tbuckley/cabot-search huggingface dataset:
BG03 A case of nasal tip necrosis secondary to giant cell arteritis and a review of the cutaneous manifestations reported in large-vessel vasculitis
Authors: Hannah Binns, Alan Steuer, Hannah Zacharias
Journal: British Journal of Dermatology (2024)

Abstract A 90-year-old woman presented to the emergency department with a 6-week history of a nasal tip lesion associated with left-sided headache, and scalp and facial tenderness. Visual symptoms, jaw claudication and systemic upset were absent. On physical examination, an 8 × 8-mm annular ulcerated and necrotic lesion was present on the nasal tip. Pain was elicited on palpation of the left superficial temporal artery. At presentation inflammatory markers were elevated, with C-reactive protein (CRP) 310 mg L−1 and erythrocyte sedimentation rate (ESR) 131 mm h−1. The white cell count was 13.6 × 109 L−1 and platelets were 410 × 109 L−1 and estimated glomerular filtration rate 31 mL min−1 1.73 m−2. Computed tomography of the head showed no acute abnormality. A subsequent ultrasound doppler scan of the left superficial temporal artery demonstrated changes typical of giant cell arteritis (GCA). Prednisolone (40 mg once daily) was initiated. Two weeks later the patient reported complete resolution of the headache, the necrotic area of nasal tip skin was healing, and the temporal arteries were pulsatile and nontender. CRP and ESR had reduced to 13 mg L−1 and 57 mm h−1, respectively. While GCA commonly affects the branches of the external carotid artery, any artery can be affected. Necrosis in this case was thought to be a direct result of inflammation of the distal branches of the facial artery, a branch of the external carotid artery that supplies superficial facial structures. The nasal tip area is supplied predominantly by the superior labial and angular vessels. The diagnosis of GCA was established due to the classical presentation of acute-onset headache, scalp tenderness and raised inflammatory markers, combined with the left temporal artery ultrasound Doppler findings and in association with rapid response to steroid therapy. Temporal artery biopsy was not performed. Cutaneous manifestations of GCA and other large-vessel vasculitides are rare, and as a presenting complaint are exceptional. Necrosis of the scalp and tongue is a well-recognized ischaemic complication of GCC. However, nonischaemic manifestations such as panniculitis-like lesions and acute inflammatory nodules have also been reported in the context of GCA and Takayasu arteritis. GCA presenting with necrosis of the nasal tip has rarely been reported. An older person with such a lesion could forcibly present to a 2-week-wait dermatology clinic and clinicians should consider GCA as a differential, if other suggestive features are present. Older people are more likely to be referred with suspected skin cancers, and given that GCA is the most common vasculitis among this population group, dermatologists should have a good working knowledge of the disease’s clinical features, namely headache, scalp tenderness, visual manifestations and claudication of the tongue and jaw.
Poster presentationsBG05 Menopause and the skin: prevalence of skin symptoms in patients attending a menopause clinic
Authors: Hamisha Salih, Olivia Hum, Zoe Schaedel, Claudia DeGiovanni
Journal: British Journal of Dermatology (2024)

Abstract The peri- and postmenopausal period of a person’s life is a natural part of physiological ageing driven by declining ovarian function. A hypo-oestrogenic state follows the onset of the menopause and persists for the remainder of their lives. The skin contains oestrogen receptors, and impairment of the skin barrier is noted in oestrogen-deficient skin (Rzepecki A, Murase J, Juran R et al. Estrogen-deficient skin: the role of topical therapy. Int J Womens Dermatol 2019; 5: 85–90). It is therefore expected that this may affect the normal function of the skin and common skin conditions. We suspect that these symptoms experienced may be under-reported and, when they are reported, may not be considered associated to the menopause. We have conducted an observational study exploring the symptoms that patients experience during the perimenopausal and postmenopausal time. Patients seen in a community-based specialist menopause clinic were invited to complete a questionnaire enquiring about skin, oral, genital and hair symptoms. In total, 32 responses were collected. Overall, 46% of respondents still had menstrual periods and 77% were on hormonal treatments, of which oestrogen therapy was most frequently taken. The most reported skin symptoms included dry skin (78%) and itchiness (75%). Dry mouth was the commonest reported oral symptom, and 84% of patients had experienced at least one hair symptom since the onset of their menopause. In total, 91% reported experiencing at least one vulval symptom, with the most common being dryness (66%), itchiness (55%) and soreness (41%). One-half (50%) noticed worsening in a previously diagnosed dermatological disorder. In total, 63% patients reported skin symptoms that they had attempted to manage themselves without consulting their doctor. The Dermatology Life Quality Index was also collected for each patient, which showed an average score of 6 out of 30 and ranged up to 17 out of 30, indicating that skin symptoms cause a moderate impact on the quality of life of peri- and postmenopausal people. Our results highlight the significant effect the menopause can have on quality of life and the wide range of dermatological symptoms associated with it. Patients appear reluctant to seek medical support for skin symptoms related to the menopause and consequently may not receive optimal treatment. It is paramount that dermatologists and menopause specialists are aware of the immense impact menopause has on the skin, hair, vulva and mouth in order to improve the quality of life for affected patients. Further research is required to explore management options, including hormone replacement therapy, for skin symptoms associated with the menopause.
