sensations of ‘something biting, scratching and crawling from place to place’. Traver trialled numerous topical treatments, including mercuric iodide and sulfur ointments. Alongside topical agents, Traver also tried ‘digging out’ the ‘mites’ with her fingernails, without success. However, her condition spread downwards to involve her eyes, ears and nostrils. On one occasion, Traver describes her eyes becoming so swollen that she was unable to move her eyeballs and experienced ‘sharp pin-prick like sensations in one eye’. Desperate for relief, Traver consulted a dermatologist, who she recounts disdainfully as advising that her symptoms were ‘largely imaginary’. Following 3 days of ineffective in-hospital treatment, Traver was referred to a neurologist, who assessed for a ‘psychoneurotic condition’. However, she ‘succeeded in convincing [him] that she had no need of his services’. Traver also sought advice from a parasitologist, to whom she mailed samples of the ‘mites’ that she caught through skin scrapings and inspecting her pillowcases. Traver’s published article describes these organisms in taxonomic detail as belonging to a family of rare dust mites, and includes several hand-drawn figures of the mites. Despite concerted efforts to identify a cure, Traver’s condition persisted for 40 years until her death in 1974. Today, Traver is recognized as having had delusional parasitosis. Her article is considered a textbook case of the condition, describing characteristic features such as the use of home remedies and self-mutilation to remove offending ‘mites’, preserving skin scrapings in paper and/or small jars, consulting multiple physicians while rejecting the possibility of psychological or other explanations, and shared delusions among family members. Debate continues as to whether Traver’s publication warrants retraction due to conclusions being drawn from data that were unconsciously fabricated in the author’s mind.
BI38 A rare case of acquired epidermodysplasia verruciformis
Authors: Lisa Murphy, Niamh Leonard, Susan O’Gorman
Journal: British Journal of Dermatology (2024)

Abstract Epidermodysplasia verruciformis (EV) is a rare, genetic disease characterized by an increased susceptibility to infection with specific types of human papillomavirus. These patients also have a higher likelihood of developing malignant skin tumours. We report the unusual case of a 51-year-old female patient who presented with 7-month history of tender, verrucous papules and nodules on the dorsum of both her hands. Her medical history was significant for sero­negative arthritis and diabetes mellitus, and she was being treated with methotrexate for her arthritis. She had never had lesions similar to these in the past and there was no history of a cutaneous malignancy. A biopsy from a lesion on the right elbow demonstrated epidermal acanthosis and a prominent granular layer suggestive of viral aetiology, such as EV. Acquired EV typically occurs in immunosuppressed patients such as those who have had transplants or haematological malignancies. The lesions generally appear at sun-exposed sites such as the hands and arms, as was seen in this case. Treatment options include topical treatments such as cryotherapy and fluorouracil, or oral agents such as acitretin. Photoprotection advice is also imperative. This case highlights the importance of considering EV in patients who are immunosuppressed, who present with a significant number of viral warts that are resistant to treatment.
H03 (P068) A history of mycosis fungoides: from Alibert to mogamulizumab
Authors: Nicholas A Johnson, Zoe C Venables, Khaylen Mistry, Nick J Levell
Journal: British Journal of Dermatology (2024)

Abstract In 1806, French physician Baron Jean-Louis Alibert treated a 56-year-old man with a desquamating rash and skin tumours. Alibert considered this to be a variant of yaws. In 1829 Alibert named the condition mycosis fungoides (MF), meaning ‘mushroom-like fungal disease’. Over 100 years later, French dermatologist Albert Sézary published papers from 1938 to 1949 detailing a mysterious disease that caused erythroderma and ‘cellules monstrueuses’, describing cutaneous ‘monster cells’. In 1961, these clinical findings were collated together into ‘Sézary syndrome’. Over this time there was widespread confusion between these conditions, fungal infections and yaws. In the 1870s English dermatologist William Tilbury Fox published a dermatology atlas detailing cases similar to what we know now as MF, with the name ‘fibroma fungoides’. The atlas described MF as a type of fungus, before giving a description of yaws and painting a clinical picture that differed from that of a lymphoma. In 1975, Pierre-Antoine-Ernest Bazin and associates in suggested the classification system and term we now recognize as cutaneous T-cell lymphoma (CTCL). Neoplastic cells have been thought to arise from chronic activation of T cells via antigen-presenting cells, yet the antigen to trigger this response remains unknown. Several potential bacterial, viral, fungal and iatrogenic causes have been studied, but no reliable triggers have been discovered. In 2018, the World Health Organization and European Organisation for Research and Treatment of Cancer officially recognized four types of MF. These are the classic Alibert–Bazin type (representing 88.6% of cases) and its three subtypes; folliculotropic MF (11.4%), Pagetoid reticulosis, and granulomatous slack skin (both with a combined 1% prevalence). CTCL has an incidence of approximately 0.2–0.6 per 100 000 person-years, with MF being the most common subtype. MF is twice as common in male as in female patients. It is twice as common in those of Black ethnic background than in White and Asian ethnicities. Development of immunohistochemistry and polymerase chain reaction for the T-cell receptor gene in the 1980s improved the diagnosis of CTCL. However, diagnosis of MF remains challenging due to its heterogeneous presentation, often mimicking inflammatory dermatoses. Advanced disease therapies have evolved from cytotoxic chemotherapy in the 1970s to novel monoclonal antibodies such as mogamulizumab, targeting proteins on T-cell lymphoma cells (CCR4). Reflection on the past two centuries from Alibert to mogamulizumab offers insight into the challenges that accompany the aetiology, diagnosis, classification and management of MF.
BT14 (P026) Teledermatology from the other side: a clinical photographers’ perspective
Authors: Aarthy Uthayakumar, Tamara Searle, Noha Elshimy
Journal: British Journal of Dermatology (2024)

