tbuckley/cabot-search huggingface dataset:
DS03 Survey of dermatological surgical training in the UK
Authors: Lucy Webber, Richard Barlow, Adam Bray
Journal: British Journal of Dermatology (2024)

Abstract Skin cancer incidence is rising annually in the UK, creating a substantial surgical burden. The dermatology training curriculum stipulates the need for regular supervised surgical lists with increasing independence throughout training to help address this growing demand. We distributed an electronic survey to dermatology trainees via the British Association of Dermatologists and British Society for Dermatological Surgery to evaluate current dermatological surgery training in the UK. The survey focused on training experience, satisfaction, and procedural competence to identify areas for improvement. Overall, 79 out of approximately 280 trainees responded (28.2%), of whom 64 (82%) were based in England, 8 in Wales (10%), 5 in Scotland (6%) and 1 in Northern Ireland (1%). Twelve deaneries within England were represented. The majority worked full time (56 trainees; 71%), and 76% of respondents were female. Twelve respondents were CESR trainees (15%) and three were clinical fellows (4%), with the remainder distributed from ST3 to ST6. In total, 59 respondents (76%) had surgical exposure within dermatology or allied surgical specialties before entering the training programme. Fifteen respondents (19%) reported having a supervised surgical list prior to starting training, defined as a consultant, senior dermatologist or equivalent observing their list. Around one-half of trainees (45, 53%) first received surgical supervision during their ST3 year, and 20.3% (16 trainees) had never received direct surgical supervision. Of these respondents, more than one-third (38%, six trainees) were at ST5/ST6 level. Overall, 65% (50 trainees) received intermittent direct supervision during their training, influenced by factors such as departmental staffing and prioritization of service provision; 68% of respondents (54 trainees) reported seeking additional hands-on surgical opportunities to fill gaps in their training. In total, 20% (16 trainees) felt that the procedural curriculum was unachievable within their training programme, and 29% of ST6 trainees (6 of 21) reported an inability to perform excision biopsies on the head and neck unsupervised. Dissatisfaction with surgical training was expressed by 35% (27 trainees). While our response rate limits the ability to draw definitive conclusions, our survey highlights significant intra- and interdeanery disparities in dermatological surgical training. A striking 86% of trainees (68) expressed the need for more consistent supervision to maintain and develop their surgical skills. Trainees call for clearer curricular guidance on surgical exposure and supervision, and national standardization of training to enhance surgical proficiency among the future consultant workforce.
P031 Experience from a UK dermatology regional virtual biologics and high-cost drugs multidisciplinary team
Authors: Arnav Katira, Helen Ramsay
Journal: British Journal of Dermatology (2024)

Abstract There are over 20 biologics and high-cost drugs (BHCD) in routine use in dermatology in the UK, each associated with NICE technology appraisals and local guidelines, and there are more emerging. This, coupled with increasing clinical complexity, can make individual decision making challenging. In January 2021 a fortnightly BHCD multidisciplinary team (MDT) was initiated to support clinical practice and audit. Meetings are held virtually on a fortnightly basis using Microsoft Teams and are attended by dermatology consultants, trainees, specialist nurses and a biologics coordinator. Regional colleagues join to discuss patients needing a supraspecialist view (e.g. fourth or more BHCD) and to support shared care service level agreements for NHSE specialized commissioned drugs (e.g. adalimumab for hidradenitis). We work to locally agreed pathways, incorporating NICE standards. Between January 2021 and December 2023 there were 632 case discussions (106 in 2021, 250 in 2022, 276 in 2023) comprising psoriasis (n = 318), atopic eczema (n = 246), hidradenitis suppurativa (HS; n = 64) and other (n = 4). Examining outputs and outcomes from 2022, we discussed 250 cases (133 psoriasis, 92 atopic eczema, 22 HS, 3 other) and demonstrated 100% compliance with local and national standards for the cases of eczema and psoriasis. There was 100% compliance with national standards and 93% compliance with local standards for HS. This collaborative approach to decision making in a virtual MDT for BHCD has supported clinical practice, improved adherence to guidelines and reduced the time needed to undertake audits for individual drugs. A regional ‘hub and spoke’ arrangement for NHSE-commissioned drugs has supported care closer to home. The MDT further supports cost-effect­ive practice (e.g. drug choices, sequencing and Blueteq submission via the coordinator), research (e.g. recruitment into national registry studies), continuing professional development, teaching and training, and provides MDT support for individual funding applications.
