British Association Of Dermatologists Research Articles

British Association of Dermatologists and British Society for Rheumatology living guideline for managing people with Behçets 2024.

British Association of Dermatologists and British Society for Rheumatology living guideline for managing people with Behçets 2024.

British Association of Dermatologists and British Society for Rheumatology living guideline for managing people with Behçets 2024.

The overall objective of the guideline is to provide up-to-date, evidence-based recommendations for the management of Behçets. The document aims to offer an appraisal of all relevant literature up to 25 August 2023 focusing on any key developments; to address important, practical clinical questions relating to the primary guideline objective; and to provide guideline recommendations and appropriate research recommendations.

Systemic isotretinoin in modern clinical guidelines on acne management

Objective — to analyze the medical and technological documents developed on the basis of evidence­based medicine (guidelines, recommendations, consensuses) regarding the treatment of patients with acne of various degrees of severity with systemic retinoids (systemic isotretinoin preparations) dating from 2013 to 2023, as also to focus attention on the pharmacokinetic features of the original systemic isotretinoin according to innovative Lidose technology. Materials and methods. An analysis was conducted of clinical European guidelines (French guideline and those of the European Dermatology Forum), guidelines of the American Academy of Dermatology, the National Institute for Health Protection and Improvement of Medical Care (NICE) of Great Britain in conjunction with the British Dermatology Association and the Canadian Dermatology Association, recommendations of the American Academy of Pediatrics and the French Society of Dermatology, the International Consensus of the Global Alliance for the Improvement of Acne Treatment Outcomes, and consensus­based practical and daily guideline for the management of acne patients. The key words for the search were «acne», «clinical guideline», «consensus», «systemic treatment», «isotretinoin», «isotretinoin­ Lidose». Results and discussion. Clinical guidelines (2013, 2015, 2016) for the management of acne recommend isotretinoin at a dose of 0.5—1 mg/kg/day for 16—24 weeks to a total (cumulative) dose of 120—150 mg/kg for severe acne (nodular/conglobate acne). Low-­dose regimens of isotretinoin (< 0.5 mg/kg/day) have been used with varying degrees of success in the treatment of severe papulopustular/moderate nodular acnе. The International Consensus of the Global Alliance to Improve Acne Treatment Outcomes (2017) supports standard isotretinoin dosing for severe acne until the cumulative dose is reached. At the same time, for patients that have severe papulopustular acne, poor tolerance, risk of serious side effects, or rash regression before the cumulative dose is achieved it is recommended to continue taking the drug until the skin is completely cleansed of acne­elements and for additional 1—2 months. Such provisions are set out in the guidelines developed jointly with the British Association of Dermatologists (2021). According to the American Academy of Dermatology (2023) guidelines, standard isotretinoin or isotretinoin ­Lidose® is recommended for patients for whom isotretinoin is indicated, which is supported by high­quality evidence. Due to the Lidose technology, the soluble fraction of isotretinoin increases, while the insoluble fraction responsible for side effects, on the contrary, decreases. The bioavailability of the drug increases, which allows lowering the daily and course doses of the drug. Conclusions. Systemic isotretinoin has a convincing evidence base as highly effective treatment for severe and moderate forms of acne, providing a sustained therapeutic effect at standard or low doses. In current US guidelines, isotretinoin and isotretinoin­ Lidose® are recommended for the treatment of severe acne, as well as acne that causes psychosocial burden or scarring, or acne that does not respond to treatment with oral or topical therapy. The use of isotretinoin ­Lidose® due to extrabioavailability, high solubility, independence from food intake allows to obtain better clinical results, has a favorable safety profile, characterized by a minimal frequency of adverse reactions.

British Association of Dermatologists national clinical audit on the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults.

UK guidelines for managing adults with Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), published by the British Association of Dermatologists (BAD) in 2016, outline a set of audit standards. To audit current management of SJS/TEN in adults against standards in the BAD guidelines. BAD members were invited to submit data on five consecutive adults with SJS/TEN per department over an 8-week period in 2022. Thirty-nine dermatology centres in the UK (29%) participated, and data for 147 adults with SJS/TEN were collected. Within 24 h of the diagnosis being made or suspected, the following were documented, per 147 submitted cases: Severity-of-Illness Score for Toxic Epidermal Necrolysis (SCORTEN) for 76 (52%), list of medications for 113 (77%) and timelines for commencement/alterations of medications for 104 (71%). The initial assessment was documented of the eyes by an ophthalmologist in 71 (48%), of the mouth in 130 (88%), of the genital skin in 103 (70%) and of the urinary tract in 93 (63%). During the first 10 days after a suspected or confirmed diagnosis of SJS/TEN, daily assessments of the mouth were documented in 26 of 147 cases (18%), of the eyes in 12 (8%), and of the urinary tract and genital skin in 14 (10%). At discharge, a drug was declared to be the cause of SJS/TEN for 130 of 147 cases (88%), while 9 (6%) were thought to be secondary to infection. Eleven of 147 (8%) had no response to this question. Documentation regarding advice was present on avoidance of the culprit drug in 76 of 130 declared SJS/TEN cases (58%), and on requesting a MedicAlert® bracelet/amulet in 9 of the 147 cases (6%). This audit suggests that a clinical review checklist might be needed to enable colleagues to maintain standards outlined in the guidelines, including documentation of SCORTEN, daily assessments of mucosal areas, and advice to avoid culprit drug(s) and to request a MedicAlert® bracelet/amulet.

