H21 These Barbies were dermatologists Quigley, Claire
British journal of dermatology (1951),
06/2024, Letnik:
191, Številka:
Supplement_1
Journal Article
Recenzirano
Abstract Greta Gerwig’s 2023 Barbie blockbuster provided an infectious reminder that women are capable of the success of their male counterparts, as well as emphasizing the impressiveness of female ...empowerment and leadership. Luckily, in dermatology, we have had this leadership from the beginning. According to the 2022 UK consensus of consultant physicians, women make up 51% of higher specialty trainees, and there have been more women than men in training since 2013. However, despite this, only 41% of the consultant physician workforce are women while 59% are men (Royal College of Physicians of Edinburgh. Focus on Physicians. Census of Consultant Physicians and Higher Specialty Trainees in the UK 2016–17. Edinburgh: Royal College of Physicians, 2017). However, dermatology stands out as a female-predominant area of specialization. In the UK in 2016, 57% of consultants and 75% of higher specialty trainees in dermatology were women Royal College of Physicians. The UK 2022 census of consultant physicians. Available at: https://www.rcplondon.ac.uk/projects/outputs/uk-2022-census-consultant-physicians (last accessed 29 February 2024). There is likely a multitude of reasons contributing to this, but the historical influence of prominent female leaders in the specialty cannot be ignored. Presented here are a select group of pioneering female dermatologists whose careers and contributions to the field of dermatology paved the way for the development of one of the few female-dominated medical specialties. Helen Ollendorff-Curth was a female pioneer of genodermatology and is commemorated with four eponyms: the Ollendorff probe sign, the Curth criteria, Buschke–Ollendorff syndrome, and ichthyosis hystrix, Curth–Macklin type (IHCM). Loretta Joy Cummins was the first woman to pass the Dermatology Board examination in the USA and the first to be president of the New England Dermatological Society. Cummins founded a fund for Massachusetts General Hospital and a scholarship fund for women at Tufts Medical School. Agnes Blackadder was the first female consultant dermatologist in the UK, when she was appointed consultant dermatologist at St John’s Hospital, London in 1907. Daisy Maude Orleman Robinson’s achievements include becoming the first female dermatologist in the USA in 1905, as well as being the first female dermatologist to present a case at a dermatological meeting, to publish a scholarly paper in dermatology, and to present a case at an international dermatology meeting. These influential women were catalysts for creating and cultivating a specialty that promotes female leadership in the world of dermatology, medicine and science.
Basal cell carcinomas (BCCs) are among the most common non-melanoma skin cancers in the world. However, given their slowly progressive nature, metastatic BCCs are a relatively uncommon entity. Below, ...we discuss two separate cases of metastatic BCC that we encountered in our clinical practice. The first is the case of a 57-year-old male with a right cheek BCC and bilateral pulmonary metastases. The second is the case of a 71-year-old male who also presented with a right BCC and pulmonary metastases. We discuss their altered clinical courses. We also conducted a review of the literature focusing on the use of the relatively novel hedgehog inhibitors as a treatment option for individuals diagnosed with metastatic BCC.
