Dermatology Referrals Research Articles

Parent experiences during delivery, postpartum, and adoption of children with congenital melanocytic nevi.

Congenital melanocytic nevi (CMN) are often unexpected discoveries at time of childbirth or adoption. Understanding how parents/guardians cope with these visible birthmarks can help clinicians better care for children and their families. Using qualitative methods, we sought to categorize early family responses to CMN and identify approaches to better engage with parents early in their child's life. Semi-structured interviews were conducted within a broader study on shared decision making for families with children with CMN. Discussions included information on birth and early life experiences. Data was dual-coded, inductively and deductively, and analyzed with the Parker and Endler framework exploring emotion-, task-, and avoidance-oriented coping. Fifteen parents of 13 children were interviewed. Parents described all three categories of coping. Emotions ranged from guilt, to neutrality, to positive responses seeing their child's CMN. Stress was lower in families with prior knowledge of CMN. Dermatology referral provided an opportunity for learning, but also triggered worry for some families. Parents process and react to the diagnosis of CMN with a range of emotions and coping styles. Dermatologists can utilize open-ended questions to understand family emotions and provide families with tailored knowledge and resources. Early discussion of the diagnosis and family education are important support tools.

Topical immunotherapy with diphenylcyclopropenone in paediatric patients with alopecia areata-A retrospective study of 97 patients.

Alopecia areata (AA) is an autoimmune disease causing chronic non-scarring hair loss. Different therapeutic regimens have been suggested for AA, which depend on patients' age, scalp involvement extent and duration. Topical immunotherapy with diphenylcyclopropenone (DPCP) is one of the treatment options for these patients. We aimed to investigate the response to DPCP in paediatric AA patients. This retrospective study included 97 paediatric AA patients followed in the DPCP clinic from March 2016 to March 2021 at a referral dermatology hospital. In a cohort of 97 paediatric patients with AA under treatment with DPCP, with a mean age of 11.10±0.9, 53.6% of the patients were male. Patchy alopecia was the most prevalent type (45.4%). After 6months of DPCP treatment, 51.5% showed no response, while 3.1% achieved complete response. At the 12-month evaluation, among the 68 patients who continued treatment, complete response was observed in 8.8%. A significant positive correlation was found between alopecia type, specifically patchy, and treatment response (p=0.031). Additionally, treatment duration emerged as a significant predictor of positive response at both six (OR 1.450, p=0.026) and 12months (OR 1.310, p=0.043). A higher initial Severity of Alopecia Tool score was inversely correlated with treatment response (Spearman's rho -0.14, p=0.002), indicating that initial disease severity may predict treatment efficacy. One year after the onset of DPCP in paediatric AA patients, the complete response and any hair regrowth rates were 8.8% and 61.8%, respectively. The milder initial disease severity and longer duration of treatment resulted in a better response.

Prevalence of dermatoses in geriatric singaporeans in the community - a cross-sectional study

BackgroundLittle is known about the prevalence of dermatoses in “skin-well” geriatric Singaporeans. We aim to identify the prevalence of dermatoses and their associations within the geriatric population in Singapore, and to understand the distribution of dermatological encounters presenting to primary care physicians, and the resultant referral behaviour.MethodsA joint quantitative-qualitative study was performed across 8 months. Patients aged 65 years and above who visited a local polyclinic for management of non-dermatological chronic diseases were recruited. They were administered questionnaires, and underwent full skin examinations. Online surveys were disseminated to polyclinic physicians under the same healthcare cluster.Results201 patients and 53 physicians were recruited. The most common dermatoses identified in patients were benign tumours and cysts (97.5%), and asteatosis (81.6%). For every 1-year increase in age, the odds of having asteatosis increased by 13.5% (95% CI 3.4–24.7%, p = 0.008), and urticarial disorders by 14.6% (95% CI 0.3–30.9%, p = 0.045). Patients who used any form of topical preparations on a daily basis had higher odds of having eczema and inflammatory dermatoses (OR 2.51, 95% CI 1.38 to 4.56, p = 0.003). Physicians reported dermatological conditions involving 20% of all clinical encounters. Eczema represented the most commonly reported dermatosis within the first visit. 50% of dermatology referrals were done solely at the patient’s own request.ConclusionThe prevalence of dermatoses in the elderly in Singapore is high, especially asteatosis. Prompt recognition by the primary healthcare provider potentially prevents future morbidity. Outreach education for both primary care physicians and the general public will be key.Ethics approvalNational Healthcare group (NHG) Domain Specific Review Board (DSRB), Singapore, under Trial Registration Number 2020/00239, dated 11 August 2020.