Artificial intelligence-generated patient information leaflets: a comparison of contents according to British Association of Dermatologists standards.

Patient information leaflets (PILs) can supplement a clinical consultation and provide additional information for a patient to read in their own time. A wide range of PILs are available for distribution by the British Association of Dermatologists (BAD) and undergo rigorous review ahead of publication. In the UK, 7.1 million adults are estimated to have the reading age of a 9-year-old child and 43% are unable to comprehend written health information. To determine whether artificial intelligence (AI) can produce PILs that include a similar degree of content to current BAD PILs. Using the AI tool ChatGPT, 10 PILs were generated, and their contents compared with those of existing BAD PILs using an author-generated list of commonly included themes. Omissions were noted and a repeat series of PILs generated using targeted request phrasing. The readability of AI-generated PILs was also analysed. AI-generated PILs were found to include similar factual content to BAD PILs but excluded information that was felt to be more pertinent to patient concerns such as curability and heritability. Targeted request phrasing saw AI generate PILs including this content. The readability of AI-generated PILs was beyond that of a large number of UK adults. Where a condition-specific PIL is not readily available, an AI-generated PIL can provide relevant information of lesser quality than existing BAD PILs, which may be inaccessible to some patients. Specific caution is advised regarding AI-generated medication-specific PILs.

Undergraduate dermatology education: The importance of curriculum review.

In this letter, we highlight the considerable diversity in undergraduate dermatology training in the United Kingdom and acknowledge the barriers faced in implementing the revised national undergraduate curriculum provided by the British Association of Dermatologists (BAD). We provide a pragmatic approach of ensuring that our dermatology placement aligns with the BAD national undergraduate curriculum and Medical Licensing Assessment (MLA) content map, in the face of limited clinician time and placement length. We urge other medical schools to adopt our approach of curriculum mapping, particularly in light of the upcoming MLA, and sustainable educational resource development.

Variation in the practice of wide local excision for melanoma in Ireland and the UK: a questionnaire survey.

Wide local excision (WLE) is standard practice in the management of melanoma, but no national or international guidelines exist regarding its technique. To assess variation in the practice of WLE and to explore the effect of clinicians' specialty and grade on such variation. This was an international, anonymized, cross-sectional study. An online questionnaire was distributed to the Irish Association of Dermatologists, British Association of Dermatologists, British Association of Plastic and Reconstructive and Aesthetic Surgeons, Melanoma Focus and BioGenoMEL members. Of 128 respondents, 57% were dermatologists and 38% plastic surgeons. Most (80%) were consultants. Almost all clinicians learned their technique from colleagues (99%) 'on the job', although 21% also used textbooks or other media as part of WLE training. There was significant variation in planning and performing WLE: 59% considered margins already achieved, 71% marked margins with the skin relaxed. For 1 cm WLE, 84% delineated 1 cm from the edge of the scar; with a greater proportion of plastic surgeons than dermatologists marking from the centre of the scar (P < 0.05). Most followed a longitudinal/oblique axis on the limbs for WLE (81%). Only 40% sent 'dog ears' for histology. Most (70%) incised through the marked line, 27% incised outside it. Most (79%) excised to deep fascia, 18% to the next biological margin. This study demonstrates significant variation among clinicians performing WLE, an essential component of melanoma management. We postulate that this could have an impact on patient outcomes. A consensus statement should be developed, to achieve more consistency in the practice of WLE.

A scoping review exploring the confidence of healthcare professionals in assessing all skin tones.

