ABSTRACT
Teledermatology is a useful tool in facilitating dermatology outpatient services since the advent of COVID-19. Assessment of lesions has become difficult to facilitate in large numbers. Teledermoscopy has been used for remote lesion assessment. However, the majority of teledermoscopy has been facilitated by healthcare professionals rather than the patient themselves (Vestergaard T, Prasad S, Schuster A et al. Introducing teledermoscopy of possible skin cancers in general practice in Southern Denmark. Fam Pract 2020;37: 513-18). Patients referred with lesions deemed to be low risk are now often initially assessed via telephone consultation in conjunction with photographs of the lesion. The majority of patients are subsequently called for dermoscopy. However, many of those referred have benign lesions and could be safely discharged if dermoscopy images of the lesion were available. Low-cost mobile dermoscopy attachments are available and have been marketed to patients for self-monitoring. We compared a smartphone-compatible dermoscopy device (Dermlite HUD) with traditional dermoscopic photography to assess the feasibility of using this device to photograph skin lesions. This device has equivalent magnification (x 10) to dermatoscopes, a smaller field of view (which in all lesions still allowed complete visualization) and employs polarized light. Dermoscopic photography using the Dermlite HUD was taken of 30 consecutive lesions over a 1-month period by dermatology registrars in the dermatology department. Lesions assessed included pigmented lesions, vascular lesions, nonulcerated skin cancers and benign lesions. Images were assessed by a consultant dermatologist and compared to dermoscopic photographs taken using the standard method employed in the department. Images were compared in terms of resolution, field of view and colour quality between the two instruments as per validated image analysis (Celebi M, Mendonca T, Marques J. Dermoscopy Image Analysis, 1st edn. Boca Raton, FL: CRC Press, 2015). The photographed lesions were assessed by a consultant dermatologist and compared with the standard method. Photos taken with the smartphone attachment were found to be 97% equivalent in terms of resolution, field of view and colour quality to those taken using the standard method and 29 of 30 were deemed suitable for remote lesion assessment. Low-cost smartphone dermatoscope attachments provide images of comparable quality to those taken with a dermatoscope and camera. This offers an opportunity to facilitate fully virtual assessment of low-risk skin lesions and is of use in patients unable to travel to clinics or during lockdowns to facilitate virtual clinics.
ABSTRACT
A 51-year-old woman presented to our service with a 2-year history of severely painful, thickened skin of her bilateral hands and feet. She advised of considerable skin pain on mobilizing. She intermittently applied acrylate nails. This was on a background of chronic urticaria, asthma and allergic rhinitis. She described a positive family history of psoriasis. On examination, there was marked hyperkeratosis with welldemarcated erythema on the central palms and entire fingers with deep fissuring and scale. Similar finding were noted on the soles of the feet particularly affecting the heels, arch and also the tips of the toes. The morphology of the lesions favoured psoriasis, but the differential diagnosis included chronic hand dermatitis. She was referred for topical psoralen + ultraviolet A (PUVA) and patch testing to standard battery and acrylates. Treatment with topical PUVA was discontinued and patch testing lists were cancelled as a result of the emergence of COVID-19 in Ireland. Topical therapy of clobetasol propionate was initiated. On follow-up review, the appearances of her feet and hands had deteriorated significantly. She was commenced on acitretin 10 mg once daily, which was escalated to 20 mg 2 months later. Clinical improvement was noted, but appearances deteriorated once again following the application of acrylic nails. Further history revealed the patient had assisted with the application of acrylic nails to clients years prior to her initial review. Patch testing took place 18 months after initial review due to outpatient list cancellations secondary to the COVID-19 pandemic. Upon review 48 h after the application of the (METH) Acrylate Series, the patient was found to have a +2 reaction to 2- hydroxyethyl methacrylate and a further +2 reaction to 2- Hydroxypropyl methacrylate. At her 96-h review, both reaction sites were marked at +1. Following complete avoidance of acrylates, the palmoplantar inflammation entirely resolved. This case highlights the importance of a detailed clinical history where contact dermatitis is considered. In our patient's case, the clinical history and examination of the palmoplantar eruption combined with the first-degree family history of psoriasis were highly suggestive of a diagnosis of psoriasis. The episodic severe flares and its refractory nature to treatment raised suspicion for allergic contact dermatitis. Dermatologists should remain alert for potential contact allergens in cases of severe palmoplantar psoriasis. A further area for consideration is the deleterious effect the COVID-19 pandemic had on the successful diagnosis and treatment of dermatological patients through the cancellation of outpatient services.
ABSTRACT
We present the case of a severe cutaneous reaction following COVID-19 vaccination. A 60-year-old white woman presented to our service with an extensive painful, pruritic rash affecting her bilateral lower limbs. This was on a background of psoriasis, psoriatic arthritis and notably inoculation against COVID-19 with the Johnson & Johnson vaccine hours prior to onset. There was no history of new medications, illicit drug use or infections. On examination, extensive palpable purpura was noted circumferentially at both lower limbs from the knee distally. Tense bullae were described at her bilateral ankles. She was apyrexial. Her cardiopulmonary and gastrointestinal examinations were normal. A punch biopsy taken from her right lower limb demonstrated findings consistent with leucocytoclastic vasculitis (LCV). Direct immunofluorescence demonstrated IgA deposits within the vasculature. IgA LCV secondary to COVID-19 vaccination was proposed on the basis of histological and clinical findings. Treatment consisted of oral steroids, oral antibiotics for secondary infection and wound dressings. Opioid analgesia and nitrous oxide were implemented for severe pain associated with dressing changes. As her urinary protein creatinine ratio was in excess of 100 mg dL-1 and microscopic haematuria was noted on urine microscopy, she was referred to nephrology. We note case reports of patients diagnosed with LCV up to 2 weeks following COVID-19 vaccination (Cavalli G, Colafrancesco, De Luca G et al. Cutaneous vasculitis following COVID- 19 vaccination. Lancet Rheumatol 2021;3: E743-4). In this case, onset of symptoms occurred within hours. While this presentation may have been coincidental, the relationship between immune complex vasculitis, COVID-19 infection (Iraji F, Galehdari H, Siadat AH, Bokaei Jazi S. Cutaneous leukocytoclastic vasculitis secondary to COVID-19 infection: a case report. Clin Case Rep 2020;9: 830-4) and vaccination (Cavalli et al.) has been reported in the literature and represents the most likely diagnosis.