Identifying Patients At Risk for Melanoma in an Aesthetic Practice.

In the United States, melanoma skin cancer deaths are expected to rise by 4.4% in 2023, reaching 7990. Early detection through visual screening can save lives, but the US Preventive Services Task Force cites insufficient evidence to recommend universal skin screening for all adults. For this reason, the risk for melanoma may be overlooked outside of dermatology settings, leading to delayed diagnoses and poor survival rates. Our project aimed to address this issue by increasing the identification of at-risk individuals visiting a medical aesthetic practice in the Midwest. The literature regarding melanoma risk stratification outside of dermatology settings is deficient. A search yielding 336 articles produced 8 articles for review. Five suggested melanoma risk screenings in general practice are feasible and/or can lead to early detection. Using the Plan-Do-Study-Act model, we executed our project from February through April 2023. Patients visiting the medical aesthetic practice completed a Self-Assessment Melanoma Risk Score questionnaire. We assessed the completed questionnaires and offered visual cancer screenings or dermatology referrals to patients identified as at-risk. A total of 211 patients participated, and 26% (n =55) were identified as at-risk. This intervention improved the quality of care by identifying patients at risk for melanoma. Future steps include adapting the Self-Assessment of Melanoma Risk Score questionnaire to a new electronic medical record system, incorporating the questionnaire as part of the initial intake and annual patient documentation, and improving patient education and follow-up.

Do patients who read visit notes on the patient portal have a higher rate of "loop closure" on diagnostic tests and referrals in primary care? A retrospective cohort study.

The 2021 US Cures Act may engage patients to help reduce diagnostic errors/delays. We examined the relationship between patient portal registration with/without note reading and test/referral completion in primary care. Retrospective cohort study of patients with visits from January 1, 2018 to December 31, 2021, and order for (1) colonoscopy, (2) dermatology referral for concerning lesions, or (3) cardiac stress test at 2 academic primary care clinics. We examined differences in timely completion ("loop closure") of tests/referrals for (1) patients who used the portal and read ≥1 note (Portal + Notes); (2) those with a portal account but who did not read notes (Portal Account Only); and (3) those who did not register for the portal (No Portal). We estimated the predictive probability of loop closure in each group after adjusting for socio-demographic and clinical factors using multivariable logistic regression. Among 12849 tests/referrals, loop closure was more common among Portal+Note-readers compared to their counterparts for all tests/referrals (54.2% No Portal, 57.4% Portal Account Only, 61.6% Portal+Notes, P < .001). In adjusted analysis, compared to the No Portal group, the odds of loop closure were significantly higher for Portal Account Only (OR 1.2; 95% CI, 1.1-1.4), and Portal+Notes (OR 1.4; 95% CI, 1.3-1.6) groups. Beyond portal registration, note reading was independently associated with loop closure (P = .002). Compared to no portal registration, the odds of loop closure were 20% higher in tests/referrals for patients with a portal account, and 40% higher in tests/referrals for note readers, after controlling for sociodemographic and clinical factors. However, important safety gaps from unclosed loops remain, requiring additional engagement strategies.

Needs and challenges among general practitioners in the management of actinic keratosis: a qualitative study

BackgroundBecause of the increasing incidence of actinic keratosis (AK), optimal use of limited healthcare resources is essential. Although most patients can be managed in primary care, dermatology referrals are common. More profound knowledge of general practitioners’ (GPs) considerations might assist in enhancing AK care.MethodsThe aim of the current study was to gain insight into AK management in primary care by exploring the needs and challenges among GPs in the Netherlands. A qualitative study was conducted based on semi-structured in-depth interviews with 15 conveniently sampled Dutch GPs, focusing on the needs and challenges in AK management. A literature-informed, predefined topic list guided the interviews, which were recorded, transcribed ad verbatim, and thematically analysed using the Framework Method.ResultsAll GPs reported AK to be a clinical diagnosis and most GPs indicated that most AK patients could be managed in primary care. Cryotherapy was preferred and experience with 5-FU therapy was limited. Most GPs applied cryotherapy without discussing other treatment options with patients. Reasons for dermatology referrals included an incomplete treatment response, extensive lesions, difficult-to-treat areas, and serious doubts about the diagnosis. GPs reported a need for more education, especially on 5-FU therapy. Their main challenges were dealing with diagnostic uncertainty, treating extensive lesions, managing treatment-related skin reactions, and reconciling patient misconceptions.ConclusionsThis study shows various AK management approaches among Dutch GPs with suboptimal guideline compliance due to diverse underlying barriers. It suggests that more education might contribute to a more standardised and uniform AK management and supports further transition of AK care from hospital to primary care.