Health inequalities and poorer outcomes have been identified for patients with dark skin tones. The reasons are multi-factorial, but may include delayed treatment due to a lack of recognition of early clinical signs of physiological deterioration. Within the medical literature there is a light skin tone bias, leading to healthcare professionals having insufficient knowledge regarding the assessment of patients with different skin tones, which may result in reduced confidence and create patient safety issues. The aim of this scoping review was to explore the confidence levels of healthcare professionals when assessing patients of different skin tones. The methodology followed scoping review frameworks set out by Arksey and O'Malley (2005), the Joanna Briggs Institute (Peters et al., 2020) and the PRISMA extension for Scoping Reviews (PRISMA-ScR) (Tricco et al., 2018). Searches for literature were performed between February and June 2022 using electronic databases EBSCO (Academic Search Complete, the Allied Complementary Medicine Database, e-journals, MEDLINE, CINAHL), British Nursing Index (ProQuest), Scopus, Web of Science, Zetoc, UpToDate, Google Scholar, NICE Evidence, ResearchGate, Opengrey and the British Association of Dermatologists. No date range was specified, expanders were left on and the findings were screened using inclusion and exclusion criteria. Included papers were synthesised using narrative synthesis. Thirteen papers were identified, and the extracted data charted by the paper's origin, sample size, profession and confidence levels. Our synthesis revealed reduced confidence in assessing, managing and diagnosing skin conditions in dark skin tones. A lack of training was cited by different health professionals, but undertaking tailored training and experiential learning increased confidence. There is a safety issue for patients with dark skin tones, as healthcare professionals lack clinical confidence in managing and treating all ethnicities equally. Tangible diversity within healthcare training is required, supported by inclusive skin tone imagery and appropriate terminology within medical literature.

Current issues with procollagen III N-terminal peptide assay performance relevant to 2016 British Association for Dermatologist methotrexate-monitoring guidance.

Procollagen III N-terminal peptide (P3NP) testing is routinely used to detect possible liver fibrosis according to the cutoffs in the British Association of Dermatologists (BAD) 2016 guidelines for the safe and effective prescribing of methotrexate in skin disease. We report significant changes to P3NP test performance that will potentially change patient management according to the BAD 2016 guidelines.

DE03 Using the British Association of Dermatologists’ medical student app to promote a better representation of skin of colour in undergraduate education

Abstract It was exactly 10 years ago, in Liverpool, that the ‘BAD medical student app’ was launched. At a time when digital learning was becoming popular, a platform that is accessible globally, on your phone, which provides evidenced-based information to aid medical students’ educational needs in undergraduate dermatology, was born. In the wake of the need for promoting fair medical education, the General Medical Council, in their ‘2021–25 corporate strategy’, stipulated a requirement for an increased focus on equality, diversity and inclusion in medical education. Furthermore, medical students lack training on how skin disease presents differently in patients who have darker skin tones (Adelekun A. Skin color in dermatology textbooks: an updated evaluation and analysis. J Am Acad Dermatol 2021; 84:194–6). A 2018 study of general medicine texts found that &amp;lt; 5% of images included dark skin tones. Louie and Wilkes (Louie P, Wilkes R. Representations of race and skin tone in medical textbook imagery. Soc Sci Med 2018; 202:38–42) discovered that in general medicine texts commonly used by medical students, &amp;lt; 5% of the images included darker skin tones. The effects of the COVID-19 pandemic and the semipermanent transition to using virtual learning methods have required medical students to become more autonomous in supplementing what is learnt in lectures. Furthermore, the under-representation of skin of colour in primary medical texts will lead to students connecting diagnosis with a one-dimensional presentation and, in turn, hesitation in diagnosing skin diseases in darker skin tones. Understanding the existence of this limitation and recognizing the value of using the British Association of Dermatologists’ medical student app to reach out to medical students, we embarked upon a project to diversify education on cutaneous diseases in darker skin tones. The app, which contains didactic clinical information, as well as picture quizzes designed to challenge a student’s ability to make a spot diagnosis, has been expanded to include a larger proportion of images of darker skin tones. Where cutaneous diseases present significantly differently in lighter and darker skin tones, we have included contrasting images to illustrate this. We hope these structural changes to the app will complement higher initiatives to improve equity in skin-of-colour image representation in undergraduate medical education on cutaneous diseases.