Abstract In recent years there has been much discussion and exploration for a chemopreventive agent for skin cancer. This is something of particular interest for our transplant patients, who are at ...high risk of developing skin cancers, particularly keratinocyte cancers (KCs). Previous studies have highlighted benefit in immune-competent patients. A recent study by Allen et al. (Allen NC, Martin AJ, Snaider VA et al. Nicotinamide for skin-cancer chemoprevention in transplant recipients. N Engl J Med 2023; 388: 804–12) sought to investigate whether oral nicotinamide supplementation in organ transplant recipients provided any benefit. Their study demonstrated a 24% reduction in invasive SCCs in the nicotinamide group, but overall did not demonstrate a statistically significant reduction in KCs or precursor lesions. Some have challenged that the outcome of this trial will define future chemoprevention practices. We aimed to better define nicotinamide prescribing by surveying all members of the Irish Association of Dermatologists with a 13-item questionnaire focusing on barriers to and thresholds for prescribing oral nicotinamide chemoprevention. We asked respondents how often they prescribe oral nicotinamide for chemoprevention for the following indications: (i) ‘A patient with sun-damaged skin but no focal actinic keratosis’, (ii) ‘Patient with focal actinic keratosis but no history of KC’, (iii) ‘Patient with field actinic change but no history of KC’, (iv) ‘At the time of diagnosis of first KC’ and (v) ‘Patient with more than one KC’. We applied these scenarios for both immunocompetent and immunosuppressed patients. In total, 81% of respondents reported that they prescribe oral nicotinamide for KC chemoprevention. For all chemoprevention indications, we found increased nicotinamide prescribing for immunosuppressed patients. The majority of nicotinamide prescribers introduce treatment in immunocompetent patients at the time of first KC diagnosis (48%) and prescribed oral nicotinamide ‘often’ if the patient had more than one KC (55%). For the same indications in the immunosuppressed cohort, rates of prescribing were 62.5% and 69%, respectively. For secondary chemoprevention, prescribing of nicotinamide (67%) is favoured over acitretin (20%) or a combination of both (11%) in patients at highest KC risk. Overall, 20% of respondents do not prescribe nicotinamide, citing the following reasons as barriers: lack of evidence (50%), cost to patient (22%) and lack of availability (14%). Closer surveillance and changing immunosuppressive protocols reducing skin cancer risk make it difficult to distil the chemopreventive effects of nicotinamide. Our study highlights high current rates of oral nicotinamide prescribing among Irish dermatologists, as secondary chemoprevention particularly in immunosuppressed patients. This baseline will allow for monitoring of potential future changes to skin cancer chemopreventive prescribing patterns among dermatologists. The use of nicotinamide, a drug with a well-established safety profile and favourable price point, warrants further studies before its chemopreventive potential is discounted.
A 38-year-old female patient presented with a 3-month history of painful lower limb ulceration on a background history of poorly controlled hypertension.
PA16 Isotretinoin under the lens Long, Amy; O’Malley, Sean; Quigley, Claire ...
British journal of dermatology (1951),
06/2024, Letnik:
191, Številka:
Supplement_1
Journal Article
Recenzirano
Abstract Isotretinoin has been a widely prescribed medication in the field of dermatology for almost 50 years. It has been heavily scrutinized because of its teratogenicity, association with mood ...disturbance, and now its potential for sexual dysfunction. Ophthalmic adverse sequelae, although frequent, are the subject of less scrutiny. A 22-year-old woman was referred urgently to dermatology with a 6-month history of severe nodulocystic facial acne and extensive ice pick scarring. She had not responded to a combination retinoid and benzyl peroxide cream and an oral tetracycline antibiotic. She had an intrauterine device for contraception, and her medical history was otherwise unremarkable. Her most recent eye exam was 4 years previously for a mild convergent squint. Low-dose isotretinoin was commenced in conjunction with oral erythromycin. Her dose of isotretinoin was uptitrated until control of her acne was achieved. Six weeks into treatment, a routine ocular exam revealed bilateral early cataracts. Congenital cataracts could be excluded, and no other associated risk factors could be determined. In view of the temporal relationship a potential causal association with isotretinoin was postulated. She remained on isotretinoin after a discussion regarding the risk and benefit was had. She completed a further 4 months of therapy, averaging 0.25 mg kg−1 daily, with full clearance of her acne. She had no progression of the cataracts at a 6-month ophthalmological follow-up. Despite many ocular side-effects being generally reversible and mild, there is potential for significant harm and ocular morbidity to be caused by isotretinoin. Adverse events range from surface evaporative disease and blepharoconjunctivitis more commonly, to reports of rarer events such as cataracts. Data on cataracts in the context of isotretinoin are scant and largely historical. With the added pharmacovigilance accompanying the new UK Medicines and Healthcare products Regulatory Agency’s guidance on isotretinoin, there may be an opportunity to record the impact of the ocular and mucocutaneous adverse events that have been less well studied Commission in Human Medicines. Report of the Commission on Human Medicines Isotretinoin Implementation Advisory Expert Working Group. Available at: https://www.gov.uk/government/publications/report-of-the-commission-on-human-medicines-isotretinoin-implementation-advisory-expert-working-group (last accessed 19 April 2024). Our case serves to remind prescribers of isotretinoin of potential serious ocular toxicity associated with this common drug, and to include ocular symptoms in our checklist of adverse events.
DS21 Perils of a 3-mm punch biopsy Victory, Liana; Brady, Ronan; Quigley, Claire ...