Completion of Recommended Tests and Referrals in Telehealth vs In-Person Visits

Use of telehealth has increased substantially in recent years. However, little is known about whether the likelihood of completing recommended tests and specialty referrals-termed diagnostic loop closure-is associated with visit modality. To examine the prevalence of diagnostic loop closure for tests and referrals ordered at telehealth visits vs in-person visits and identify associated factors. In a retrospective cohort study, all patient visits from March 1, 2020, to December 31, 2021, at 1 large urban hospital-based primary care practice and 1 affiliated community health center in Boston, Massachusetts, were evaluated. Prevalence of diagnostic loop closure for (1) colonoscopy referrals (screening and diagnostic), (2) dermatology referrals for suspicious skin lesions, and (3) cardiac stress tests. The study included test and referral orders for 4133 patients (mean [SD] age, 59.3 [11.7] years; 2163 [52.3%] women; 203 [4.9%] Asian, 1146 [27.7%] Black, 2362 [57.1%] White, and 422 [10.2%] unknown or other race). A total of 1151 of the 4133 orders (27.8%) were placed during a telehealth visit. Of the telehealth orders, 42.6% were completed within the designated time frame vs 58.4% of those ordered during in-person visits and 57.4% of those ordered without a visit. In an adjusted analysis, patients with telehealth visits were less likely to close the loop for all test types compared with those with in-person visits (odds ratio, 0.55; 95% CI, 0.47-0.64). The findings of this study suggest that rates of loop closure were low for all test types across all visit modalities but worse for telehealth. Failure to close diagnostic loops presents a patient safety challenge in primary care that may be of particular concern during telehealth encounters.

Predictor Variables Associated With Dermatology Referral Completion and the Impact on Surgical Treatment: A Retrospective Cohort Study.

Delays or failure to complete a dermatologic referral may affect health care outcomes. Factors associated with these delays remain understudied. This study investigated socioeconomic and demographic factors associated with delays or failure to complete dermatology referrals and potential impact on surgical outcomes. A retrospective chart review was performed for 400 patients internally referred to an academic dermatology center from 19 primary-care clinics from July 2018 to June 2019. Only patients referred after an in-person primary-care visit in which the provider documented a specific concerning lesion were included. Multivariate analyses were performed to explore variables associated with delays or failure to complete dermatology referrals. Patients were more likely to complete their referral if they had a personal history (adjusted odds ratio [aOR] = 7.843, 95% CI 1.383-14.304) or family history (aOR = 11.307, 95% CI 2.344-20.27) of skin cancer. Patients were more likely to delay referral completion past 30 days if they were ages 18 to 34 (aOR = 6.665, 95% CI 1.285-12.044) and less likely to delay referral past 30 days if they had a previous history of skin cancer (aOR = 0.531, 95% CI 0.181-0.882). Single institution, retrospective study, limited surgical patients. Understanding factors associated with delays in dermatology referral completion can help identify at-risk patient populations.

Iranian psoriasis registry: Research protocol and preliminary results of a pilot study.

Psoriasis as a common cutaneous inflammatory disease affect many aspects of patients' life. Disease registries render it possible to collect valuable data regarding a disease prevalence and burden as well as long-term observations concerning possible therapeutic regimens. This registry was designed for the ongoing systematic data collection on patients with psoriasis at two referral dermatology centers in Iran. The pilot phase of the registry was used to identify possible obstacles in the application and execution of systematic registration. A total of 281 patients were registered with the mean age of 42.02 years. The disease duration was 12.06 ± 10.90 years with the variety of clinical presentations. There was no significant difference between males and females in the age of disease onset (p = 0.53). Notably, 167 patients had children. Among them, 13 had children with psoriasis. The gender of the affected parent did not affect the possibility of psoriasis transmission to the child, and no significant difference was seen between the two sexes (P = 0.569). Regarding treatment, 99.4% of patients (n = 280) had used topical agents, 52.3% (n = 147) biologics, and 60.9% (n = 171) nonbiologic medications. Clinical trials report the efficacy and safety data regarding limited study populations in a restricted time window, and the results may differ from the general population. This highlights the importance of registry-based studies for collecting and analyzing longitudinal information. In terms of long-term disease complications such as malignancies, cardiovascular events, and serious adverse events, registry-based studies will help clinicians better recognize and manage each disease.