Abstract Teledermatology has transformed the way we deliver our skin cancer service, with medical photographers playing a vital role in our trust. We sought to further streamline our existing teledermatology service and explore challenges faced by the photography team. Our teledermatology model involves patients directly attending the hospital for a professional photography appointment before consultant triage of the lesion(s). After observing teledermatology photography lists with detailed photographer feedback, 1 week of teledermatology clinics across all three sites of the trust were analysed. Referral type, discrepancies between the general practitioner (GP) referral and photos taken, and chaperone availability were explored, in addition to the referral pathway and patient information supplied. In total 122 teledermatology patients were included. Photographers highlighted difficulties with patients requesting lesions not specified on the GP referral to be photographed, and not having sufficient information prior to their teledermatology appointment, making it often difficult to manage expectations. Furthermore, due to minimal staffing, the availability of chaperones was often limited. In 19% of cases there was a discrepancy between the GP referred lesion and photograph taken, which was due to additional lesions being photographed (35%), patients having multiple moles (22%), and unlikely suitability for teledermatology and no GP referral being present (17%). Improvements have been implemented at different levels along the teledermatology pathway to further streamline the service and reduce some of the pressures faced by our clinical photographer colleagues. Modifications to the GP suspected skin cancer pathway referral make it clearer which patients are suitable for teledermatology, and request a mandatory lesion and locator photograph. The triage process has been altered to improve robustness, with an additional triage step to minimize patients inappropriate for teledermatology being booked in, such as those with more than three lesions, genital lesions and patients on stretchers. Patient information has been clearly displayed in the medical photography department, highlighting that only the referred lesion can be photographed, and a paper copy of the teledermatology patient information leaflet is provided to highlight the next steps to the patient. This minimizes questions directed at the photographers and aids management of patient expectations. Finally, a protocol for medical photographers has been implemented to standardize teledermatology images taken, with changes to include polarized and nonpolarized dermoscopy. With these changes we have minimized the challenges faced by our clinical photography colleagues, whose perspective and experience of a successful teledermatology service is critical, and we believe this should be explored in order to make meaningful improvements.
BT09 Multicentre prospective clinical performance analysis of an artificial intelligence as a medical device deployed within urgent suspected skin cancer pathways
Authors: Felix Brewer, Jonathan Kentley, Dilraj Kalsi, Dan Mullarkey, Lucy Thomas
Journal: British Journal of Dermatology (2024)