P045 An international Delphi consensus to define a clinically appropriate definition of disease modification for plaque psoriasis
Authors: Killian Eyerich, James Krueger, Mona Stahle, Knut Schakel, Curdin Conrad, Robert Gniadecki, Luis Puig, Thomas Scoble, Nick Williams
Journal: British Journal of Dermatology (2024)

Abstract In moderate-to-severe psoriasis, biologic therapies have achieved high levels of complete skin clearance and maintenance of this response over several years for many patients. However, questions remain as to how the disease can be controlled, brought into remission, or modified. Current definitions and measurement of disease modification are of limited utility in a clinical setting. This work acknowledges that the rapidly developing therapeutic landscape for plaque psoriasis brings into focus the question of potential for disease modification. Our objective was to achieve consensus on a definition of disease modification that can be applied within a clinical setting. In May 2021, a literature review on the topic of disease modification in psoriasis was conducted using the PubMed database. Search terms included but were not limited to ‘disease modification’, ‘disease progression, ‘disease interception’, ‘treatment target’, ‘drug therapy’, ‘biomarker’ and ‘drug-free remission’. Following the review, a panel of experts in psoriasis care from across Europe and North America convened in October 2021. Employing Delphi methodology guided by an independent facilitator, the panellists identified six main topics of focus. These topics were discussed, and 35 statements were developed and used to inform an online Delphi survey. This was distributed through a convenience sampling method to 97 healthcare professionals specializing in psoriasis care across Europe and North America. Respondents were offered a four-point Likert scale to indicate their responses. Completed surveys were anonymously collated and analysed by the independent facilitator. The results were then shared with the expert panel to determine conclusions. Stopping criteria for consensus rounds were defined as a 3-month period to collect responses, a minimum of 50 responses within this timeframe, and 90% of statements passing the threshold for consensus. The a priori threshold for consensus agreement was set at 75% and was further defined to be ‘very high’ at ≥ 90%. In total 63 responses (65% response rate) were received. Consensus was achieved for 32 statements and was not achieved for three statements. Given the high level of agreement with the statements, and that the stopping criteria were met, a second round of testing was not performed. The authors offer a definition of disease modification for plaque psoriasis that could be utilized in a clinical setting: ‘A sustained improvement in the disease course of plaque psoriasis resulting from a change in pathophysiology that minimizes the need for treatment.’ To determine the strength of this definition, the next step will be to test it within a real-world clinical setting.