Implementation evaluation of a teledermatology virtual clinic at an academic medical center

BackgroundTeledermatology (TD) is an evidence-based practice that may increase access to dermatologic care. We sought to use the Exploration, Preparation, Implementation, and Sustainment (EPIS) and the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) frameworks to evaluate implementation of TD at Duke.MethodsThe EPIS and RE-AIM frameworks were deployed to design and implement a TD program that leveraged the strengths of the Duke University Health System and addressed previously reported barriers to implementation of store-and-forward and synchronous TD models. In the resultant hybrid TD model, trained primary care providers (PCPs) sent e-comm referrals with clinical and dermatoscopic images to dermatology. These e-consults were reviewed asynchronously and patients were scheduled for a synchronous video visit with dermatology within days. Dermatologists managed the patient plan. This hybrid TD model was piloted at four primary care clinics. Pertinent outcomes from a TD-adapted RE-AIM framework were tracked using electronic health record data. Patient satisfaction was assessed using a post-video visit survey (n = 18). Implementation barriers and facilitators were also collected through provider surveys (n = 24 PCPs, n = 10 dermatologists, n = 10 dermatology residents).ResultsAt four PCP clinics throughout 9/1/2021–4/30/2022, there were 218 TD referrals. Video visits occurred on average 7.5 ± 0.5 days after referral and 18/18 patients completing the post-visit survey were satisfied. Adoption varied between clinics, with one placing 22% of all dermatology referrals as TD and another placing 2%. The primary PCP barriers to TD were time burdens, lack of fit in clinic flow, and discomfort with image taking. Top-endorsed potential facilitating interventions included allowing for rash referrals without dermoscopy and assurance for clinical evaluation within 3 days.ConclusionsThe use of implementation science frameworks allowed for identification of system and contextual strengths which informed the hybrid TD pilot. Barriers and facilitating interventions will provide guidance for expansion and ongoing maintenance of TD.

Low Rate of Completion of Recommended Tests and Referrals in an Academic Primary Care Practice with Resident Trainees

A frequent, preventable cause of diagnostic errors involves failure to follow up on diagnostic tests, referrals, and symptoms-termed "failure to close the diagnostic loop." This is particularly challenging in a resident practice where one third of physicians graduate annually, and rates of patient loss due to these transitions may lead to more opportunities for failure to close diagnostic loops. The aim of this study was to determine the prevalence of failure of loop closure in a resident primary care clinic compared to rates in the faculty practice and identify factors contributing to failure. This retrospective cohort study included all patient visits from January 1, 2018, to December 31, 2021, at two academic medical center-based primary care practices where residents and faculty practice in the same setting. The primary outcome was prevalence of failure to close the loop for (1) dermatology referrals, (2) colonoscopy, and (3) cardiac stress testing. The primary predictor was resident vs. faculty status of the ordering provider. The authors present an unadjusted analysis and the results of a multivariable logistic regression analysis incorporating all patient factors to determine their association with loop closure. Of 12,282 orders for referrals and tests for the three studied areas, 1,929 (15.7%) were ordered by a resident physician. Of resident orders for all three tests, 52.9% were completed within the designated time vs. 58.4% for orders placed by attending physicians (p < 0.01). In an unadjusted analysis by test type, a similar trend was seen for colonoscopy (51.4% completion rate for residents vs. 57.5% for attending physicians, p < 0.01) and for cardiac stress testing (55.7% completion rate for residents vs. 61.2% for attending physicians), though a difference was not seen for dermatology referrals (64.2% completion rate for residents vs. 63.7% for attending physicians). In an adjusted analysis, patients with resident orders were less likely than attendings to close the loop for all test types combined (odds ratio 0.88, 95% confidence interval 0.79-0.98), with low rates of test completion for both physician groups. Loop closure for three diagnostic interventions was low for patients in both faculty and resident primary care clinics, with lower loop closure rates in resident clinics. Failure to close diagnostic loops presents a safety challenge in primary care and is of particular concern for training programs.

Neuropsychiatric disorders in adults with atopic dermatitis: Apopulation-based cohort study.

