tbuckley/cabot-search huggingface dataset:
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.
P087 The British Hair and Nail Society present a review of our national grand round of challenging hair disorders and the benefits to the wider British Association of Dermatologists membership
Authors: Sonia Sharma, Alyson Bryden, Nicola Clayton, Paul Farrant, Megan Mowbray, Susan Holmes, Anastasia Therianou, Yusur Al-Nuaimi, Nekma Meah, Leila Asfour, Anita Takwale
Journal: British Journal of Dermatology (2024)

Abstract The British Hair and Nail Society was formed in 2011. We currently have 133 members and invite them to submit challenging cases of hair disorders to our grand round (with relevant history, histopathology and photographs) for review by our expert hair panel. This comprises consultants with hair expertise from around the UK, and together we aim to address the referrers’ queries relating to diagnosis, treatment or both. We appreciate the complexity of hair disorders and the limited number of specialist hair clinics around the country, and therefore we have recently offered the opportunity for all British Association of Dermatologists (BAD) members to submit cases once a year. The aim of our review is to present the types of complex hair disorders that have been referred to our dedicated national hair-related grand round and showcase some of the most educational cases. The hair disorders grand round began in 2018 and since then a total of 26 hair cases (10 children and 16 adults) have been submitted from various regions. The main aims of referral include diagnostic expertise (n = 4), aid with treatment plans (n = 8) or both (n = 14). The median age of patients was 33 years (range 4–75). There were 14 female and 12 male cases. The regions of referral include Oxford, Brighton, Manchester and Scotland. There were equal numbers of scarring alopecia (n = 13) and nonscarring (n = 13) cases. The most common nonscarring hair condition was alopecia areata (n = 6), with the possibility of other concurrent hair conditions (n = 1) or an underlying genetic disorder (n = 3). The most common diagnosis of scarring alopecia was folliculitis decalvans (n = 6). The diagnosis was altered in 10 cases (38%). Examples of some of our rare diagnoses include keratosis follicularis spinulosa decalvans, genetic hypotrichosis and scalp dermatomyositis. We reviewed cases of recalcitrant disease such as folliculitis decalvans, and novel therapeutics were suggested such as the use of naltrexone, utilizing photodynamic therapy after removing crusts, and even the use of manuka honey and cannabinoid oil. Our grand round has recommended independent funding requests in three cases and supports applications from clinicians for their patients with complex conditions. We hope our presentation showcases to the wider BAD membership the value of our national hair disorders grand round in supporting complex diagnostic and therapeutic decisions, as well as offering support for clinicians in the form of individual funding request submissions or trialling novel therapies, which may have limited evidence. We welcome any future submissions.
P095 Ten cases of scabies successfully treated with topical ivermectin
Authors: Jaimie Oldham, Anshoo Sahota, Edel O’Toole, Malvina Cunningham
Journal: British Journal of Dermatology (2024)

Abstract Scabies is an increasing problem in the UK with a surge in cases reported by dermatologists and the media. It is intensely itchy and caused by the highly contagious mite Sarcoptes scabiei. There are many theories regarding the increased prevalence, including hypotheses related to global warming, increased poverty, reduced treatment availability and resistance. The standard treatments in the UK include topical malathion, topical permethrin and oral ivermectin. All have had significant supply issues as reported by the British Association of Dermatologists. There have also been concerns of permethrin resistance. Oral ivermectin is expensive, with four tablets listed at £116.84 in the British National Formulary (BNF). Finally, oral ivermectin is not licensed in children weighing &amp;lt; 15 kg (although data seem to suggest this is safe). One option that is less used but reported is topical ivermectin. This was in the 2018 Cochrane review that assessed the efficacy of topical permethrin, and oral and topical (as 1% lotion) ivermectin. This showed no difference in efficacy and few or mild adverse events. These findings are also replicated in recent studies and there are case reports of topical ivermectin to treat neonatal scabies that seems resistant to permethrin. In our centre, we have used topical ivermectin (as the 10 mg g−1 cream Soolantra) to treat 10 patients, with great success. The first was a 14-month-old child who weighed 9.2 kg. She had previously had three courses of permethrin and two courses of malathion with ongoing signs and symptoms of scabies, including burrows. The entire family had been treated every time and the entire family (except this patient) was treated with oral ivermectin during the final treatment before topical ivermectin. The patient was treated top to toe with two applications of topical ivermectin cream 1 week apart, with resolution after one application. Subsequently we have had success using the same protocol to treat a 21-year-old man (with no response to four courses of permethrin) and his 53-year-old mother (with no response to three courses of permethrin). We have also treated a 31-year-old man, a 48-year-old man and his partner (all of whom had not responded to one course of permethrin), and a 68-year-old man and his family who had no previous treatment. Our patients have not experienced any adverse effects and there have been no treatment failures. We report on 10 patients who we treated successfully with topical ivermectin. Topical ivermectin provides an exciting option for treatment and, of note, one tube is listed at £27.43 in the BNF, making it significantly cheaper than the oral alternative.
British Photodermatology GroupOral presentationsPD01 Accelerated oral psoralen–ultraviolet A therapy in the management of polymorphic skin eruption: real-world data from a specialist centre
Authors: Fiona Campbell, Rachel Montgomery, Victoria Goulden
Journal: British Journal of Dermatology (2024)