P111 A retrospective analysis of cutaneous sarcoidosis
Authors: Siwaporn Hiranput, Lucy McAllister, Stacey Li Hi Shing, Namiz Damani, Doaa Abdalla, Paul Devakar Yesudian
Journal: British Journal of Dermatology (2024)

Abstract Sarcoidosis is a multisystem granulomatous disorder of uncertain aetiology, manifesting with cutaneous features in one-third of affected individuals. We retrospectively reviewed medical records of patients with a clinical diagnosis of cutaneous sarcoidosis in dermatology departments within our region. Sixty-five patients were identified. The mean age at presentation was 49 years (range 28–75), with increased prevalence in women (44, 68%). Twenty-six patients (40%) had localized disease affecting a single anatomical location, three of which were within tattoos. Thirty-nine (60%) had involvement of at least two anatomical locations. Limbs were the most frequently affected site (41). Other affected areas were the face (32), torso (25), scalp (9) and neck (5). Plaques were the most common morphology, seen in 26 cases, followed by papules (23), nodules (23), patches (6), erythema nodosum (4), annular (3), ulceration (3) and subcutaneous nodules (3). The colours of lesions were erythematous (37), yellow–orange–brown (22), violaceous (9) and skin coloured (5). All patients had biopsy-proven noncaseating granulomas; 60 patients had this confirmed on skin biopsy and five patients from other organs. In total, 41 patients (63%) had systemic sarcoidosis. Twenty-four of those with systemic sarcoid osis (59%) had cutaneous signs as their first presentation of sarcoid osis. Pulmonary sarcoidosis was diagnosed in 36 (55%), with relevant findings on chest X-ray, computed tomography of the thorax and/or pulmonary function tests. Of these, 22 patients did not report respiratory symptoms. Other organs involved were eye (6), joint (6), extrapulmonary lymph nodes (5), liver (4), cardiac (3), central nervous system (2) and renal (2). Lymphopenia was detected in 14 (22%) and anaemia in six (9%) patients. Twenty-three (35%) had elevated serum angiotensin-converting enzyme (ACE) levels. Four patients with elevated serum ACE levels did not have systemic sarcoidosis. Twenty-two of 41 patients with systemic sarcoidosis did not have elevated serum ACE levels. Complete resolution of skin lesions was observed in 32 patients. Management included watchful monitoring (8), potent or superpotent topical steroids (11), short courses of prednisolone (3), antimalarials (3), intralesional steroids (2), methotrexate (1), tofacitinib (1), and treatments initiated for systemic sarcoidosis including long-term prednisolone (3) and adalimumab (1). Our study highlights a lack of correlation between clinical features of cutaneous disease and systemic involvement. We found no association between biochemical profile and severity of sarcoidosis, or disease progression. It underscores the importance of maintaining a high index of suspicion and conducting thorough investigations for early detection of extracutaneous disease, as patients with extensive systemic sarcoidosis may be asymptomatic.
P034 Using artificial intelligence to bridge the technical gap in dermatology: the role of large language models in creating an interactive Fitzpatrick skin phototype assessment
Authors: Mohamad Zeina, Bassam Zeina, Parashkev Nachev
Journal: British Journal of Dermatology (2024)

Abstract Patient engagement is evolving with the advent of digital tools such as interactive websites and artificial intelligence (AI), yet significant barriers remain in the technical expertise required to create tools that benefit patients. We explore how large language models (LLMs), a type of AI that can facilitate and accelerate programming tasks, can enable clinicians and researchers to create interactive web-based patient engagement tools without the need for a dedicated web developer. We explore this possibility by developing, with the help of an LLM, an interactive skin self-assessment web tool. We used GPT4, a state-of-the-art LLM, as a web development assistant, and created an interactive JavaScript web page that guides patients through the Fitzpatrick skin phototype questionnaire. This involved building a minimal version first, and iteratively improving it. The web page initially asked the user the first two questions of the assessment, calculated a score, and returned this to the user. Once the code written by GPT4 was tested and shown to work, the tool was gradually improved to include all questions in the Fitzpatrick scale, and the result was modified to provide not only the total score, but also the result category. GPT4 allowed us, with no experience writing interactive JavaScript web pages, to develop and launch a web page that guides patients through a Fitzpatrick scale assessment. When GPT4 was asked to expand the questionnaire from two questions to the whole test, it gladly did so; however, the questions were not accurate. It then had to be given the specific wording of the questions and answers for the test, which it incorporated into functioning JavaScript code. This had to be performed in stages, adding two questions at a time, due to context limitations at the time. When this introduced issues, such as the code breaking or the website style looking inconsistent, GPT4 was able to fix these issues when they were described to it. Since the web page’s launch in March 2023, the web page has been viewed 1875 times by 1419 unique users. This study demonstrates one way that LLMs can be used to enhance patient engagement in dermatology, by facilitating the creation of interactive skin assessments with utility in many dermatology settings. Hallucination remains a problem, and any created tools must be thoroughly verified for factuality. Although no authors had any experience writing interactive JavaScript, they have coding experience elsewhere, and future work should assess whether similar results can be achieved by a broader user base. Two authors received funding from a commercial organization for this work (A &amp; Z Dermatology Clinic Ltd).