DP05 (P061) Squamoid eccrine ductal carcinomas: challenges in diagnosis and management
Authors: Amy Cunliffe, Somaia Elsheikh, Sunita Odedra, Sandeep Varma
Journal: British Journal of Dermatology (2024)

Abstract Squamoid eccrine ductal carcinomas (SEDCs) are rare adnexal carcinomas displaying both squamous and duct differentiation. We wish to remind clinicians of these recently described cancers, which can have aggressive behaviour (van der Horst MPJ, Garcia-Herrera A, Markiewicz D et al. Squamoid eccrine ductal carcinoma. Am J Surg Pathol 2016; 40: 755–60). We identified five cases in our department: four female patients and one male. All lesions developed on the face, in patients aged 69–83 years. The majority developed over one to several years, apart from one rapidly growing lesion, and measured between 5 and 40 mm. Clinical examination suggested squamous cell carcinoma (SCC) in two cases and basal cell carcinoma in three cases due to features such as puckering, rolled borders, telangiectasia, shine, ulceration and crust. Punch biopsies were performed in all five lesions; however, histological diagnosis of SEDC was suggested in only two. One of these patients underwent Mohs micrographic surgery (MMS), which successfully cleared the lesion after two stages. The second patient, diagnosed on biopsy, had a large 30-mm lesion with invasion into the lacrimal sac and left nasal bone. The patient opted for palliative radiotherapy rather than extensive surgery and subsequently developed a left-cheek metastasis and symptoms suggestive of metastatic disease. Three of our cases were diagnosed after wide local excision (WLE) based on the histological and immunological features. The punch biopsies had suggested either SCC or adenosquamous/adnexal infiltrative carcinoma. One of these patients required adjuvant radiotherapy due to perineural involvement (&amp;lt; 0.1 mm). The other two cases were incompletely excised on WLE and the patients were offered further surgery or radiotherapy. Histologically these lesions were poorly defined infiltrative neoplasms consisting of atypical squamoid cells extending into the deep dermis or subcutaneous tissue with ductal differentiation, pronounced cytological atypia and associated desmoplastic stroma. Tumour thickness measured 3–10.3 mm. Immunohistochemistry was positive for CK7, AE1/AE3, CK5/6, p63, CAM5.2, carcinoembryonic antigen and epithelial membrane antigen. These five cases highlight the challenges faced in the diagnosis of SEDC for both the dermatologist and the dermatopathologist. MMS is recommended (Lim MM, Macdonald JA. Squamoid eccrine ductal carcinoma: treatment and outcomes. Am J Dermatopathol 2022; 44: 249–53) and lesions misdiagnosed as SCC may receive less effective treatment; our three patients who underwent WLE have required further interventions. We also report one patient with locally aggressive and likely metastatic disease. Patients with SEDC benefit from early diagnosis, MMS and close follow-up to reduce the risk of recurrence and improve patient outcomes.