Abstract Polymorphic light eruption (PLE) is a common, debilitating disease. First-line management includes photoprotective measures, which are restrictive, and ineffective for severe cases. Many patients notice increased tolerance (hardening) to sunlight as summer progresses. This phenomenon can be induced by exposure to artificial sources of ultraviolet. Many studies have demonstrated the efficacy of both narrowband ultraviolet B radiation (NB-UVB) and psoralen–ultraviolet A therapy (PUVA) in reducing PLE flares (Ling TC, Clayton TH, Crawley J et al. British Association of Dermatologists and British Photodermatology Group guidelines for the safe and effective use of psoralen–ultraviolet A therapy 2015. Br J Dermatol 2016; 174: 24–55). NB-UVB is generally used first line due to simplicity of treatment and long-term safety. PUVA is second-line phototherapy and, as PUVA is associated with a dose-dependent risk of skin cancer, shorter treatment courses are desirable. A study by Palmer and Friedmann showed that six PUVA treatments provided as much protection as 12 in patients with PLE (Palmer RA, Friedmann PS. A comparison of six and 12 PUVA treatments in the prophylaxis of polymorphic light eruption. Clin Exp Dermatol 2004; 29: 141–3). We have retrospectively reviewed our patients with PLE who did not gain benefit with NB-UVB hardening and were treated with ‘accelerated’ PUVA. In the early spring, patients were treated on exposed sites with four UVA exposures after taking oral psoralen. The initial irradiation dose was 70% of the minimal phototoxic dose. Doses were then escalated by 1 J cm−2 each visit for a total of four exposures only. To prevent a significant flare of PLE during treatment, patients were prescribed oral prednisolone 20 mg once daily, commencing on the day of the first exposure and continued for the 2-week course of treatment. Fourteen patients (12 female, two male) with severe PLE and poor response to narrowband NB-UVB were treated. The age range was 25–67 years. Thirteen patients experienced a significant reduction in severity of their PLE flares. Only one patient (male, 39 years) found the treatment unsuccessful. Half of the patients went on to have further courses of accelerated PUVA. No patient experienced significant adverse effects. Our experience has demonstrated that only four exposures of oral PUVA can induce significant skin hardening, preventing PLE flares. This has the significant advantage of a short course of treatment and reduction in cumulative exposure for patients who frequently require repeated courses of treatment. Oral steroid cover is necessary to suppress reactions during treatment but was well tolerated in all cases.
P029 Targeted skin examinations: a reasonable compromise?
Authors: Aswatha Rabindranathnambi, Modupe Ojelabi, Georgina Elston
Journal: British Journal of Dermatology (2024)

Abstract There has been a significant increase in referrals for suspected skin cancer since March 2021, resulting in busy urgent skin cancer clinics across the country. Gold-standard care would include a full-skin examination for all patients referred via this route to ensure other incidental lesions are not missed, but full-skin examinations are time-consuming and decrease the total number of patients who can be seen in clinic. There is only limited evidence regarding the benefits of full-skin examinations. We conducted a service evaluation: a retrospective review of all ‘new’ patients referred to a 2-week-wait skin cancer clinic in a district general hospital over a 12-month period (January to December 2022). All 205 patients were offered a full-skin examination, of whom 175 accepted full- or partial-skin examination. Overall, 21% (37 of 175) had incidental lesions identified that either warranted treatment or were concerning enough to need photography and further monitoring. Forty-four incidental lesions were picked up in total. The majority were actinic keratoses (n = 7) and basal cell cancers (n = 12). The other incidental lesions were atypical naevi (n = 8), intraepidermal carcinoma (n = 4), lentigo maligna (n = 1), vulval melanosis (n = 1) and malignant melanoma (n = 1). Importantly, most of the incidental lesions were seen in those &amp;gt; 50 years of age (92%) and were on the head and neck or upper body (89%). The majority of these patients (89% of those who had it documented) were found to have Fitzpatrick skin phototypes I or II. Our results suggest that examining the upper body in those &amp;gt; 50 years of age with skin type I and II has the highest yield of picking up further skin lesions that are either cancerous or could be precancerous. This upper-body, targeted skin examination has the potential to avoid further referrals, thus saving time and resources in the long run, for patients and primary and secondary care. Further research is needed to evaluate the impact on ‘hard’ outcomes such as morbidity and mortality rates, as well as potential cost benefits.
P093 Bespoke omalizumab prescribing in chronic spontaneous urticaria
Authors: Isabelle Vandormael, Daniela Mock Font, Emily Carne, Sandeep Kamath
Journal: British Journal of Dermatology (2024)