Atopic dermatitis (AD) may be associated with an increased burden of neuropsychiatric outcomes such as anxiety and depression, but longitudinal data on the impact of AD severity is lacking, and a comprehensive assessment of neuropsychiatric disease in adults with AD is needed. Determine risk of incident neuropsychiatric disease among adults with AD by severity. A cohort study using electronic health records data from UK general practices from 1994 to 2015. Adults (≥18 years) with AD were matched on age, practice and index date to patients without AD. AD severity was categorized using treatments and dermatology referrals. Outcomes were incident anxiety, depression, bipolar disorder, schizophrenia, attention-deficit/hyperactivity disorder (ADHD), autism, obsessive-compulsive disorder (OCD), suicidality and completed suicide. Comparing 625,083 adults with AD to 2,678,888 adults without AD, AD was associated with higher risk of anxiety [HR 1.14 (1.13-1.15)], depression [1.14 (1.13-1.15)] and OCD [1.48 (1.38-1.58)] across all severities. Mild or moderate AD was also associated with higher risk of autism, ADHD, bipolar disorder and suicidality. Atopic dermatitis is associated with a higher risk of multiple neuropsychiatric conditions, but these risks differ by specific condition and AD severity. Clinicians should inquire about mental health in patients with AD.

Dermatological concerns for women and girls with turner syndrome.

Turner syndrome (TS) is associated with distinct manifestations in women and girls including short stature, cardiac abnormalities, premature ovarian failure as well as dermatological features, including lymphedema, keloids, onychodystrophy, and acne. Although many dermatological concerns present during the first few decades of life, the overwhelming majority of respondents are not provided with dermatology referrals at diagnosis. This cross-sectional study utilized an author designed survey to assess self-reported dermatological manifestations, dermatology referral experience, common therapies for select dermatological conditions, as well as a validated 10-question Dermatology Life Quality Index (DLQI) to assess quality-of-life impact in women and girls with Turner syndrome. In our cohort, 64% (n = 149) had been referred to a dermatologist at some point in their life time. The majority of individuals self-identified their dermatological concern (79.6%) and were referred after a dermatological concern had already occurred (90.2%). The most common dermatological findings reported were xerosis cutis (78.7%), lymphedema (73%), and more than 20 acquired melanocytic nevi (70%). The overall mean DLQI score was 3.52, indicative of a small effect on the patient's life. Onychodystrophy, history of skin biopsy, and lymphedema were statistically significant to have a higher impact on quality of life. Our data reveal that skin conditions are highly prevalent in the TS population during the early decades of life and affirm utilizing these conditions in the TS diagnostic process, as well as emphasize the need for specialized dermatology referrals to address the detrimental impacts related to skin concerns on quality of life.

Surgical Excision Margins in Primary Care and Plastic Surgery for Keratinocytic Cancers Diagnosed via Teledermatology: Retrospective Observational Cross-Sectional Study

Background The incidence of keratinocytic cancers is increasing. In New Zealand, surgical treatment of skin cancers is often undertaken in primary care. In the Waikato district, general practitioners (GPs) are encouraged to confirm diagnoses via teledermatology. Histological examination should confirm clear surgical margins to reduce tumor recurrence. International guidelines recommend a lateral margin of ≥3 mm for basal cell carcinomas (BCCs) and ≥4 mm for squamous cell carcinomas (SCCs). Objective This study aimed to determine lateral and deep margins in keratinocytic cancer excisions performed by GPs (in a private setting) and plastic surgeons (in a private or public setting) after a teledermatologist had confirmed that excision was necessary. Demographic, clinical, and histological features were recorded. Methods A retrospective observational cross-sectional study was conducted. The sample in the electronic dermatology referral database included keratinocyte cancers recommended for excision from March to May 2022. Results Histological reports revealed that excision was complete in 186 of 201 confirmed cases of keratinocyte cancer. The lateral margins of resection were considered in 10 tumors and deep margins in 8 tumors. All incomplete excisions were carried out by GPs, 11 of which were on the head and neck. There were 133 BCCs, 100 of which were excised by a GP, 3 by a private plastic surgeon, and 30 by a public hospital surgeon. In total, 52 BCCs were present on the head and neck (25 excised by GPs, 25 by hospital plastic surgeons, and 2 by private plastic surgeons) and 81 were present on other sites (75 excised by GPs, 5 by hospital plastic surgeons, and 1 by a private plastic surgeon). Lateral margins were considered in 9 cases (of which 5 cases involved head and neck tumors). The minimum distance from the tumor to the lateral margin was &lt;3 mm in 80 tumors: 64 were excised by a GP, 2 by private plastic surgeons, and 14 by hospital plastic surgeons. This distance was ≥3 mm in 44 tumors (27 excised by GPs, 1 by a private plastic surgeon, and 16 by hospital plastic surgeons). These data show significant adherence to surgical margin recommendations among plastic surgeons compared to that among GPs (odds ratio 2.873, CI 1.274-6.477; P=.009). There were 68 SCCs: 57 were excised by a GP, 2 by a private plastic surgeon, and 9 by a public hospital surgeon. In total, 21 SCCs were on the head and neck (14 excised by GPs, 6 by hospital plastic surgeons, and 1 by a private plastic surgeon) and 47 were on other sites (43 excised by GPs, 3 by hospital plastic surgeons, and 1 by a private plastic surgeon). Lateral margins were considered in 1 head and neck SCC case and were not reported in others. The minimum distance from the tumor to the lateral margin was &lt;4 mm in 35 cases: 31 were excised by a GP, 1 by a private plastic surgeon, and 3 by a hospital plastic surgeon. This distance was ≥4 mm in 31 cases (24 excised by GPs, 1 by a private plastic surgeon, and 6 by hospital plastic surgeons). These data do not show significant difference in adherence to surgical margin recommendations between GPs and plastic surgeons (P&gt;.05). Conclusions Complete resection reduces the risk of recurrence of keratinocytic tumors. GPs in our study were less likely than specialist surgeons to respect surgical margin recommendations established in international guidelines for managing keratinocytic cancer. Conflicts of Interest None declared.