Geriatric DermatologyOral presentationsBG01 The impact of menopause on eczema
Authors: Erin Kamp, Anna Nielsen-Scott, Claudia DeGiovanni
Journal: British Journal of Dermatology (2024)

Abstract The falling oestrogen levels seen in menopause have implications on the structure and function of the skin (Duarte GV, Trigo AC, Paim de Oliveira Mde F. Skin disorders during menopause. Cutis 2016; 97: E16–23). Improvement in skin barrier function and reduction in transepidermal water loss have been seen with transepidermal oestrogen. However, further research is required to understand the role of oestrogen within the epidermis. A range of dermatological conditions have been reported in up to 64% of women attending menopause clinics (Duarte et al.). These include pruritus, xerosis and eczema (Pariath K, Nair PA. A cross-sectional study on the dermatoses in postmenopausal patients at a rural-based tertiary health care center. Indian J Dermatol 2019; 64: 360–5). Our aim was to further understand the impact of the menopause and hormone replacement therapy (HRT) on eczema severity. We sent a survey by text and/or email to patients with eczema aged ≥ 40 years. We received 12 responses from patients with an age range from 40 to 85 years. Overall, 92% patients self-reported as White (11 of 12) and 8% (1 of 12) as Asian or Asian British. The mean age of menopause was reported as 47.3 years (range 35–58). The majority of patients were diagnosed with eczema as a child (9 of 12). Interestingly, three patients were diagnosed with eczema between the ages of 49 and 53 years. Previous and current treatments included emollients, topical corticosteroids, conventional systemics and biologics. One-third of patients reported a deterioration in eczema with or before menstruation. Two-thirds (67%, 8 of 12) of patients’ eczema flared with menopause, and one patient developed eczema for the first time after menopause. None of the 12 patients noticed an improvement in eczema associated with menopause. The majority of patients did not notice a change in their eczema with HRT. Dryness, irritation, contact allergy, sensitivity, skin thinning and nonspecific rash were all noticed by patients with menopause and/or after menopause. Two-thirds of patients who completed our survey reported a flare of eczema with menopause, and we believe this is an exacerbating factor likely to be an under-recognized in the disease. It is vital that further research is carried out to further understand the role of oestrogen within the epidermis and skin barrier and the possible therapeutic benefit of HRT.
DS20 Challenges and considerations of Mohs surgery in the ear
Authors: Ewa Kloczko, Mark Wilsher, Andreas Naparus, Kevin Kulendra, Navara Anjum
Journal: British Journal of Dermatology (2024)

Abstract Malignancy of the external ear represents 6% of all skin cancers, and basal cell carcinomas (BCCs) account for 40% of those. When infiltrative, these BCCs may pose unique treatment challenges given the complexity of the local anatomy and the proximity to other local structures, such as the parotid gland, the external auditory canal, the tympanic membrane, the middle ear and the facial nerve. We describe a case of a 69-year-old man who presented with a 5-year history of a crusted lesion in the left year. Inability to wear a hearing aid due to pain and discharge from the left ear prompted the patient to attend the emergency department. Following the ear–nose–throat assessment, he was referred to skin cancer clinic. Initial biopsy confirmed a clinical suspicion of an infiltrative BCC affecting the left antihelix and conchal bowl extending to the entrance of the external auditory meatus (EAM). Following a multidisciplinary approach between plastic surgery, dermatology and the head and neck team, three treatment options were discussed with the patient: Mohs micrographic surgery, standard excision, and radiotherapy. Preoperative imaging revealed the tumour abutting the parotid gland, but there was no involvement of the bony or cartilaginous aspects of the EAM. The patient pursued the Mohs procedure to preserve function and cosmesis of the ear. After two stages margins remained positive. The decision was made to stop the procedure, given the evidence of extension to the EAM. Two days later the patient underwent partial pinnectomy, which had evidence of a BCC extending to all margins with infiltration into the parotid gland and cartilaginous ear canal. Focal perineural invasion was present. Subsequently, this case was discussed with the head and neck team, with a multidisciplinary decision recommending a definitive resection. The patient underwent superficial left parotidectomy and complete pinnectomy including the cartilaginous external ear canal and tympanic membrane, followed by reconstruction with an anterolateral-thigh free flap. The patient received a prosthetic left ear and is currently awaiting an assessment for a bone-anchored hearing aid. Histologically, aggressive BCC was detected in clinically unremarkable areas of the pinna. It is likely that the multiple embryonic fusion planes within the EAM account for less predictable tumour spread. This case highlights the complexity of Mohs surgery on the ear and the need for a collaborative approach in management of those areas to provide the best quality of care for our patients.
