Axilla Research Articles

083. Bilateral Mammae Reduction in Patients with Gestational Gigantomastia

Background: Gestational gigantomastia is a rare clinical condition characterized by rapid and disproportionate breast enlargement during pregnancy. This case report describes a 24-year-old female patient with bilateral gigantomastia. Case: A 24-year-old female patient presented with complaints of a lump in both breasts that had progressively enlarged since her first pregnancy. Physical examination revealed breast enlargement measuring 30x20 cm, with signs of skin stretching, redness, no lesions, and engorged veins around both the left and right breasts. On palpation, there was no tenderness, the tissue felt soft, no masses were detected, and there was retraction of the nipple. In the right and left axillary regions, masses measuring 4x5 cm and 4x3 cm, respectively, were noted, matching the skin color. Breast ultrasound showed diffuse edematous changes in bilateral mammary parenchyma accompanied by duct ectasia, with a differential diagnosis of mastitis. The patient was diagnosed with bilateral gigantomastia and underwent reduction mammoplasty. Conclusion: This case report describes a patient with gestational gigantomastia who underwent reduction mammoplasty and excision of aberrant breast tissue.

Ayurveda management of Visarpa (Herpes zoster) - A Case Study

Skin is the largest organ of the body which acts as a first line of defence in providing resistance to the body. The aggravation of various Dhatus and Doshas result in skin diseases. Visarpa is an acute condition with a quick spreading involving mainly skin, blood, lymph and muscle tissue due to vitiation of all three Doshas. As the basic nature of the disease is Rakta and Pitta predominant, management is focused on Shodhana, Rakthamokshana, Langhana, Shamana, Lepa Chikitsa. This case study is an attempt to evaluate the role of Ayurvedic management in Visarpa. A 50 year-male presented with vesicular lesions on his chest, below the left axillary region and back associated with mild itching, burning sensation and pain. He was approached with Shodhana and Shamana therapies which showed significant improvement in the condition.

Intranodal Hemangioma: Case Report and Systematic Review

ABSTRACT Background: Intranodal hemangiomas are rare benign vascular tumors of the lymph nodes, often misdiagnosed as malignant lymphadenopathies due to their clinical and radiological features. This case report and systematic review aim to elucidate the epidemiology, clinical profile, and therapeutic interventions for intranodal hemangioma, enhancing diagnostic accuracy and management. Methods: A systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Searches were conducted in PubMed, Scopus, Web of Science, and Google Scholar up to March 15, 2024, using keywords like “intranodal hemangioma,” “primary intranodal hemangioma,” “nodal hemangioma,” “vascular tumor,” and “lymph node hemangioma.” Inclusion criteria included studies on clinical presentation, diagnostic strategies, and therapeutic interventions for intranodal hemangioma in patients of all ages. Excluded were reviews, opinion pieces, non-English studies, cases of hemangioendothelioma, sclerosing hemangioma, and animal studies. Key aspects analyzed included demographics, clinical presentation, management strategies, and histopathological findings. Results: Our case involves a 3-year-old female with a submandibular mass, initially diagnosed with hemangioma. After no response to beta-blocker therapy and conflicting imaging results, surgical excision was performed. Histopathology confirmed intranodal hemangioma. From 233 records, 19 publications (36 patients, including our case) met the inclusion criteria. The review shows common clinical presentations as painless, slowly enlarging lymph nodes, primarily in the cervical and axillary regions. Diagnostic challenges often require imaging and biopsy to differentiate from malignancies. Conclusion: Recognizing intranodal hemangiomas, particularly in childhood, is crucial to prevent misdiagnosis and inappropriate treatment. The rarity of these tumors in childhood and their clinical presentation similar to malignancies in older patients make diagnosis challenging without widespread awareness. Surgical excision remains the mainstay of both diagnosis and treatment, often leading to favorable outcomes.