002 National clinical audit on the management of Stevens–Johnson syndrome/toxic epidermal necrolysis in adults

Abstract UK guidelines for the management of Stevens–Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) in adults, published by the British Association of Dermatologists (BAD) in 2016, outline a set of audit standards (Creamer D, Walsh SA, Dziewulski P et al. U.K. guidelines for the management of Stevens–Johnson syndrome/toxic epidermal necrolysis in adults 2016. Br J Dermatol 2016; 174:1194–227). Our aim was to audit the current management of SJS/TEN in adults against audit standards in the BAD guidelines. BAD members were invited to submit data on five consecutive adults with SJS/TEN per department over an 8-week period in 2022. All data were obtained from respondents using a Microsoft Excel spreadsheet proforma returned to the BAD by email. No patient-identifiable data were requested. Initial data extraction was conducted using a novel and reproducible program written in the R statistical language (V3.7 and the readxl, ggplot2 and ggthemes packages). The data analysis was also performed using Microsoft Excel. Thirty-nine (29%) dermatology centres in the UK participated and data for 147 adults with SJS/TEN were collected. Within 24 h of a diagnosis being made or suspected, the following were documented: Severity-of-Illness Score for TEN (SCORTEN) for 52% (n = 76/147) of submitted cases, list of medications for 77% (n = 113) and timelines for commencement/alterations of medications for 71% (n = 104). Initial assessment was of the eyes (by an ophthalmologist) for 48% (n = 71) of cases, the mouth in 88% (n = 130), the genital skin in 70% (n = 103) and the urinary tract in 63% (n = 93). In the first 10 days after a suspected or confirmed diagnosis of SJS/TEN, daily assessments of the mouth were documented in 18% (n = 26) of cases, the eyes in 8% (n = 12) and the urinary tract and genital skin in 10% (n = 14). Documentation regarding advice on (i) avoidance of the culprit drug was present for 58% (n = 76/130) of cases and (ii) request for a medic alert bracelet/amulet in 6% (n = 9/147). In adults with SJS/TEN, drug causality assessment was documented adequately. Initial assessment of the mouth, eyes, urinary tract and genital skin was good to fair; however, daily assessments were poor. Other audit standards that require improving include documentation of SCORTEN and advice to avoid the culprit drug and request a medic alert bracelet/amulet. In adults with SJS/TEN, there are multiple points in the assessment pathway that require careful documentation and regular review. These are a challenge for many clinical inpatient environments. Care within a burns unit or similar may not be possible for all. This audit suggests that some form of assessment and clinical review checklist might enable colleagues to maintain standards outlined in the guideline. Among these, use of SCORTEN, advice to avoid the culprit drug and requests for a Medic Alert bracelet/amulet are key.

PS04 Assessment and management of patients with vitiligo and psychological distress: clinician survey

Abstract Vitiligo is a common, pigmentary skin disorder, affecting 1% of people worldwide. People with vitiligo have a significantly higher prevalence of psychosocial comorbidities, including anxiety, depression and suicidal ideations, than nonaffected individuals (Ezzedine K, Eleftheriadou V, Jones H et al. Psychosocial effects of vitiligo: a systematic literature review. Am J Clin Dermatol 2021; 22:757–74). The British Association of Dermatologists’ (BAD) 2022 vitiligo guidelines recommend the assessment of psychosocial impact in all patients with vitiligo, with management tailored to severity (Eleftheriadou V, Atkar R, Batchelor J et al. BAD guidelines for the management of people with vitiligo 2021. Br J Dermatol 2022; 186:18–29). We conducted a UK-wide consultation exercise aimed at establishing the current assessment and management practices of patients with vitiligo who experience psychological distress due to their skin. This project was supported by the UK Dermatology Clinical Trials Network and was also distributed to BAD members. Seventy-eight responders completed the online questionnaire (83% doctors, 14% nurses and 3% psychologists). On average, responders reviewed eight patients with vitiligo in the clinic during the preceding 6 months; 37% of these patients were estimated to have moderate/severe psychological distress. Sixty-seven per cent reported routine screening for psychological impact using mainly the Dermatology Life Quality Index (56%) and Patient Health Questionnaire-9 (16%). Forty-eight per cent used no formal screening tool but asked general questions. Thirty-three per cent do not routinely screen for psychological impact. For the management of mild psychological distress, 83% of responders signpost to online resources or advise self-referral to local services; 16% wrote to the general practitioner only. For the management of moderate-to-severe psychological distress, 28% referred patients to psychiatric services, 29% to psychological services and 37% to community services. Four per cent stated they would not take any action. Interestingly, 18% were not aware of any available local, regional or national psychological services. Waiting times for urgent psychological input ranged from 2 months to 2 years. Eighty-seven per cent of responders felt that their patients with vitiligo would benefit from a tailor-made online psychological intervention targeting specific aspects of the condition and that patients with vitiligo would engage with it (80%). Digital accessibility was highlighted as the main concern by remaining responders. Sixty per cent of responders expressed interest in participating in a trial examining the effectiveness of an online-delivered psychological intervention for patients with vitiligo and moderate/severe psychological distress. In summary, significant variation exists in the assessment and management of patients with vitiligo and psychological distress. Our survey suggests an unmet need for such an online intervention and a need for educational resources to give to clinicians regarding pathways to mental health services.