BT27 How reliable is teledermatology in diagnosing skin cancer? A retrospective analysis of skin cancer outcomes from a single centre
Authors: Emily Moon, Anna Elkins, Jo Johnson, Maria Ahmad, Chenjing Peng
Journal: British Journal of Dermatology (2024)

Abstract Teledermatology has become a pivotal tool to meet the increasing demands on skin cancer services. Factors such as referral quality and clinical judgement need to be considered when evaluating its effectiveness and reliability. A single-centre retrospective study was conducted to evaluate the diagnostic accuracy of a pilot teledermatology service used to triage 2-week-wait skin cancer referrals from primary care. Between May and July 2023 (total 158 referrals), 45% of 2-week-wait teledermatology referrals were accepted into a face-to-face (F2F) clinic, of which 80% were seen in a 2-week-wait clinic, either by dermatology or plastic surgery. The remaining accepted cases were redirected into a general dermatology clinic. Of the 87 referrals returned, 31% were due to poor-quality photographs or insufficient information provided, and 69% were thought to be appropriate for primary care management. A detailed analysis of 100 referrals was conducted to assess the referral quality and clinical outcomes. Of the 51 patients with a suspected skin cancer diagnosed on teledermatology, 21% (5 of 24) of melanomas, 17% (4 of 23) of squamous cell carcinomas and 75% (3 of 4) of basal cell carcinomas were confirmed on histological analysis. Of the 21 patients who were suspected to have a precancerous or benign lesion on teledermatology, two were diagnosed with a malignancy on histology. When comparing the teledermatology diagnosis vs. histological diagnosis as the gold standard, diagnostic accuracy was 0.66 [95% confidence interval (CI) 0.51–0.78], with 92% sensitivity, 42% specificity and κ = 0.33 (95% CI 0.11–0.56). This was comparable with the diagnostic accuracy of a F2F clinic review, which was 0.66 (95% CI 0.51–0.79) with 96% sensitivity, 38% specificity and κ = 0.33 (95% CI 0.13–0.54). When only the F2F diagnosis was used as the gold standard, the diagnostic accuracy of teledermatology was higher at 0.78 (95% CI 0.66–0.87), with 91% sensitivity, 56% specificity and κ = 0.5 (95% CI 0.28–0.71). Our study demonstrated that teledermatology can be a useful tool to reduce unnecessary F2F clinic reviews, if adequate information and photographs are provided. It has demonstrated high skin cancer diagnostic sensitivity, but with compromised specificity. There was a moderate level of concordance between diagnoses made in teledermatology and the F2F clinic. Although teledermatology and F2F assessment had very comparable diagnostic accuracies, a higher sensitivity and lower specificity were noted on F2F assessment. This could be attributed to the initial diagnosis made on teledermatology influencing the subsequent clinical decision in a F2F clinic. Ongoing caution, critical reflection and more studies are warranted to elucidate teledermatology’s full potential in the diagnosis and management of skin cancer.