Rare locations of peripheral aneurysms in Marfan syndrome treated surgically: a case report

Marfan syndrome (MFS) is a connective tissue disorder that can lead to cardiovascular and musculoskeletal abnormalities. Aortic aneurysms and dissections are frequently seen in patients with MFS whereas peripheral vascular aneurysms in subclavian and axillary arteries territory considered very unusual. We reported a case of 54-year-old female with known history of MFS who had undergone a mechanical valve Bentall procedure due to severe aortic regurgitation and ascending aorta aneurysm in addition to thoracoabdominal aortic repair and who presented with a pulsatile painful mass in her right axillary region that turn to be significant true aneurysms of right subclavian and axillary arteries. To relive symptoms and to avoid further complications patient underwent successful surgical repair. Our case demonstrated rare locations of true peripheral aneurysms as a possible manifestation of MFS appeared several years post Bentall procedure and thoracoabdominal aortic repair and highlights also the importance of long-term monitoring to detect earlier such manifestation and avoid complications by surgical repair.

Essential Considerations for Radiologists in Diagnosing Hidradenitis Suppurativa.

Hidradenitis suppurativa, also referred to as inverse acne, manifests as a persistent inflammatory skin disorder characterized by lesions such as deep nodules, abscesses, sinus tracts, and fibrotic scars. These manifestations predominantly occur in skin folds and intertriginous areas, notably in the axillary, inguinal, perianal, perineal, and inframammary regions. Due to similarities with other conditions in its initial stages, accurate diagnosis of hidradenitis suppurativa is often delayed, sometimes spanning several years. Diagnosis relies on identifying specific morphologic features (such as deep, inflamed, and painful nodules; sinus tracts; and scars), considering the affected sites (skin folds and areas with apocrine glands), and recognizing the chronic nature of the condition (persistent course with periods of exacerbation and remission). There are no definitive biologic or pathologic diagnostic tests, and biopsy of the affected area is not necessary. Treatment varies based on severity and may include topical and systemic antibiotics, hormonal therapy, immunomodulators, and surgery. Due to associated pain, increased site sensitivity, secretion drainage, odor, and scarring, this condition can have a negative psychosocial impact. Imaging studies, including high-frequency US and MRI with subsequent three-dimensional reconstruction, serve as valuable tools for precise staging, monitoring disease activity, and preoperative assessment. Currently, high-frequency US stands as the preferred method, incorporating sonographic classifications, while MRI and thee-dimensional imaging represent an emerging and promising approach. Imaging helps identify the extent of sinus tracts, assess involvement dimensions in advanced disease stages, and monitor proposed treatments. ©RSNA, 2024 Supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article.

Factors Affecting the Complete Response in Breast and Axillary Regions Following Neoadjuvant Chemotherapy for Breast Cancer

Factors Affecting the Complete Response in Breast and Axillary Regions Following Neoadjuvant Chemotherapy for Breast Cancer

Gorham-Stout disease and multiple cervical lymphangiomas: case report.

Gorham-Stout disease is a rare condition characterized by extensive bone loss due to the proliferation of new vascular and lymphatic structures. It can occur in any bone and cause pathologic fractures with poor bone healing. Complications such as effusions and lymphangiomas can also develop. Gorham-Stout disease pathogenesis is still being studied, and treatment options are limited, but sirolimus has shown promise in stabilizing or reducing symptoms. We present a case of a 19-year-old male with Gorham-Stout disease, multiple cervical lymphangiomas, and several thoracic complications successfully treated with sirolimus. Rare lymphatic diseases should be considered as a potential cause in adult patients with bone involvement and multiple cystic lesions in the neck, axillary, or abdominal regions after excluding more common causes. The complexity of diagnosing Gorham-Stout disease should be emphasized.