P22 Clinicopathologic characteristics of metastatic cutaneous squamous cell carcinoma: a cohort study

Abstract Cutaneous squamous cell carcinoma (cSCC) is a keratinocyte tumour with excellent prognosis following early-stage surgical treatment. Nevertheless, cSCC possesses an inherent potential for locoregional and distant metastasis in approximately 4% of cases, contributing to disease-specific mortality. Recent guidance on cSCC management risk stratifies patients based on clinicopathological factors to identify those patients most at risk of metastasis. A retrospective cohort study identified 3455 cSCCs arising in 2522 patients, via review of histopathological diagnoses of cSCC at a tertiary hospital in Dublin, Ireland, between the years of 2009 and 2019. The aim of the study was to describe adequately a large cohort of patients with metastatic cSCC and investigate factors associated with metastasis. Metastatic disease was identified by histopathological and/or radiological confirmation in 116 patients, with complete data available in 105 cases. Twenty-two (21%) were female. Mean age at primary tumour diagnosis was 74.8 years and mean time to first metastasis was 0.8 years. Twenty-six (25%) patients were immunosuppressed, the commonest reason for which was haematological malignancy. Median (SD) size of the primary tumour was 36 (21.65) mm and median depth was 10 (7.43) mm. Eighty-six (82%) tumours were located on the head and neck. Seventeen (16%) of the tumours were recurrent, 58 (55%) were &amp;gt; 20 mm, 38 (36%) demonstrated extension beyond subcutaneous fat, 22 (21%) demonstrated lymphovascular invasion, 24 (23%) demonstrated perineural invasion of nerves &amp;gt; 0.1 mm in diameter and 41 (39%) tumours were poorly differentiated. Twenty-six patients developed distant metastatic disease in addition to nodal metastasis. In most patients in our cohort, AJCC 8th Edition histopathological high-risk cSCC features were absent, apart from size &amp;gt; 20 mm. Conversely, most patients exhibited at least one clinical high-risk cSCC feature as per the British Association of Dermatologists’ guidelines for the management of cutaneous squamous cell carcinoma, including advanced age and tumour location (Keohane SG, Botting J, Budny PG et al. British Association of Dermatologists guidelines for the management of people with cutaneous squamous cell carcinoma 2020. Br J Dermatol 2021; 184:401–14). All patients were discussed at a specialist skin multidisciplinary team meeting, with significant variability noted in preoperative imaging, depending on the primary treating specialty. This cohort illustrates the importance of risk stratification of cSCC on clinicopathological features. This facilitates management decisions and ongoing patient surveillance with a view to preventing disease-specific morbidity and mortality.

PA16 Gynaecomastia associated with isotretinoin

Abstract Isotretinoin routinely causes mucocutaneous side-effects, such as cheilitis. Endocrine side-effects are not well documented, although reduced libido has been recognized recently. A 19-year-old male (weighing 60 kg and with a body mass index of 20.4 kg m−2) with no previous medical history developed unilateral left-sided gynaecomastia while taking oral isotretinoin for acne vulgaris (daily dose 20 mg for 1 month, 30 mg for 1 month, then 40 mg). He was taking no other medication or supplements, had never taken anabolic steroids and exercised daily. After 3 months of treatment, he noticed a firm, tender, left-sided subareolar mass, enlarging to 4.5-cm diameter, causing the areola to protrude approximately 5 mm above the level of the contralateral areola. Serum testosterone was 35.9 nmol L−1 (reference interval 8.7–29); a-fetoprotein and human chorionic gonadotropin were normal. Isotretinoin was discontinued, and the breast tissue returned to normal within 2 months, with no recurrence after 3 years of follow-up. Gynaecomastia in young adult males is uncommon, usually bilateral and is typically idiopathic in origin. Potential causes include hypogonadism and medications such as oestrogens, cimetidine, methyldopa, ketoconazole, spironolactone and tricyclic antidepressants. Obesity may lead to a similar appearance (pseudogynaecomastia). Isotretinoin has recently been linked to sexual dysfunction in both sexes, but a link is not proven: symptoms may have started after discontinuing isotretinoin and be long-lasting. Erectile dysfunction, loss of libido, anorgasmia and genital anaesthesia are reported; a minority of male patients have reduced testosterone. Gynaecomastia appears to be a very rare complication of isotretinoin use; only four previous cases have been reported in the literature. It is not listed as a potential side-effect in the Summary of Product Characteristics (SPC) leaflets for generic forms of isotretinoin, only being mentioned in the Roaccutane® SPC. The Medicines and Health products Regulatory Authority, in its updated online information leaflet (March 2022), lists gynaecomastia as a potential side-effect. The British National Formulary’s listing and the British Association of Dermatologists’ isotretinoin patient information leaflet do not mention gynaecomastia; however, reduced libido is stated. The European Medicines Agency and the National Health Service’s isotretinoin information webpage mention no endocrine side-effects. Cessation of isotretinoin was associated with resolution of the gynaecomastia; hence, we believe that it was responsible for it, although the mechanism of induction is unclear. An androgen–oestrogen imbalance has been suggested, leading to relative androgen deficiency. However, our patient had a high level of endogenous androgen, thought to be due to a high muscle mass, and entirely normal sexual function. Although uncommon, we would like to alert colleagues to the possibility of gynaecomastia resulting from isotretinoin treatment.