BT16 A service evaluation of dermatology Clinical Assessments, Services, Education and Support which aims to reduce referrals from primary to secondary care through peer review and education

Abstract Clinical Assessments, Services, Education and Support (CASES) is a collaboration between primary and secondary care to aid management of routine referrals via the National Health Service e-Referral Service (eRS) by providing clinical support and education to primary care through peer review, advice and guidance from local general practitioners (GPs) since 2016. The service covers 10 specialities. The CASES is optional, and primary care can choose to bypass the service, referring directly to secondary care. Three GP peer reviewers work under the supervision of dermatology consultants. They review elective referrals from primary healthcare professionals (GPs, advanced clinical practitioners and physician associates) via the eRS. Referrals are either sent back to the referrer with advice and educational resources or sent on to secondary care, often with interim advice. Monthly mentoring meetings enable the assessors to discuss difficult cases. Data were recorded for dermatology referrals from January 2022 to December 2022. Within the 12-month period, 3940 referrals were processed via CASES (mean 328 referrals a month). Of the referrals received, 90.0% (n = 3545) were routinely referred on to secondary care and 1.4% (n = 55) required a 2-week wait. However, 6.9% (n = 273) were returned to the referrer with advice and guidance. Further information was requested for 1.1% (n = 44) of the referrals that had been returned to the referrer. Twenty-three (0.6%) had been referred to the wrong specialty. Lesions (n = 1835; 46.6%) made up the bulk of the referrals, alongside rashes referred for diagnosis (n = 573; 14.5%). Chronic disease management (acne, eczema, psoriasis, contact dermatitis, etc.) made up 36.1%. Overall, the results suggest that 6.9% (n = 273) of referrals were managed in primary care. Almost half of the referrals were related to lesions. We have not yet been able to establish the proportion of cases where referrals were returned with advice and guidance and were then later referred to secondary care for the same issue, which is currently a limitation. Secondary care dermatology is overwhelmed with the current workload and waiting times. Peer review services like CASES, using a digital platform like the eRS, have the potential to be extremely beneficial to help manage the workload. However, the sharing of information between primary and secondary care needs to be improved in our service, and we would aim to make images mandatory to enable triage, although our beleaguered primary care colleagues currently feel that this is not possible.

BI14 Photoprotection and skin cancer awareness in kidney transplant recipients living with HIV: a single-centre cross-sectional study

Abstract Kidney transplant recipients (KTRs) are up to 65 times more likely to develop nonmelanoma skin cancers than age-matched general populations. HIV has also been associated with increased skin cancer rates. However, to date, there has been no study evaluating photoprotection and skin cancer awareness in KTRs living with HIV (KTRLHIV). Using validated photoprotection and skin cancer awareness questionnaires, we evaluated knowledge and practices in KTRLHIV and an HIV-negative KTR cohort, matched for age, sex, ethnicity and years since transplant. KTRLHIV (n = 27) and matched HIV-negative KTRs (n = 25) completed the questionnaires. Thirty-four (65%) were male and 37 (71%) were Black. The average age was 56 years (range 43–74). On average, patients were 7.3 years post-transplant (range 0.7–24). Twenty-two (81%) KTRLHIV vs. 15 (60%) matched HIV-negative KTRs had not seen a dermatologist in the last year. Only 14 (52%) KTRLHIV had received sun protection advice vs. 20 (80%) of the matched KTRs (P = 0.033). There were statistically significant lower rates of overall sunscreen use in KTRLHIV compared with matched HIV-negative KTRs (33% vs. 60%; P = 0.054). Only a small proportion used sunscreen daily (22% vs. 27%), of a sun protection factor &amp;gt; 25 (78% vs. 100%). A strongly positive tetrachoric correlation coefficient of 0.77 indicated that providing photoprotection advice correlates to sunscreen use. Significantly lower rates of photoprotection behaviours were seen in the KTRLHIV compared with HIV-negative KTRs, particularly never avoiding direct sunlight (59% vs. 16%; P = 0.001) and never dressing to protect from the sun (52% vs. 12%; P = 0.002). We have identified statistically significant lower knowledge of photoprotection and skin cancer awareness in KTRLHIV vs. matched HIV-negative KTRs. Lower rates of skin cancer protection advice may have resulted in lower rates of sunscreen use and poorer photoprotection behaviours in KTRLHIV. A dedicated skin cancer awareness education to promote patient-led skin cancer prevention alongside formal dermatology referral is recommended.