De-Differentiated Metastatic Melanoma: A Diagnostic Challenge

Abstract Introduction/Objective Melanoma is one of the common malignant neoplasms with several histological appearances. Its diagnosis is usually based on histomorphologic findings and immunohistochemistry (IHC). De-differentiated melanoma (DM) is a special form of malignant melanoma with different histo-morphologic and immunohistochemical characteristics than conventional malignant melanomas. It has a worse prognosis and can impose a diagnostic challenge. Methods/Case Report A 62-year-old male previously had melanoma on his chest, which was surgically removed with negative margins and no involvement of nearby sentinel lymph nodes. The patient presented two months later with a rapidly enlarging mass in the right axillary region. Subsequent lymph node dissection revealed several nodes, the largest measuring 14 cm with extensive necrosis. Microscopic examination of the largest mass revealed clusters of irregularly shaped cells displaying marked nuclear abnormalities, prominent nucleoli, and heightened mitotic activity. Immunohistochemical analysis of this mass showed negative results for SOX-10, HMB45, Melan-A, S100 protein, CAM5.2, BRAF, and myogenin. Conversely, the remaining lymph nodes exhibited typical signs of melanoma metastasis, expressing relevant melanoma markers. Given the patient’s history of melanoma and the presence of metastatic melanoma in nearby lymph nodes, the histological and immunohistochemical findings support the diagnosis of dedifferentiated cutaneous metastatic melanoma. Results (if a Case Study enter NA) N/A Conclusion The distinctive appearance and lack of typical markers in this type of melanoma pose considerable difficulties in distinguishing it from other malignancies like poorly differentiated carcinomas and high-grade sarcomas. Furthermore, dedifferentiated melanoma tends to be highly aggressive, often resisting standard and immunological treatments. Therefore, comprehensive clinical and histomorphological assessments are crucial for accurately diagnosing these complex and challenging cases.

Lichen Planus Pigmentosus Inversus: case report and systematic review

Lichen Planus Pigmentosus Inversus (LPPI) is a rare variant of lichen planus characterized by well-demarcated, often slight pruritic, dark-gray plaques in intertriginous zones, hence the attribute of “inversus”, originally described by Pock et al. in 2001. Less than 100 cases have been reported to date, and here we present a case in a 52-year-old male who presented with two months duration of grey-brownish plaques in bilateral axillary, submammary, antecubital, and inguinal folds. No triggering agent was present, and the biopsy showed an interface/lichenoid dermatitis with plenty of pigment incontinence. Topical tacrolimus 0.1% ointment was administered with moderate improvement at five weeks. A review of the literature showed no significant differences in involved sites and age distribution among genders, with a slightly longer duration of manifestations in females. The most administered therapeutic agents were topical corticosteroids, alone or in combination with other agents, and tacrolimus.

Monogenic obesity in a familial cluster: insights into laurence-moon-bardet-biedl syndrome and leptin deficiency associated with genetic variants in BBS12 and LEPR genes

Monogenic obesity is a rare but clinically significant condition characterized by excessive weight gain due to genetic mutations that affect appetite regulation and energy balance. This case series explores the clinical presentation and genetic underpinnings of monogenic obesity in a familial cluster, focusing on Laurence-Moon-Bardet-Biedl Syndrome (LMBBS) and leptin deficiency associated with genetic variants in the BBS1 and LEPR genes. The index patient, an 11-year-old female, presented with progressive weight gain since infancy, accompanied by acanthosis nigricans on the neck and axillary region. Genetic testing revealed mutations in both the BBS1 and LEPR genes, confirming a monogenic etiology of obesity. Remarkably, her two siblings and a cousin from the paternal side exhibited similar clinical profiles and shared the same genetic variants. This report shows the significance of genetic testing in diagnosing monogenic obesity disorders and highlights the familial clustering observed in such cases. The findings emphasize the need for heightened awareness and consideration of genetic factors in the evaluation of obesity, particularly in pediatric patients with a family history suggestive of monogenic obesity.

Mortality and Associated Risk Factors in Patients With Candida auris: Insights From a Tertiary Care Hospital in Bahrain.