DS17 Postoperative wound complications following dermatological surgery: an audit leading to improved clinical practice, patient outcomes and informed consent

Abstract In 2021, an apparent spike in wound complications presenting to our dressings clinic prompted a prospective audit of complications following dermatological surgery. The aim was to quantify the rate of and identify risk factors leading to postdermatological surgery complications for clinical governance and to improve clinical practice and patient outcomes. Secondary outcomes were to provide operators with individual annual complication rates. A further outcome pertinent to the Montgomery ruling was to use the data to refine preoperative patient information with precise detail on risk prior to surgery. Patients undergoing a dermatological surgery procedure between 1 April 2021 and 31 December 2022 across three hospital sites were included in this audit. Prospective data were collected via a departmental surgical complications proforma, supplemented by collating retrospective data from nurse-led wound review clinics via our electronic patient record system. Data were gathered on patient age and sex; operator grade; presenting problem (pain/dehiscence/infection/bleeding/other); surgical site; route of referral; microbacterial swab, cultured organism, antibiotic prescribing; anticoagulation; type of procedure; suture type; days to suture removal; and provision of pre- and postoperative patient information on skin surgery. Over a 21-month period &amp;gt; 11 000 procedures were performed, with a median of 574 procedures per month. In total, 256 patients reported 331 complications: 124 were suspected infections (37.5%); 63 were reports of pain (19.0%), 62 of bleeding (18.7%) and 52 of dehiscence (15.7%); and 30 (9.1%) were other complications such as graft failure. Surprisingly, the majority of complications (41%) occurred on the head and neck. Of patients presenting with bleeding, most were not taking prescribed anticoagulants. Seventy-two per cent of positive swabs grew Staphylococcus aureus. In 2019, the British Association of Dermatologists (BAD) performed a national audit of process, based on measures of quality in a dermatology skin surgery service. Sixty-four per cent of 201 respondents from the BAD and British Association of Dermatological Surgery reported no formal mechanism for determining wound complications following skin surgery (https://cdn.bad.org.uk/uploads/2022/02/29200022/Skin-Surgery-National-Audit-Report-2019.pdf). In our experience, using a departmental proforma has enabled quantification of departmental postoperative complication rates against anatomical site, procedure, patient factors and level of operator, improving clinical practice, governance, informed consent and patient outcomes. It is hoped that our work might usefully contribute to the development of a national proforma for collating data on wound complications, which has wider implications for maintaining high standards of dermatological surgery practice across the UK.

PS07 Delusional infestation: are delays in access to care adversely affecting patient outcomes? A case series

Abstract Delusional infestation (DI) is the fixed, false belief of pathogenic infestation of the skin or body, despite no supporting medical evidence. Patients may be difficult to treat successfully, because of their reluctance to accept referral or involvement of psychiatric services. Research consistently supports assessment of this cohort in multidisciplinary psychodermatology clinics, where integrated medical and psychiatric care can be seamlessly provided. The British Association of Dermatologists (BAD) All Parliamentary Group has recommended increased psychodermatology services across the UK, but provision is still scanty. We report a review of 49 consecutive patients (12 men and 37 women) with a diagnosis of DI assessed in a regional psychodermatology service. Mean patient age was 63 years (range 41–92). Mean duration of symptoms before attending was 4.9 years. Forty-one (84%) patients complained of living creatures, with the other eight (16%) perceiving fibres or other inanimate objects. Perception of nonliving mater­ial was strongly associated with substance misuse. Low-dose antipsychotics were prescribed in 44 (90%) patients. Risperidone (n = 39; 89%) and olanzapine (n = 5; 11%) were the drugs prescribed. Medications were well tolerated, with no significant adverse side-effects reported. Twenty-three (47%) responded to treatment. Four patients developed full-blown psychotic disorders. We were unable to engage 13 (27%) patients in treatment, and in three (6%), the treatment outcomes were unknown. Responders had a mean time to presentation of 3.7 years vs. nonresponders who had symptoms for an average of 5.9 years. Ten (20%) patients admitted to current or previous substance misuse. Twenty-one (43%) had a history of psychiatric disease. Substance misuse and established psychiatric disorders were associated with poorer engagement and response. Response to treatment and engagement with services is multifactorial. This review demonstrated that delays in presentation are associated with poorer outcomes (Romanov DV, Lepping P, Bewley A et al. Longer duration of untreated psychosis is associated with poorer outcomes for patients with delusional infestation. Acta Derm Venereol 2018; 98:848–54). In 2016, early intervention in psychosis services was introduced as a National Institute for Health and Care Excellence standard in the UK. In psychiatry, there is well-established evidence of the relationship between delays in treatment of psychosis and poorer outcomes. The BAD guidelines have recently been published to encourage more widespread prescribing of low-dose antipsychotics to expedite treatment. Our review highlights that all patients with DI face significant delays to treatment, which may adversely impact or increase the complexity of clinical presentations. This review emphasizes the importance of early assessment and supports the expansion of psychodermatology services.