DE04 Large-scale virtual dermatology teaching for internal medical trainees across the UK

Abstract Dermatology is often overlooked within the internal medical training (IMT) programme. Although dermatology represents only 0.8% of inpatient admissions, over 54% of the UK population experience a skin condition in any 12-month period. IMT trainees self-report a lack of knowledge and confidence in dealing with patients presenting either primarily or with coexistent dermatological conditions. This is likely to stem from a lack of undergraduate dermatology exposure, reported to be, on average, only 6 days. This leads to missed opportunities to improve patient care and unnecessary referrals to dermatology. The COVID-19 pandemic brought about a shift toward virtual teaching, albeit of varying quality. The Medical Trainee Network (MTN) designed virtual dermatology teaching sessions to deliver national teaching on common and acute emergency dermatoses. We aimed to assess the effectiveness of a virtual platform as a means of delivering dermatology teaching and establish whether this is comparable with traditional face-to-face teaching. We developed a standardized protocol with sessions delivered live by specialty registrars, case-centred with a focus on interactivity, using live-polled multiple-choice questions and question-and-answer sessions. The sessions are recorded and available to view afterward. Feedback is collected via anonymous online surveys (consented). A preliminary questionnaire conducted with 369 trainees revealed that only 43% felt digital teaching would be as effective as face-to-face teaching. The sessions ran twice, 1 year apart, with 184 and 315 attendees, respectively. Feedback showed, on average, that 99.5% would recommend this teaching to others, 88% reported that digital teaching was as effective as face-to-face teaching, and 88% felt able to ask questions. Feedback was positive, highlighting the interactivity and engagingness of the teaching. Specific comments included ‘interactive with Slido and case-based discussions’, ‘great focused sessions with clear explanations…in a topic that is not frequently covered’ and ‘super talk, very engaging, knowledgeable speaker’. A national survey of the MTN teaching revealed trainees preferred digital teaching and found it more engaging than face-to-face teaching, but the loss of social engagement was criticized. We have demonstrated that by using a standardized protocol with a focus on interactivity to maintain engagement, successful high-quality dermatology teaching can be provided using a digital platform. Although we acknowledge that this was undertaken during the pandemic and the feedback is subjective, virtual teaching can reach large audiences, reduce the spread of communicable disease and save travel costs, fossil fuel emissions and clinician time. This teaching has the potential to be applied to dermatology trainees, general practitioners and foundation trainees with the aim of improving care, the understanding of dermatological diseases and the quality of dermatology referrals beyond the pandemic.

DP04 Role of multidisciplinary team meetings in management of inflammatory skin conditions

Abstract The multidisciplinary team (MDT) model has been previously demonstrated to improve early diagnosis and outcomes for psoriatic arthritis [Zheng YX, Zheng M. A multidisciplinary team for the diagnosis and management of psoriatic arthritis. Chin Med J (Engl) 2021; 134:1387–9; Luelomo J, Gratacós J, Martínez-Losa MM et al. A report of 4 years of experience of a multidisciplinary unit of psoriasis and psoriatic arthritis. Reumatol Clin 2014; 10:141–6]. However, there is little evidence for a similar role in inflammatory skin disease (ISD). A monthly psoriasis MDT has been established in our tertiary referral dermatology centre. We analysed referrals from February 2021 to February 2022. A total of 37 patient cases were discussed, 29 from within the geographical region of the centre and eight from outside the region. Reasons for referral were the presence of comorbidities; in the majority of cases, this was the presence of an internal malignancy (n = 15). Additional comorbidities were organ transplantation (n = 2), inflammatory bowel disease (n = 2), coexisting inflammatory arthritis (n = 4) and history of severe infection (n = 2). The secondary reason for referral was a history of multiple treatment failures (n = 8) and/or adverse effects of current biologics (n = 2). Where outcome data for regional patients could be assessed, the majority (n = 16) subsequently demonstrated objective improvement in their skin condition, with a mean reduction in Psoriasis Area and Severity Index score of 79.0% (n = 16) and a concurrent mean improvement of 59.6% in Dermatology Quality of Life Index (n = 11). Three patients died (unrelated to psoriasis/treatment). In summary, the presence of comorbidities and prior treatment failures are the primary reasons for referral to a tertiary referral service psoriasis MDT. Multidisciplinary team discussion results in objective improvements in patient care at early follow-up assessments. Further data on MDT outcomes for ISD are required.