Chronic spontaneous urticaria (CSU) represents the most common form of chronic urticaria and is estimated to affect 0.5–1% of the worldwide population. This condition has an underestimated but significant impact on the quality of life of patients. It represents a high socioeconomic burden to healthcare systems due to its chronic nature and the challenges currently faced in its treatment. Omalizumab is the only IgE-targeted biologic currently approved for patients with CSU who have persistent symptoms despite high-dose antihistamines. The licensed dose for omalizumab is 300 mg every 4 weeks and it is currently recommended for 6 months; however, it is estimated that approximately 30% of patients do not respond to this standardized regimen and there is currently no clear guidance on managing this cohort of patients. This study provides an overview of our clinical practice when prescribing omalizumab for the management of CSU and further evidence of the efficacy of a personalized dosing regimen. We report on 36 patients started on omalizumab during the year 2022 from five separate dermatology centres. Data were collected retrospectively from pharmacy records using data spreadsheets. Twenty-seven patients were given omalizumab for the first time, while nine patients were on their second course. Dosing and treatment intervals were adjusted according to disease activity using the Urticaria Activity Score (UAS7). Eleven patients received personalized dosing, with their dose titrated up or down based on symptom control. Three patients required updosing to 450 mg 4-weekly, one patient was given 600 mg 4-weekly, one patient had their dose titrated down to 150 mg monthly, and six patients remained on 300 mg 4-weekly beyond 6 months. Our results suggest that 30.5% of patients would have had to discontinue treatment and consider switching to ciclosporin had personalized dosing not been considered. Immunosuppression comes with its challenges, with significant adverse events, rigorous blood monitoring and more frequent hospital reviews all contributing to the ever-increasing financial burden on the NHS. Omalizumab, in comparison, is better tolerated and carries a much better safety profile. This study also supports findings from a proportion of patients will require longer treatment courses, as a reduction in UAS7 scores may occur beyond the fourth dose. Overall, 25% of patients were on their second course of treatment at the time of analysis, suggesting a lack of remission at 6 months and the need for more guidance on longer-term treatment.
P053 Synchronous melanoma: a single-centre 5-year retrospective study
Authors: Ji Fung Yong, Michael O’Connell, Alana Durack, Lyndsey Paul
Journal: British Journal of Dermatology (2024)

Abstract Synchronous melanoma (SM) is defined as at least two melanomas diagnosed at the same time, or a second within 3 months of diagnosing the first melanoma. Previous studies have shown that 0.5% of all patients with cutaneous melanoma have synchronous second primaries. A retrospective study of melanoma data in one of the eight designated cancer centres in the Republic of Ireland was undertaken. We reviewed the demographics, risk factors and melanoma types in all the cases of SM discussed at the melanoma multidisciplinary team (MDT) meeting for the last 5 years. Melanoma MDT lists, and histopathology and clinical records were reviewed from July 2018 to July 2023 inclusive, for SMs. This study included invasive malignant melanoma (MM), lentigo maligna (LM) and melanoma in situ (MIS). In total, 1082 patients were diagnosed with cutaneous melanomas over the 5-year period. Of these patients, 42 (3.9%) with SMs were identified (26 male, 16 female). Ages ranged from 44 to 93 years. Thirty patients (71%) had SMs diagnosed at the same time, with the rest diagnosed within a 3-month period. Nine cases (21%) had a previous history of melanoma, with four having previous SMs. Other risk factors noted included history of immunosuppression (10%, n = 4), first-degree relatives with a history of melanoma (7%, n = 3) and history of previous nonmelanoma skin cancer (5%, n = 2). Of the 42 patients, four (10%) had more than two individual melanomas identified on the same occasion (three patients had three melanomas and one had five). Of these four patients, two had a first-degree family history of cutaneous melanomas and were referred for genetic testing, with results pending. Of the total number of SMs (n = 91), 29% (26) were invasive MM, 24% (22) were LM and 47% (43) were MIS. Most lesions (33%, n = 30) were located on the trunk, with 19 (58%) on the back. Twenty patients (48%) had synchronous in situ lesions (LM/MIS), 20 (48%) had LM/MIS with an invasive melanoma (pathological stage 1A to 4B) and two (5%) had synchronous stage 1a and 1b melanomas. In total, 93% of cases (n = 39) attended dermatology services for follow-up. To the best of our knowledge, this is the largest reported case series to date of SM. A higher incidence of SMs in our cancer centre is noted compared with the literature (3.8% vs. 0.5%). It highlights the importance of a full skin check, especially once a melanoma has been identified, to ensure further melanomas are not missed. For patients diagnosed with SMs, who also have first-degree family history of cutaneous melanoma, genetic testing should be considered to look for germline mutations and genetic variants.
PD15 Ultraviolet overexposure in solar urticaria: beyond the rash
Authors: Hannah Ross, Donna Parkin, Jean Ayer
Journal: British Journal of Dermatology (2024)