Introduction Candida auris poses a significant healthcare challenge due to its high mortality rates, difficulties in identification, and resistance to antifungal treatment. This study aims to identify risk factors associated with 30-day mortality in patients with either invasive Candida auris infection or colonization. Methods We conducted a prospective study at Salmaniya Medical Complex, a tertiary care hospital in Bahrain, from September 2023 to February 2024. The study included 59 patients infected or colonized by Candida auris. Data were systematically collected from patient records, including demographics, clinical characteristics, and outcomes. Risk factors for 30-day mortality were analyzed using both univariate and multivariate statistical methods. Results Among the 59 patients studied, the mean age was 63.9 years, and the cohort was predominantly male (74.6%). Key findings include a high prevalence of multiple indwelling catheters (44.2%) and recent intubation (42.4%). Candida auris was most frequently isolated from the groin (33.9%) and urine (25.4%), with a notable presence in the axillary regions (23.7%). The mortality rate was 44.1%. Univariate and multivariate analyses revealed that age (≥65 years), multiple indwelling catheters, ICU admission for over 24 hours, and recent intubation were significant risk factors for mortality while chronic kidney disease did not retain its significance in the multivariate model. Conclusion The study underscores the critical need for focused infection control and strong antimicrobial stewardship to address the high mortality associated with Candida auris infections. Emphasizing the importance of early detection and a multidisciplinary approach, these strategies are essential for managing and mitigating the impact of Candida auris in healthcare settings.

Partial agenesis of the pectoralis major and minor muscle: A cadaveric case report.

The pectoralis major and minor muscles, located in the anterior chest wall, are crucial for upper limb movements. Their nonsyndromic absence is rare but significant for surgical procedures involving the axillary and pectoral regions. Ultrasound can confirm the diagnosis and delimit the extent of the muscular abnormality, detect abnormalities of the costal cartilages, among others. This descriptive, cadaveric case report involves a formalin-fixed 57-year-old North American male, with no clinical or family history of similar conditions. The study was conducted at the Human Anatomy Laboratory of the School of Medicine of the Universidad Finis Terrae in Santiago, Chile, in August 2022. We present a cadaveric case of bilateral partial agenesis of the pectoralis muscles discovered during routine dissection. The pectoralis major muscle exhibited only the clavicular portion, with the sternocostal and abdominal portions absent and replaced by a thin layer of connective tissue bilaterally. The pectoralis minor muscle showed partial muscle fibers only in the most distal and inferior portions bilaterally. This case report is significant due to the rarity of this condition without accompanying anatomical variations. Understanding this variant is valuable for clinical situations involving the shoulder and thorax region, such as trauma to the proximal third of the humerus, clavicular region, suprascapular region, and anterior chest wall. It may complicate conservative and/or surgical treatments due to different functional and irrigation patterns in the area and is also important for educating future professionals.

Potential of the Thoracoepigastric Vein as a Drainage Vein in Breast Reconstruction With a Free Flap: An Anatomical Study Using Computed Tomography.

The recipient vessel choice is very important when performing free-flap breast reconstructions. Usually, the concomitant vein of the recipient artery is anastomosed, and mismatches in the diameter are occasionally observed. We consider the thoracoepigastric vein (TEV) as a potential useful recipient vein. The use of the TEV is not a novel technique. It has been used by surgeons for free-flap anastomoses in the axillary region, but usually as an anastomotic site for the second vein. However, anatomical findings such as TEV diameter, its deficiency rate, and influence on mastectomy are not clear. In this study, computed tomography (CT) was performed to evaluate the use of the TEV as a recipient vein for breast reconstruction. The medical records of patients who underwent breast reconstruction with free-flap transfer were retrospectively evaluated. In most cases, CT was performed using a tissue expander inserted after mastectomy. The TEV was considered suitable if its diameter on the mastectomy side was >1 mm and the vertical distance from the most distal slice level where the TEV could be seen at the third costal cartilage height of the parasternal region was <50 mm. Sixty-six sides of 33 patients were evaluated. The mean age of the patients was 49.3 ± 5.1 years. The TEV was used in five flaps. TEV diameters were not significantly different between the left and right sides (1.85 ± 0.53 vs. 1.82 ± 0.6, respectively, p = 0.836). On the mastectomy side, eight (25%) TEVs were injured, but only three (8.6%) were considered unavailable. On the healthy side, 96.4% TEVs were available. TEVs may be a good choice as vein anastomosis targets for breast reconstruction with a free flap because of their relatively large vessel diameter. UMIN-CTR: R000061573.