P26 Risk factors for complications in cutaneous squamous cell carcinoma and proposal of a simplified follow-up strategy, making use of available healthcare resources

Abstract Cutaneous squamous cell carcinoma (cSCC) is a common malignancy, generally cured by surgical excision. A minority of such tumours recur, metastasize or even cause death. The 2021 British Association of Dermatologists (BAD) guidelines outline high-risk features that are used to guide the follow-up of patients after a primary cSCC. The aims of this study were to identify histological features of cSCC that are significantly associated with the development of complications, and to compare the sensitivity, specificity and number of appointments required to follow-up patients using different follow-up criteria. In total, 556 cases of primary invasive cSCCs excised between January 2014 and March 2018 were included and followed-up for a minimum of 4 years. Five per cent (n = 26) of tumours were associated with at least one cSCC-related complication, namely, local recurrence 3.8% (n = 21), nodal metastasis 1.6% (n = 9), distant metastasis 0.4% (n = 2) and disease-specific death 0.7% (n = 4). The initial diagnosed complication was local recurrence in 20 of 26 cases. Only two patients had the first complication beyond 2 years of the original cSCC. Factors that were statistically significantly associated with the development of a complication (P &amp;lt; 0.001) are larger diameter, larger depth of invasion, tumour invasion beyond the dermis, perineural invasion (irrespective of size), lymphovascular invasion, gross bone erosion and deep margin &amp;lt; 1 mm. Differentiation and peripheral margin were not significantly associated with complications. Therefore, it may be proposed that patients with tumours with at least one of the following risk factors be followed-up: diameter &amp;gt; 40 mm; depth of invasion &amp;gt; 6 mm; invasion beyond the dermis; presence of perineural or lymphovascular invasion or deep margin &amp;lt; 1 mm. In adopting these criteria, 739 appointments in 156 patients would be required over 2 years (4 monthly during the first year and 6 monthly during the second year). Twenty of the patients who developed a complication would be followed-up (sensitivity 76.9%, specificity 69.4%). Using the BAD guidelines, up to four more patients with complications would have been followed-up (sensitivity 92.3%, specificity 44.7%), but this would have required a total of 1556 follow-up visits in 242 patients. Given the limited resources, patient burden and the fact that local recurrence is most often the first complication, it may be reasonable to offer routine follow-up only to patients who have at least one of the proposed criteria. Coupled with patient education, this strategy could greatly reduce the number of follow-up visits required. Such a strategy may allow resources to be utilized to reduce waiting times, particularly for 2-week wait referrals, decreasing the delay in new skin cancer diagnoses.

DS08 (P26) Risk factors for complications in cutaneous squamous cell carcinoma and proposal of a simplified follow-up strategy: making use of available healthcare resources

Abstract Cutaneous squamous cell carcinoma (cSCC) is a common malignancy, generally cured by surgical excision. A minority of such tumours recur, metastasize or even cause death. The 2021 British Association of Dermatologists (BAD) guidelines outline high-risk features that are used to guide the follow-up of patients after a primary cSCC. The aims of this study were to identify histological features of cSCC that are significantly associated with the development of complications and to compare the sensitivity, specificity and number of appointments required to follow-up patients using different follow-up criteria. In total, 556 cases of primary invasive cSCCs excised between January 2014 and March 2018 were included and followed-up for a minimum of 4 years. Five per cent (n = 26) of tumours were associated with at least one cSCC-related complication, namely, local recurrence 3.8% (n = 21), nodal metastasis 1.6% (n = 9), distant metastasis 0.4% (n = 2) and disease-specific death 0.7% (n = 4). The initial diagnosed complication was local recurrence in 20 of 26 cases. Only two patients had the first complication beyond 2 years of the original cSCC. Factors that were statistically significantly associated with the development of a complication (P &amp;lt; 0.001) were larger diameter, larger depth of invasion, tumour invasion beyond the dermis, perineural invasion (irrespective of size), lymphovascular invasion, gross bone erosion and deep margin &amp;lt; 1 mm. Differentiation and peripheral margin were not significantly associated with complications. Therefore, it may be proposed that patients with tumours with at least one of the following risk factors be followed-up: diameter &amp;gt; 40 mm, depth of invasion &amp;gt; 6 mm, invasion beyond the dermis, presence of perineural or lymphovascular invasion or deep margin &amp;lt; 1 mm. In adopting these criteria, 739 appointments in 156 patients would be required over 2 years (4-monthly during the first year and 6-monthly during the second year). Twenty of the patients who developed a complication would be followed-up (sensitivity 76.9%, specificity 69.4%). Using the BAD guidelines, up to four more patients with complications would have been followed-up (sensitivity 92.3%, specificity 44.7%), but this would have required a total of 1556 follow-up visits in 242 patients. Given the limited resources, patient burden and the fact that local recurrence is most often the first complication, it may be reasonable to offer routine follow-up only to patients who have at least one of the proposed criteria. Coupled with patient education, this strategy could greatly reduce the number of follow-up visits required. Such a strategy may allow resources to be utilized to reduce waiting times, particularly for 2-week wait referrals, decreasing the delay in new skin cancer diagnoses.