Retrospective cohort study of CDK4/6-inhibitor-induced alopecia in patients with breast cancer.

e13083 Background: The synergistic effects of novel combined cyclin-dependent kinase 4 and 6 inhibitors (CDK4/6i) and endocrine therapy has increased their utilization for treatment of metastatic breast cancer. When compared to endocrine monotherapy, CDK4/6i may increase the risk of alopecia by nearly two-fold (Eiger D, et al. PMID: 32167397; Chan D, et al. J Clin Oncol.). The prevalence of this adverse effect underscores the importance of characterizing CDK4/6i-induced alopecia (CDKIA) and investigating therapeutic options. Methods: A retrospective cohort of 28 female patients with breast cancer and endocrine-induced alopecia (EIA) or CDKIA. Onset of alopecia was measured by time (months) between initiation of anticancer therapy and dermatology referral. Therapeutic response to minoxidil (LDOM or topical [5%] solution or foam) was assessed by both Dean Scale and qualitative clinical improvement by comparison of pre-treatment and post-treatment clinical images by 2 board certified academic dermatologists (ST and BD). Results: Androgenetic alopecia was the most common hair loss distribution (n=27, 96.4%), with CDKIA patients having preferential vertex involvement (n=7 [70.0%] CDKIA vs. n=4 [36.4%] EIA; p=0.04). Patients on CDK4/6i had shorter times to dermatology referral (mean time [months]: 44.6±37.1 for EIA vs. 9.4±13.7 CDKIA; p=0.003). After 16-24 weeks of minoxidil, moderate to significant improvement of alopecia occurred in 80% of CDKIA patients versus 94.4% of EIA patients. Despite similar baseline alopecia grade severity, significant improvement was only observed in EIA patients (mean pretreatment Dean Score – post-treatment Dean Score: -0.44; p=0.0002). Conclusions: Compared to EIA, the onset of CDKIA happened more rapidly and was more resistant to minoxidil. The preferential vertex involvement observed among patients with CDKIA may suggest combination therapy with topical or oral minoxidil and topical anti-androgens may lead to more favorable outcomes. Prompt dermatology referral should be considered for patients treated with CDK4/6i + ET. [Table: see text]

A Retrospective Study to Analyze the Pattern of Referrals to the Department of Dermatology, Venereology, and Leprosy at a Tertiary Care Center in Karnataka

Background: Dermatology is mainly considered as an outpatient specialty. In an institutional set up, the patients who are hospitalized in nondermatology departments may have skin diseases. The patients visiting other outpatient departments might have skin disorders. Such patients are referred to the department of dermatology and can be diagnosed and treated better in dermatology departments. Objectives: The objective was to analyze the pattern of referrals to the department of dermatology, venereology, and leprosy from other departments of the hospital. Materials and Methods: The records of the department of dermatology, venereology, and leprosy were analyzed for referrals between September 2019 and February 2020. Results: There were 214 males (46.8%) and 188 (53.2%) females in the study. The mean age of the patients in the study was 40.9 ± 20.8 years. Maximum number of referrals were received from the department of general medicine (192 cases, 47.7%), followed by general surgery (64 cases, 15.9%). Infections and infestations accounted for 183 (45.5%) cases out of the 402 referrals, and eczematous disorders were seen in 58 (14.4%) cases. The referring departments mentioned their dermatological diagnosis in 24% of the cases and were found to be correct in 18% of cases. Conclusion: The common dermatological conditions are often undiagnosed or misdiagnosed by nondermatologist, leading to incorrect treatment, and contributes to delay in treatment. By focusing on improving the training of undergraduate and postgraduate students in the conditions for which dermatology referrals are usually sought might help in improving their knowledge and later help them treat patients better.