Unilateral and Bilateral Axillary Arches in Male and Female Cadavers

Among sixteen donors (32 axillae) dissected in our gross anatomy lab, axillary arch was incidentally observed in three cases (five axillae). In three cases, the axillary arch was observed in five axillae-bilateral in one male and one female donor, and unilateral in one male donor. In all the three cases, the five arches consisted of muscular and connective tissue (aponeurotic/tendinous) parts. The muscular parts originated as slips from the lateral borders of the latissimus dorsi muscles and their connective tissue parts ascended and crossed anterior to the axillary neurovascular bundles to attach to various non-osseus structures on the proximal aspects of the arms. This created a canal dorsal to the axillary arch (designated here as axillobrachial canal or ABC) through which the axillary neurovascular bundles ran to enter the proximal aspect of the arms. The presence of such variant fibromuscular slip can be a cause of neurovascular compression syndrome of the upper limb and may complicate surgical procedures in the axillary region. Therefore, it should be considered in the differential diagnosis of neurovascular compression syndromes of the upper limb and axillary mass to avoid misdiagnosis and unintended damage or injury causing complications.

Effect of adalimumab treatment on inflammatory and hematological parameters in patients with Hidradenitis suppurativa

Objective Hidradenitis suppurativa (HS), a chronic inflammatory disease that typically manifests after puberty, is characterised by painful nodules, abscesses, draining sinus tracts, and scars in areas rich in apocrine glands such as the axillary and inguinal regions. In recent years, blood-based biomarkers such as the Neutrophil/Lymphocyte Ratio (NLR), Platelet/Lymphocyte Ratio (PLR), Monocyte/Lymphocyte Ratio (MLR), Mean Platelet Volume (MPV), Systemic Immune-Inflammation Index (SII) and Pan-Immune-Inflammation Value (PIV) have been used as significant indicators of systemic inflammation. While there are few studies evaluating these biomarkers in HS, the response of these markers to treatment has only been assessed in one study to date. Our study aims to investigate the effect of adalimumab treatment on blood-based systemic inflammation biomarkers in HS, where inflammation plays a significant role. Methods The study included 42 adult patients who received adalimumab treatment at our dermatology and venereology clinic between January 2020 and January 2023. Medical records for complete blood count results of the patients were retrospectively reviewed. All systemic inflammation-based biomarkers were calculated from the absolute values of the complete blood count. The SII was calculated with the following formula: (neutrophil count × platelet count/lymphocyte count). The PIV was calculated as follows: (neutrophil count × platelet count × monocyte count/lymphocyte count). Values before the treatment and at the 12th week of treatment were compared. Results When the changes in the inflammatory parameters of the patients were examined, it was found that NLR (2.13 ± 0.87 vs 2.26 ± 1.12), PLR (111.01 ± 39.89 vs 99.43 ± 35.34), MLR (0.27 ± 0.11 vs 0.28 ± 0.12), MPV (9.59 ± 0.71 vs 9.70 ± 0.79), SII (680.79 ± 330.18 vs 687.89 ± 442.66), and PIV (552.02 ± 330.71 vs 605.05 ± 415.96) values did not change statistically significantly after treatment (p > 0.05). While there was a significant decrease in platelet count compared to before treatment, no statistically significant difference was found in the other evaluated blood cells. Conclusion Adalimumab treatment has not had a significant effect on systemic inflammation markers in HS, an inflammatory disease. More studies are needed to evaluate the effect of adalimumab on these markers in HS.