Abstract Over 25% of patients with suspected skin cancer in England waited over 4 weeks from urgent referral to diagnosis in October 2023. Implementation of artificial intelligence (AI) can augment this pathway to improve timely diagnosis. A prospective, postdeployment, multicentre clinical performance review of AIaMD was performed. AIaMD is a UKCA class IIa-approved artificial intelligence as a medical device intended for use in the screening, triage and assessment of skin lesions suspicious for skin cancer. AIaMD was deployed at four sites as part of the National Health Service AI in Health and Care Award. Patients assessed by the most recent version of AIaMD from April 2022 to November 2023 were eligible for inclusion. Outcomes were confirmed from histology reports for cancerous lesions and histology reports or consultant teledermatology assessment for premalignant and benign lesions. AIaMD assessed 3979 lesions with outcomes confirmed, including 38 melanomas, 68 squamous cell carcinomas, 181 basal cell carcinomas, 5 rare skin cancers, and 612 premalignant lesions such as Bowen disease and actinic keratoses. The negative predictive value – how often AIaMD labelled lesions as premalignant or benign and correctly ruled out cancer – was 99.8% (539 of 540). The sensitivities of AIaMD for melanoma, all skin cancer and premalignancy were 97% (37 of 38), 96.6% (282 of 292) and 86.3% (528 of 612), respectively. The specificity of AIaMD for benign lesions was 74.9% (2118 of 2827). For benign lesions confirmed by biopsy only, the specificity was 27.6% (105 of 381). One site reported a reduction in average wait time to first appointment by 11 days, a 10% reduction in biopsies and a 13% reduction in routine follow-up appointments. This postmarket service evaluation reported the clinical outcomes of AIaMD – an AI device used for assessment of skin lesions. The pathway was sensitive, identifying 282 out of 292 skin cancers, and specific, correctly identifying three out of every four benign lesions assessed and confirmed clinically or histologically. Moreover, implementation of AIaMD was linked to benefits to the pathway such as a reduction of biopsies. The integration of AIaMD into skin cancer diagnostic pathways could significantly improve the accuracy of urgent suspected skin cancer referrals, removing unnecessary specialist review of benign lesions. Part of the deployment period was funded as part of the NHS AI in Health and Care Award, and two of the authors are employed by one of the deployment sites. Three of the authors are employed by the AI provider.
H06 The changing face of skin disease in warfare: from World War I to modern times
Authors: Manu Shah
Journal: British Journal of Dermatology (2024)

Abstract Skin disease has been always been associated with human conflict, causing considerable morbidity and removing soldiers from the battlefield. Records of skin disease in soldiers improved significantly from the early 20th century. Analysis of these quality data gives us an insight into the changing picture of skin disease across many theatres of war. In World War I, the most common skin conditions reported were bacterial infection (42%), scabies (28.5%), eczema/dermatitis (13%) and acne (5.4%). Interestingly, body lice were so common that cases were not routinely recorded, even though the association with typhus, which led to many deaths, was recognized. Trench foot, again common, was not routinely classified as a skin disease. By World War II, skin disease in combatants had changed considerably. Overall rates of skin disease varied by conflict zone from 25% (in temperate climates) to 75% (tropical climates). For example, the commonest skin conditions afflicting the British Army in India were fungal disease and scabies. The British Liberation Army found that their rates of skin disease doubled from July 1944 to March 1945, with high rates of eczema (42%) and bacterial infections (30.9%) and lower rates of fungal infections (5.1%) and scabies (7.4%). The dramatic difference between rates and types of skin disease reported in different climates is still seen today: 25.2% of medical consultations in the East Timor conflict (1999) were for skin disease, compared with 9.3% during the Gulf War (1990). Scabies became less important after World War II (apart from a small rise in the first Gulf War). In Vietnam (1965–70), dermatitis had become the most common skin problem (16.5%), with significant issues of fungal disease: mainly ‘jungle rot’ (a resurgence of the original trench foot, 13%), viral conditions including warts (11.5%) and acne (4.3%). Recent figures are similar for Afghanistan (2008–15), although cases of dermatitis had fallen (8.5%). The incidence of scabies in soldiers has hugely reduced since the World War I, probably due to effective treatments and improved military hygiene, as well as less prolonged, less intensive conflicts. Climate continues to play a major role in types and rates of skin disease. It is important to point out that skin disease, even in the modern age, continues to cause major morbidity among combatants, and soldiers need to be screened for pre-existing skin disease before being sent into combat zones.
BT23 Artificial intelligence generation of patient information leaflets can have a useful role in the dermatology clinic
Authors: Callum Verran, Michael R Ardern-Jones, Ella Seccombe
Journal: British Journal of Dermatology (2024)

Abstract Provision of information to patients via written patient information leaflets (PILs) is an important component of clinical care. The British Association of Dermatologists (BAD) PILs follow a consistent template and undergo quality testing with input from experts and nonmedical reviewers, and therefore they are time-consuming and costly to generate. Hence, existing PILs cover a limited range of skin conditions and treatments. General-language AI can use existing knowledge to infer, synthesize and summarize information and output this in any number of styles, including lay language. The aim of this study was to evaluate whether AI offers a useful function in generation of new PILs. ChatGPT (v3.5) was tasked to generate eight PILs where a BAD-produced PIL was not available. AI-generated PILs were reviewed by eight dermatologists and five nonmedical reviewers using a five-point Likert scale to assess document structure, accuracy, relevance and utility. Dermatologist responses varied based on PIL subject and were positive for structure, relevance and accuracy in 98%, 88% and 65% of responses, respectively, for condition-related PILs, whereas positive responses were seen in only 81%, 38% and 25% for medication-related PILs. While 64.6% of condition-related PILs were considered acceptable for patient distribution, this was only 12.5% for medication-related PILs. Nonmedical reviewers were more uniformly positive about the AI-generated PILs, with a majority of positive responses to presentation (97%), structure (97%), and language and content (97%) for condition-related PILs, and 70%, 70% and 70% of responses, respectively, for medication-related PILs. Our data show that dermatologists and nonmedical reviewers are positive towards the structure and relevance of condition-related PILs, but less so towards their content accuracy, and to medication-related PILs as a whole. We highlight the potential use of AI in clinical practice for PIL generation but recommend caution on content checking before publication and distribution, especially for medication-related information.
BT24 Pseudonymization for artificial intelligence skin lesion datasets: a real-world feasibility study
Authors: Trisha J M Chin, Gillian X M Chin, James Sutherland, Andrew Coon, Colin Morton, Colin Fleming
Journal: British Journal of Dermatology (2024)