British journal of dermatology (1951),
06/2024, Letnik:
191, Številka:
Supplement_1
Journal Article
Recenzirano
Abstract An 83-year-old woman underwent a 3-mm diagnostic punch biopsy from a Bowenoid patch on her right cheek. Her medical background was significant for invasive cholangiocarcinoma and she was on ...active treatment with gemcitabine under the care of oncology. In terms of anticoagulation she was on aspirin 75 mg as a preventative measure. Unfortunately, the patient developed ongoing bleeding from the biopsy site and presented to the emergency department. She was reviewed in the emergency department, the wound was sutured and haemostasis was noted. Over the next few days, she had progressive bleeding from the biopsy site. A plastic surgeon was consulted and the site was examined, cauterized and resutured. During the procedure haemostasis was achieved. The patient was discussed with haematology, and tranexamic acid for 3 days was recommended and aspirin was held. Routine bloods and a coagulation screen were sent. It was noted there was an isolated prolongation of the activated partial thromboplastin time. A diagnosis of acquired factor VIII deficiency was made following a coagulation screen in the department. She was transferred to the National Coagulation Centre for management and replacement of factor VIII. She was commenced on prophylactic FEIBA (anti-inhibitor coagulant complex) intravenous three times per week. Acquired haemophilia A is a rare but severe autoimmune bleeding disorder caused by circulating autoantibodies that inhibit the coagulant activity of factor VIII. It is more frequent in older patients and is associated with several conditions such as malignancies, the postpartum period, autoimmune diseases and drug exposure. This is a rare presentation; however, it highlights the risks involved with even minor dermatological surgical procedures and the importance of consenting patients for these possible complications.
CPC03 Notch your average dermatitis Long, Amy; Murphy, Lisa; Quigley, Claire ...
British journal of dermatology (1951),
06/2024, Letnik:
191, Številka:
Supplement_1
Journal Article
Recenzirano
Abstract We present the case of triangular nasal notch sign in a White woman with previous exposure to tumour necrosis factor (TNF) inhibition for Crohn disease, which persisted throughout a ...biologic-free period. The 33-year-old woman presented with symptoms of nasal rash, itch and cosmetic concern for bilateral indentations in the nasal soft triangle, ongoing for 6 years. Medical history was notable for childhood atopic dermatitis, herpes labialis and Crohn disease. Her Crohn disease was well controlled on ustekinumab, commenced in the last year. She commenced adalimumab 6 years before the rash first appeared, but had discontinued this agent 4 years prior to her presentation to dermatology. On examination she had patchy erythema with scale and crust affecting her nasal tip, septum, alar sidewalls and columella, with loss of the normal nostril contour and cicatricial indentation at the apex of the nasal soft triangle bilaterally. She had evidence of acute herpes simplex virus (HSV)-1 infection of the upper lip. A punch biopsy from the left nasal tip showed acanthosis and spongiosis with a dermal mixed inflammatory infiltrate including lymphocytes, histiocytes and neutrophils. There was focal ulceration and intraepithelial small abscesses, without features of granulomatous inflammation. Triangular nasal notch sign is a clinical sign that was first described in 2019 (Mesnard C, Aubert H, Bourreille A et al. The triangular nasal notch sign in patients with Crohn disease treated with tumour necrosis factor inhibitors. Br J Dermatol 2019; 181: 1103–4). This group reported eight patients with Crohn disease exposed to TNF inhibitors, presenting with a cicatricial triangular nasal notch, and hypothesized that TNF inhibition specifically was implicated in the development of the phenomenon. Similarly to these patients, our case had exposure to anti-TNF; however, the persistence of nasal dermatitis throughout a ‘biologic-free’ period is novel. The pathophysiology of TNF inhibitor-induced nasal dermatitis and triangular nasal notch sign is not fully understood. It has been hypothesized that it is within the scope of paradoxical reactions seen with TNF inhibitors and persistent Staphylococcal aureus infection. An association with HSV-1 has not been previously reported in the context of this condition. Nasal swabs in this case showed commensals only; however, clinical improvement of nasal inflammation was achieved with topical mupirocin, prophylactic valaciclovir and a short course of oral azithromycin. The singular association with Crohn disease and limited involvement of the nose is also as yet unexplained and requires further research. We encourage greater reporting of this phenomenon, to increase awareness among clinicians and to help identify the exact pathomechanism and optimal treatment.
P008 In over our heads? Long, Amy; Murphy, Lisa; Quigley, Claire ...