DP23 Stage presentation of melanomas arising in the back: a 20-year retrospective study of site-specific distribution and review of the literature
Authors: Faris Kubba, Joanna Hawkins, Haya Alaani
Journal: British Journal of Dermatology (2024)

Abstract This is a study over 20 years to assess the pathological stage of presentation for melanomas arising in the back. We have reviewed studies for presentation of body-site-specific melanoma to compare against our findings and to see whether there has been any significant improvement in the rate of early detection. We extracted and analysed data from archived histopathology reports on the WinPath system by running a SNOMED code search on all melanomas reported from 2001 to 2011 and selected those affecting the back. The age of presentation varied from 29 to 94 years (mean 58.7). Twenty patients were male and seven female (male-to-female ratio 2.9 : 1). Most cases presented as American Joint Committee on Cancer 8th Edition stage pT1 (11 were 1a, 2 were 1b), pT2 (n = 2), pT3 (n = 4) and pT4 (n = 2). Six were in situ melanomas, mostly lentigo maligna or arising from severely dysplastic naevi. Breslow depth ranged from 0.1 to 6.5 mm (mean 1.6 mm). The cases were mostly from the upper back (n = 10). The melanoma types were superficial spreading (n = 14), nodular (n = 2), lentigo maligna (n = 3) and melanoma in situ from dysplastic naevi (n = 3). On reviewing the literature, we found one study suggesting that melanomas in visible areas present earlier. Another concluded that a melanoma is more often self-detected in female patients, explained by the high proportion of lesions in men presenting on the back. Further research suggests that older patients recognize melanomas at a lower rate than younger patients. Older men frequently have lesions in difficult-to-see areas such as the scalp and the back, and therefore also may be limited to self-notice new or changing lesions. The role of family members is as important in early detection as that of trained health professionals. As a delay in diagnosis may be responsible for the thicker melanomas in hidden areas, preventive and screening programmes should stress the importance of not neglecting these locations in self-examination. Special attention should be given to educating older men. To conclude, we have presented a laboratory-based study on the presenting pathological stage of melanoma of the back in patients aged &amp;gt; 20 years. Half of our patients presented as stage pT1, while the other half of the tumours included in situ melanoma to stage pT4. Men predominated over women (ratio 2.9 : 1). There is no screening programme for melanoma, and providing education that raises awareness of the early signs and patient self-examination with opportunistic screening is the current standard. As the back area is not routinely inspected by patients, we believe that late presentation should be avoidable by recommending whole-body examination in general practice and dermatology clinics to ensure early detection and better prognosis of melanomas arising in the back and other hidden anatomical sites.
CPC10 A curious case of recurrent melanomas and field change confined to the left thigh over 25 years
Authors: Khawar Hussain, Jenny Chung, Charlotte Goss, Carolina Fernandez, Siddarth Dave, Justin Weir, Emma Craythorne, Louise Fearfield
Journal: British Journal of Dermatology (2024)

Abstract A 52-year-old woman presented in 1999 with an atypical erythematous plaque on her left thigh containing a flesh-coloured nodule surrounded by four pink scaly papules. She had no significant past medical, drug or family history. Excision of the nodule revealed an amelanotic malignant melanoma (MM) of Breslow thickness (BT) 1 mm. Biopsies of the four surrounding lesions confirmed satellite MM in one, with no radiological evidence of metastases. She received adjuvant interferon therapy for 1 year. Repeat imaging was normal. Eighteen years later, she developed a new pigmented lesion on her left thigh confirmed as MM (0.9 mm BT), with three further erythematous plaques on the left thigh reported as (i) proximal left-thigh MM (1.08 mm BT), (ii) middle-left-thigh amelanotic MM (0.6 mm BT) and (iii) left-thigh MM (1.7 mm BT). Wide local excision (WLE) failed to obtain histological clearance of (i) and (iii), with mildly dysplastic naevus and melanoma in situ (MiS), respectively, at the peripheral margins. Reflective confocal microscopy (RCM) was used to guide further surgery, with continued incompletely excised MiS and field change at the margins. Eighteen months later she presented with another MiS and MM (0.5 mm BT) on the left thigh. Imiquimod 5% once daily for 