Abstract Solar urticaria is a rare photodermatosis characterized by an immediate type I hypersensitivity reaction, usually to ultraviolet (UV)A and visible light, and less commonly to ultraviolet B (UVB). Symptoms of itch and burning to exposed sites occur after seconds of sun exposure and are followed by erythema and often wealing of the skin. Patients can report associated systemic symptoms including headache, hypotension, nausea and syncope following significant exposure. We describe the rare case of a 54-year-old white British man with a diagnosis of solar urticaria who experienced vasomotor collapse following sunbed use. The patient had previously undergone monochromated light testing, which demonstrated exquisite photosensitivity to both UVB and UVA from 300 to 370 nm and severity in the visible range from 400 nm. Treatment options for solar urticaria are limited, with avoidance of sunlight, photoprotective measures and antihistamines being the mainstay of management. Omalizumab is a more recent therapy; however, access to this at present is limited to tertiary centres for this indication. Phototherapy can be considered to induce skin hardening; however, this is used only in a controlled setting with the choice of treatment dependent on the provoking wavelengths. Our patient used a commercial sunbed in a desperate effort to self-treat his solar urticaria. Shortly after use, while sitting upright in a car, he become unresponsive and displayed involuntary movements, urinary incontinence and tongue biting, resulting in assessment at a local emergency department. He went on to have an unremarkable magnetic resonance imaging scan of the brain and electroencephalogram. Later review resulted in a diagnosis of an anoxic seizure. This was felt to be caused by hypotension and reduced cerebral perfusion, secondary to sunbed use and further exacerbated by his upright seated position in the car passenger seat. The case highlights the complexity of solar urticaria and the potentially fatal consequences of significant UV and visible light exposure.
P060 An analysis of eye colour and iris pattern as a risk factor for skin cancer in immunosuppressed renal transplant recipients
Authors: Marion Leahy, Mary Laing
Journal: British Journal of Dermatology (2024)

Abstract Renal transplant recipients (RTRs) are at increased risk of keratinocyte skin cancers, with a tendency to have multiple, aggressive and difficult-to-treat tumours. The eye and the skin share the same embryological ectoderm. Iris pattern has recently been reported as a predictive risk factor for skin cancer in nonimmunosuppressed Southern European and Irish populations. Our aim was to analyse whether an individual’s iris pattern is an independent risk factor for the development of keratinocyte carcinoma in RTRs. Iris patterns of 110 RTRs were evaluated using the Simionescu visual three-step technique (iris periphery, collarette and iris freckling). Established risk factors for skin cancer in patients with transplants were recorded as confounding factors. This was an observational cross-sectional study. Among the 110 RTRs, 31 participants had skin cancer. In the skin cancer group, iris periphery was blue/grey in 74% (P = 0.053, odds ratio 2.5), the collarette was light brown in 57% (P &amp;lt; 0.004) and iris freckles were present in 55% (P = 0.04). Dark brown and blue collarettes were observed in controls. Binary logistic regression analysis showed that light brown collarette is a significant independent risk factor for skin cancer (odds ratio 4.54, confidence interval 1.56–10.6, P = 0.02). Within this RTR population a blue iris periphery, light brown collarette and presence of freckling confer an independent risk for skin cancer. Iris pattern is a useful tool for identification of transplant patients at risk of skin cancer and an easy-to-use technique for risk evaluation in this cohort. This is the first study to investigate iris pattern and skin cancer risk in RTRs.