BH11 A curious cause of ‘shrimp nail’
Authors: Nicola Kearney, Muireann Roche
Journal: British Journal of Dermatology (2024)

Abstract A 25-year-old woman presented with a 7-year history of dystrophic great toenails, on a background of ulcerative colitis treated with the tumour necrosis factor (TNF)-α inhibitor, infliximab. The reported nail changes occurred after initiation of infliximab. Prior to review in the dermatology clinic, this patient had been treated with a year of oral antifungals without significant benefit. On examination, both great toenails were dystrophic with a stacked abnormal nail plate, particularly at the left great toenail, and had the appearance of ‘shrimp nail’. She was also noted to have a mild paronychia with some periungual ooze at the toenail of her right hallux. Her fingernails were normal. She was prescribed hydrocortisone plus miconazole to use for cuticular inflammation, and also had an avulsion of her left great toenail 8 months following the initial review, with very slow nail regrowth of approximately two-thirds over an 18-month period. A 32-year-old woman also attended our dermatology department with a history of psoriasis with associated psoriatic arthritis. She had been treated with apremilast for 2 years before being switched to the anti-TNF agent, certolizumab, as she was trying to conceive. Approximately 6 months following the initiation of this anti-TNF medication, the patient was noted to have dystrophic great toenails, most markedly at her left hallux, with a stacked abnormal nail plate. This patient’s nails also had the appearance of shrimp nails. She was referred for and is awaiting an avulsion of her left great toenail. These two clinical vignettes highlight cases of shrimp nail in patients who were newly commenced on anti-TNF medications. ‘Shrimp nail’, a rarely described entity, refers to a pronounced vertical curvature of the nail plate that resembles the back of a shrimp. It is caused by sequential onychomadesis that occurs before sufficient regeneration of the new nail is completed. Onychomadesis, related to spontaneous arrested growth of the nail matrix, has a multitude of causes including traumatic insults, systemic insults, local inflammation or infectious involvement of the nail matrix, and drug-induced arrest of nail matrix growth (Buttars B, Braswell MA, Huynh T et al. Congenital malalignment of the great toenail and onychomadesis in monozygotic twins. JAAD Case Rep 2021; 14: 1–3). To date, there are no cases in the literature that describe shrimp nail occurring in association with anti-TNF medication. Due to the development of shrimp nail within a number of months following the initiation of anti-TNF medication, coupled with an absence of traumatic insults to the nails, we contend that shrimp nail has occurred in these patients as an adverse effect of anti-TNF medication.
BH12 A case of reverse ageing phenomenon of the hair secondary to vitamin B supplementation
Authors: Emma Amoafo, Archana Rao
Journal: British Journal of Dermatology (2024)

Abstract An 80-year-old woman is known to the dermatology department with darkening of previously grey hair. She was initially referred to the dermatology department for scalp pruritus. Her past medical history included atrial fibrillation and heart failure. Regular medications included furosemide, omeprazole, ferrous fumarate, and over-the-counter supplements, namely vitamin B, vitamin D, zinc, magnesium, cod liver oil, glucosamine and chondroitin. Examination of the scalp revealed erythema, scaling and crusting on the crown with no alopecia. Initial blood tests revealed normal full blood count, renal function, liver function, thyroid function, vitamin D and iron studies, and a raised vitamin B12 level. The scalp pruritus was attributed to seborrhoeic dermatitis and was treated successfully with topical steroids and antifungal shampoo. Changes in hair colour have been described in the literature. Overnight white hair has been attributed to alopecia areata. Conversely, darkening of hair has been reported secondary to vitamin B supplementation. Vitamin B has been reported to repigment grey or white hair in both premature and age-related achromotrichia. Hair repigmentation can begin as early as within 1 month of supplementation. A 2020 review of the literature suggests that vitamin B supplementation is only useful to reverse hair greying where there was underlying vitamin B deficiency initially (Yale K, Juhasz M, Atanaskova Mesinkovska N. Medication-induced repigmentation of gray hair: a systematic review. Skin Appendage Disord 2020; 6: 1–10). The mechanism for hair greying and repigmentation with vitamin B supplementation is incompletely understood, but some authors have hypothesized a ‘free radical theory of ageing’. This is where the production of free radicals increases while endogenous defence mechanisms decrease with age. It has been suggested that the antioxidant properties of orally ingested B vitamins in targeting these free radicals may explain the reverse ageing phenomenon (Trüeb RM. Oxidative stress in ageing of hair. Int J Trichol 2009; 1: 6–14). Other medications that have been reported to cause reverse ageing of the hair include thalidomide, lenalidomide, adalimumab, acitretin, etretinate, prednisone, ciclosporin, cisplatin-based chemotherapy, interferon-α, psoralen, latanoprost, erlotinib, imatinib, tamoxifen, levodopa, clofazimine and captopril (Yale et al.). Further studies and trials into this unique phenomenon could prove extremely beneficial to a society that is significantly focused on antiageing.