8 weeks to the affected area was instigated to treat any residual in situ component. BRAF, CDKN2A, CDK4 and BAP1 showed no pathological variants, and xeroderma pigmentosum testing was negative. Six months later a further MM (1.2 mm BT) on the left thigh was treated with WLE and skin graft. Sentinel lymph node biopsy was deemed not possible due to previous multiple surgical excisions. Ultrasound groin scan and whole-body FDG-PET computed tomography showed no occult metastases. Several months later, another MM (0.5 mm BT) was excised at the edge of the graft site. Residual dysplastic lentiginous proliferation at the edge with no MM was reported on the 1-cm WLE. This represents a complex case with recurrent MM, often indistinguishable from primary MM histologically. Widespread dysplastic field change evidenced by involvement at the edges of the WLEs and the RCM images was also challenging. RCM can be a noninvasive adjunct in identification of superficial skin tumours. Adjuvant interferon therapy for high-risk MM has demonstrated an increase in disease-free survival (Petrella T, Verma S, Spithoff K et al. Adjuvant interferon therapy for patients at high risk for recurrent melanoma: an updated systemic review and practice guideline. Clin Oncol 2012; 24: 413–23). This may have contributed to the 18-year delay between her first and second melanomas, as well as her complex, recurrent presentations and ongoing local confinement of the MM to the left thigh with lack of disease progression.
DP14 ALK-positive histiocytosis with involvement confined to the skin: report of two cases in adults
Authors: Su Xin Lim, Sarajeni Pugalenthy, Niall Wilson, Cristina Vasile, Arti Bakshi, Stuart Cohen
Journal: British Journal of Dermatology (2024)

Abstract We present two interesting cases of anaplastic lymphoma kinase (ALK)-positive histiocytosis in adults. The first was a 79-year-old woman with a 10-year history of a firm, violaceous, exophytic nodule on her right upper arm. It was asymptomatic, and stable in size and colour. It measured 11 mm in diameter and had a scaly surface. Dermoscopy was nondiagnostic, showing a featureless, violaceous appearance. Histology revealed a dermal histiocytic infiltrate with epithelioid and foamy histiocytes and occasional Touton-type giant cells. Immunohistochemistry showed the histiocytes to be CD68 and ALK positive (clone AlkD5F3). S100 and CD1a were negative. The second case was a 42-year-old man with an enlarging, latterly tender lesion on the chest for many years. Examination showed a nonspecific 5 × 4-mm shiny pink papule. Excision histology revealed a dermal histiocytic infiltrate, with numerous lymphocytes and focal emperipolesis. Immunohistochemistry showed the histiocytes to be CD68 and S100 positive with patchy ALK positivity (clone AlkD5F3). CD1a was negative. A diagnosis of ALK-positive histiocytosis was concluded in both cases. This rare subtype involves a genetic alteration in genes encoding receptor tyrosine kinases. Its full clinicopathological features have not been fully elucidated. It most commonly presents in young infants as a multisystem disease with liver and haematological disturbances. Localized disease is more common in adults, for which the prognosis is good. Clinicopathological correlation is important as the clinical features are usually nonspecific. Previous reports involving cutaneous disease have tended to focus on extracutaneous manifestations, although papules, which may be yellow or purple, at various sites have been described. Symptoms from the skin lesions have not been clearly reported. Histopathologists need to be aware of this new entity and include ALK immunostain in all dermal histiocytic lesions. The morphology is variable, consisting of an admixture of epithelioid and foamy histiocytes, sometimes with emperipolesis and thus mimicking juvenile xanthogranuloma and Rosai–Dorfman disease morphologically. Previous cases have found gene fusions of KIF5B–ALK, TPM3–ALK, CLTC–ALK, TFG–ALK, EML4–ALK and DCTN1–ALK, and ALK-fluorescence in situ hybridization positivity. The clinical relevance of this gene fusion is not known. Blood tests and imaging to assess for other organ involvement should be considered. Retrospectively our cases showed no signs or symptoms of other organ involvement, and investigations were clear. Targeted ALK inhibitor therapy has shown responsive results in treating ALK-positive histiocytosis with multisystem involvement. Surgical resection has been successful in treating cutaneous disease, with no reported recurrence. As further cases of this rare condition come to light, its full clinicopathological and molecular features may become more apparent.