P15 Progressive papulonodular eruption following COVID-19 infection: a rare diagnosis and review of the literature

Abstract We report a rare case of primary cutaneous CD8+ aggressive epidermotrophic cytotoxic T-cell lymphoma with striking clinical and histopathological features. A 51-year-old man, originally from Cameroon, presented to the department with a 6-week history of a progressive, itchy papulosquamous eruption that started on the lower abdomen shortly following infection with COVID-19. It became widespread over a short number of weeks, with blistering and ulceration in some areas. The patient reported fatigue with an intermittent low-grade pyrexia, but no systemic symptoms otherwise, and he was previously fit and well. Physical examination revealed an extensive, infiltrated papulonodular eruption with thick scale that was more marked in the skinfolds and involving the acral surfaces. Histology from three morphologically different sites showed marked epidermal hyperplasia and a prominent epidermotrophic infiltrate of medium-sized atypical lymphoid cells. There were frequent mitotic figures and evidence of apoptosis. Immunohistochemistry revealed that the atypical lymphoid cells in the epidermis were T cells expressing CD3, CD7 and CD8, together with cytotoxic markers and a high Ki67 proliferation fraction. These features were consistent with a diagnosis of CD8+ aggressive epidermotrophic cytotoxic T-cell lymphoma. Initial bloods and imaging were fairly unremarkable. Since the diagnosis, the patient has been treated with multiple types and courses of chemotherapy, with relapses in between. Most recently, the patient has been referred for total skin electron beam therapy with investigations for allogenic stem cell transplant ongoing. Owing to its rarity, primary cutaneous CD8+ aggressive epidermotrophic cytotoxic T-cell lymphoma is categorized only as a provisional entity in the most recent World Health Organization classification (Gilson D, Whittaker SJ, Child FJ et al. British Association of Dermatologists and U.K. Cutaneous Lymphoma Group Guidelines for the management of primary cutaneous lymphomas 2018. Br J Dermatol 2018; 180:496–526). Despite a variable and polymorphic presentation, the histology is distinctive in showing monomorphous, medium-sized atypical lymphocytes in the epidermis. We discuss the epidemiology of the disease and the paucity of therapeutic guidelines. In addition, our patient’s disease developed soon after COVID-19 infection; hence, we review the growing literature on the association between COVID-19 infection and vaccination and diagnosis, and relapse and remission of cutaneous T-cell lymphoma.

DS05 Future guidelines should consider time needed to treat in clinics

Abstract The British Association of Dermatologists (BAD) published comprehensive guidelines on the management of cutaneous squamous cell carcinomas (cSCC) in 2021, outlining 46 recommendations over 32 pages. These recommendations include a full skin check or total body skin exam (TBSE) for the detection of new malignancies in this at-risk group. We present our experience in implementing this new guidance and the importance of considering the estimated clinician time needed to improve the outcome for one person in the target population (i.e. TNTNNT) when formulating new guidelines (Johansson M, Guyatt G, Montori V. Guidelines should consider clinicians’ time needed to treat. BMJ 2023; 380:e072953). A prospective audit of a skin cancer clinic found that the average consultation time for a patient with a newly diagnosed cSCC was 31 min (range 22–60 min). Follow-up appointments are routinely scheduled at 15 min; therefore, on average, a further 16 min is required to implement the new guidelines for each patient correctly. Recent evidence shows that one new SCC can be diagnosed per 57 TBSEs performed (Harding T, Seyffert J, Maner B et al. Exploring the clinical efficacy of the TBSE. J Clin Oncol 2020. DOI: 10.1200/JCO.2020.38.15_suppl.10078). Therefore, the approximate TNTNNT is 912 min (16 min × 57) or 15.2 h of clinical examination to detect one extra cSCC. This equates to nearly four consultant clinics (one clinic represents 4 h of activity) to detect an additional SCC in a patient group that is already attending for frequent review. There is a paucity of evidence to support the hypothesis that screening and removal of these lesions leads to reduced morbidity and mortality as compared with routine presentation and subsequent management. This lack of evidence is reflected in the US Preventive Services Task Force guidance on TBSE for skin cancer screening, where they provide ‘no recommendation’. Implementing the BAD guidelines has an effect on clinic times and generates an increased surgical caseload. We recommend that future guideline committees should indicate how much extra time in clinic would be required per patient to implement their advice adequately. The TNTNNT is one method to consider the clinical impact of such guidance.