British journal of dermatology (1951),
06/2024, Letnik:
191, Številka:
Supplement_1
Journal Article
Recenzirano
Abstract We present the case of severe circumferential folliculitis decalvans in a 42-year-old White man. He presented to dermatology age 38 years with a 5-year history of a nonpainful, occasionally ...itchy pustulating process from crown to occipital scalp, resulting in hair loss. A progressive process, it began on the nape of the neck as rough, red skin and slowly spread outwards. Past medical history included teenage acne. He did not smoke. He was on lymecycline at the time of presentation, prescribed by his general practitioner, and no other medications. On examination he had an extensive (25 × 18 cm) area with crud, pustulation with yellow discharge and cicatricial alopecia. There was an indurated red rim. Removal of the crust revealed friable granulation-like tissue. There were no other significant findings on full-skin exam. He had punch biopsies for histopathology and bacterial and fungal culture. Histopathology showed hair-bearing skin with extensive inflammation around hair follicles. There was focal acute folliculitis. The inflammatory infiltrate contained lymphocytes and prominent plasma cells. Fungal and bacterial cultures were negative. His condition had a profound impact on his quality of life. He suffered mentally from the stigma associated with folliculitis decalvans, and the severity of his condition compounded this. Over the proceeding 4 years his engagement with the service diminished and compliance wavered. He was treated with rifampicin and clindamycin, in multiple short courses and once consecutively for 6 months, which yielded some improvement. He declined nurse treatment for debridement and dressings, opting to do so himself at home with his wife’s assistance. He was highly qualified in business, yet remained unemployed. In 2023 he contacted dermatology requesting to be seen. He was off treatment for over 2 years. His scalp disease was extensive with circumferential involvement of his head, including matting of his facial hair with pus. Bacterial swabs grew Staphylococcal aureus. He attended twice-weekly nursing appointments for debridement. Clobetasol propionate was used on overgranulated tissue. He was treated with flucloxacillin (500 mg, four times daily for 2 weeks), followed by doxycycline (100 mg daily for 6 weeks), followed by azithromycin (500 mg, three times weekly for 4 weeks). He has achieved considerable improvement and is being considered for oral dapsone. Folliculitis decalvans is a debilitating disease with far-reaching personal consequence. This case depicts the severe end of the disease spectrum, and the issues that can arise in that context. Challenges faced by his team were not only medical, but also psychological by way of gaining the patient’s trust and managing vulnerabilities.
Abstract Trimethylaminuria (TMAU) is a rare metabolic disorder resulting in the accumulation of trimethylamine (TMA), which is a foul-smelling metabolite that is excreted in bodily fluids and exudes ...a characteristic odour of rotting fish. Although the condition is not life-threatening, the psychological and social consequence can be devastating. Herein, we present the case of a 35-year-old woman with a diagnosis of TMAU. This case outlines the methods by which a diagnosis of TMAU can be made, while also magnifying the negative psychosocial impact of this rare diagnosis. It also reflects real-world experience with the currently available therapeutic options. TMA is produced in the gastrointestinal tract from dietary precursors such as choline (present in eggs, liver and poultry), trimethylamine N-oxide (TMAO; found in marine fish) and carnitine (found in meat). Primary trimethylaminuria is due to a mutation in the FMO3 gene, leading to the inability to oxidize this amine to the nonodorous metabolite (TMAO) (Antoñanzas J, Querol-Cisneros E, Alkorta-Aranburu G et al. Primary trimethylaminuria syndrome: more than an unpleasant odor. Int J Dermatol 2023; 62: e176–8). At present, over 40 variants in FMO3 associated with TMAU have been identified. Secondary or acquired TMAU is the result of a combination of factors including increased consumption of dietary precursors, gut dysbiosis, hepatic impairment and hormonal fluctuations resulting in an accumulation of TMA. Treatment regimens involve limiting precursors intake, using acidic soaps to reduce the volatility of excreted TMA, targeting gut microbiota, and the use of oral sequestering agents (Schmidt AC, Leroux JC. Treatments of trimethylaminuria: where we are and where we might be heading. Drug Discov Today 2020; 25: 1710–17). However, current treatment options have had limited therapeutic effect. Referral to metabolic specialists for correct nutritional support and referral to psychiatry is paramount for these patients. As evident from our patient’s viewpoint, this diagnosis can have a lifelong impact on social engagement and psychological health.
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