Abstract The use of patient data for artificial intelligence (AI) research should be transparent, rigorous and accountable. In the UK, the General Data Protection Regulation, Data Protection Act 2018 and General Medical Council govern data handling and patients’ rights to privacy. We report on our multistep pseudonymization protocol for real-world skin lesion datasets, in preparation for research within a trusted research environment (TRE). Firstly, patients referred from primary care are triaged for community locality and imaging centre (CLIC) suitability. There, trained healthcare professionals capture lesion images (dermoscopic, macroscopic and regional) and patient information using a mobile application on trust-certified devices. Training is standardized across all CLIC sites, with specific anonymization training on removing in-frame clothing and jewellery, device positioning, and magnification to minimize identifiable features like eyes, nose and ears. Lesion datasets (paired images and clinical information) are subsequently transferred to an image management system (IMS) hosted on our trust-secured network. Within the IMS, images are manually inspected, and those with identifiable tattoos and piercings are excluded. All regional images are also excluded from transfer to the TRE. Before transfer to the TRE, images undergo a further round of review. Data fields are manually checked for identifiable patient information, patient names are removed, and dates of birth are rounded to 3-month granularity. The job ID, patient’s hospital number, date of clinical episode and responsible photographer are replaced with randomly generated project-specific identifiers. In an initial study period, 658 of 963 (68%) captured lesion datasets have undergone IMS manual inspection. Of these, 24 lesion datasets were excluded for identifiable features, 10 (41%) for more than one-third of the face being visible, 9 (38%) for full iris visibility, and 5 (21%) for tattoos. On breakdown by anatomical location these images were of the face (19, 80%), torso (2, 8%), limbs (2, 8%) and neck (1, 4%). The remaining 634 datasets (96%) were securely transferred to the TRE, where a further 5% were excluded due to potential identifiability. Although full anonymization is desirable, it is usually achieved by aggregating patient data. Pseudonymization, which allows for future reidentification in a secured fashion, strikes the balance between patient data privacy and clinical governance, while retaining a level of granularity sufficient for meaningful analysis. Currently, this protocol is manually intensive with room to partly automate. Use of common standardized protocols will strengthen the public trust in clinical AI.
BI43 Sounds fishy: a case of <i>Mycobacterium marinum</i> infection secondary to infliximab infusion
Authors: Attam Khan, Dimple Jain
Journal: British Journal of Dermatology (2024)

Abstract Mycobacterium marinum is a waterborne, atypical mycobacterium that is known to cause infection in fish, mice and bats. M. marinum in humans is rare and can manifest as a skin/soft tissue infection following exposure of damaged skin to polluted water from aqueous environments such as swimming pools, wells, rivers and fish tanks. We report the case of a 73-year-old White man with a history of collagenous colitis on treatment with infliximab. He presented with pustules, ulcerated plaques and nodules on his left wrist and left deltoid as well as some nodules on the right forearm in a sporotrichoid distribution following a second infliximab infusion. A skin biopsy revealed prominent dermal abscess formation with extension of acute inflammation into the subcutis with fat necrosis. Small granulomas were also seen at the edges without caseating necrosis. Numerous acid-fast bacilli were present on a Ziehl–Neelsen stain in keeping with mycobacterial infection. He was started empirically on rifampicin, ethambutol and clarithromycin; however, minimal improvement was noted. A subsequent mycobacteria microscopy, culture and sensitivity revealed sensitivity to ciprofloxacin, and fortunately his skin responded well to this. Tumour necrosis factor (TNF)-α inhibitors such as infliximab are widely used treatments in managing chronic inflammatory dermatoses as well as inflammatory bowel disease. These agents increase the risk of granulomatous disease. A diagnosis of M. marinum is challenging and multiple biopsies and tissues cultures may be necessary for identifying the correct diagnosis. Although this case did not have any typical exposures to M. marinum, it highlights the importance of screening and educating patients regarding the risks of certain environmental exposures prior to commencing anti-TNF treatments.