Drug Combination Nanoparticles Containing Gemcitabine and Paclitaxel Enable Orthotopic 4T1 Breast Tumor Regression.

Early diagnosis, intervention, and therapeutic advancements have extended the lives of breast cancer patients; however, even with molecularly targeted therapies, many patients eventually progress to metastatic cancer. Recent data suggest that residual breast cancer cells often reside in the lymphatic system before rapidly spreading through the bloodstream. To address this challenge, an effective drug combination composed of gemcitabine (G) and paclitaxel (T) is administered intravenously in sequence at the metastatic stage, but intravenous GT infusion may limit lymphatic GT drug accessibility and asynchronous drug exposure in cancer cells within the lymph. To determine whether co-localization of intracellular gemcitabine and paclitaxel (referred to as GT) could overcome these limitations and enhance the efficacy of GT, we have evaluated a previously reported GT drug-combination formulated in nanoparticle (referred to as GT-in-DcNP) evaluated in an orthotopic breast tumor model. Previously, with indocyanine green-labeled nanoparticles, we reported that GT-in-DcNP particles after subcutaneous dosing were taken up rapidly and preferentially into the lymph instead of blood vessels. The pharmacokinetic study showed enhanced co-localization of GT within the tumors and likely through lymphatic access, before drug apparency in the plasma leading to apparent long-acting plasma time-course. The mechanisms may be related to significantly greater inhibitions of tumor growth-by 100 to 140 times-in both sub-iliac and axillary regions compared to the equivalent dosing with free-and-soluble GT formulation. Furthermore, GT-in-DcNP exhibited dose-dependent effects with significant tumor regression. In contrast, even at the highest dose of free GT combination, only a modest tumor growth reduction was notable. Preliminary studies with MDA-231-HM human breast cancer in an orthotopic xenograft model indicated that GT-in-DcNP may be effective in suppressing human breast tumor growth. Taken together, the synchronized delivery of GT-in-DcNP to mammary tumors through the lymphatic system offers enhanced cellular retention and greater efficacy.

Liposuction Through an Axillary Fold Incision Combined with a Small Areola Incision to Treat Gynecomastia.

Gynecomastia is a progressive disease characterized by enlarged breasts, affecting a significant proportion of men. Persistent gynecomastia negatively affects the psychological and emotional development of patients; therefore, surgical intervention is required. In this article, we describe a surgical technique, where liposuction through an axillary incision is used in combination with a single small periareolar incision, to obtain the most minimal scars in the treatment of gynecomastia. Between June 2021 and June 2023, 125 patients with different Simon grades of gynecomastia were enrolled. The patients' basic conditions and operation processes were recorded. Following surgery, a score was assigned according to the five main aesthetic aspects of the surgical procedure. In total, 125 patients with gynecomastia were treated with a pre-axillary fold incision combined with a small areolar incision. There were 17 cases of Simon grade I, 46 grade IIA, 42 grade IIB, and 20 grade III. The average operation time was 45.8min, the average liposuction volume was 250.5mL, the average glandular tissue volume was 50.5g, intraoperative blood loss ranged from 15 to 60mL, and the average hospital stay was 3.2days. Regarding the postoperative aesthetic effect, doctors scored > 4 points, and the patient satisfaction score was > 7.5, which fully affirmed the aesthetic effect of this method. Treatment of gynecomastia through an anterior axillary fold incision combined with a small areolar incision is safe and feasible, involving a simple procedure, short operation time, and few complications. Its efficacy and cosmetic effects could lead to its use as a primary surgical method to treat gynecomastia. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .

Diagnostic dilemma: axillary cysticercosis masquerading as breast mass

Cysticercosis, caused by the tapeworm Taenia solium, is a significant public health concern, particularly prevalent in developing nations. We present a case of isolated cysticercosis in the axillary region, mimicking a breast mass, in a 47-year-old woman who presented with a gradually enlarging mass in her right axilla and was initially diagnosed with fibroadenoma. However, further investigations revealed cysticercosis in the larvae, including ultrasonography and fine-needle aspiration cytology (FNAC). The patient underwent surgical excision of the cysts following a two-week course of albendazole therapy. Histopathological examination confirmed cysticercosis with a foreign body giant cell reaction. Cysticercosis typically involves muscular and subcutaneous tissues, posing diagnostic challenges due to its resemblance to other conditions. Ultrasonography, FNAC, and MRI play crucial roles in accurate diagnosis. Treatment involves a combination of surgical removal and antiparasitic medications such as albendazole. This case highlights the importance of considering cysticercosis in differential diagnosis, especially in endemic regions, and underscores the effectiveness of a comprehensive treatment approach integrating medical therapy and surgical intervention. Effective management ensures the eradication of parasitic infection and the alleviation of associated symptoms, exemplifying patient-cantered care for optimal outcomes. Increased awareness, preventive measures, and early diagnosis are essential for mitigating the burden of cysticercosis, particularly in regions with poor sanitation and high prevalence rates.

Significant Improvement of Persistent Hailey-Hailey Disease with Dupilumab: A Case Report

Hailey-Hailey disease is a rare, genetic blistering disease characterized by erythematous, scaly plaques in intertriginous regions such as the axillary, inframammary, and groin regions. The plaques cause discomfort and are difficult to treat. Treatment ranges from topical to systemic and surgical. Despite the variety of treatment options, Hailey-Hailey disease is notoriously difficult to treat with each patient responding uniquely to treatment. There has been evidence of patients with Hailey-Hailey disease experiencing improvement of symptoms with dupilumab injections. Dupilumab has several off-label uses, including allergic contact dermatitis, hand dermatitis, chronic spontaneous urticaria, and alopecia areata, showing promise for its use in dermatology outside of atopic dermatitis and prurigo nodularis. Due to its minimal side effects, dupilumab can be tried for Hailey-Hailey disease with little risk. We present the case of a 37-year-old female with recalcitrant Hailey-Hailey disease who noticed significant improvement on dupilumab.

699 Gender Inequality in Orthopaedic Radiation Protection: An Audit

Abstract Aim The literature demonstrates an increased prevalence of breast cancer in female orthopaedic surgeons compared to the population baseline. One contributor to this alarming statistic may be exposure to frequent low-dose radiation inherent to orthopaedics. The British Orthopaedic Association (BOA) has emphasised the importance of wearing lead aprons that provide adequate coverage, especially of the axillary region in women. To assess the availability of vests that fulfil such criteria, an audit of the lead aprons available at our local adult tertiary centre was undertaken. Method Lead protective equipment used by the orthopaedic theatres were documented by type, size, and brand. Data collection occurred prior to theatre activity requiring lead use, to ensure all equipment was present. Results 115 pieces of equipment were identified - 43 standard vests, 9 tabard gowns with side coverage, 4 tabard gowns without side coverage, 48 skirts and 11 thyroid covers. Vests, skirts, and tabard gowns ranged from XS (n=4), S (n=21), M (n=15), L (n=46), to XL (n=12), unidentifiable size (n=6). Vests, skirts and tabard gowns ranged from several different brands including Xenolite Male (n=45), Xenolite Female (n=29) and Kenex (n=23). No boleros, high axilla vests, or vests with wings/sleeves/axillary shields, were identified. Conclusions This audit demonstrated inadequate adherence to BOA recommendations and a lack of size diversity. With increasing numbers of women in orthopaedics, there is a need to raise more awareness and address this safety concern to mitigate a larger concerning trend.