Cutaneous thrombosis associated with skin necrosis following Oxford/AstraZeneca COVID-19 vaccination: a case report

A 73-year-old man presented with left shin ulceration two weeks after receiving his first dose of the Oxford-AstraZeneca vaccine. Within 24 h of vaccination, the patient became generally unwell with fever and headache. On the third day after vaccination, he developed left shin erythema and blistering, which rapidly ulcerated. This formed two superficial ulcers with a necrotic base and a violaceous edge on the lateral aspect of his left shin, measuring approximately 2 cm × 3 cm. He had a background of atrial fibrillation and ischemic cardiomyopathy, and had been on several longstanding medications including apixaban. Blood tests revealed normal clotting, full blood count, liver and renal function. The differential diagnosis included pyoderma gangrenosum, vasculitic ulceration, and a cutaneous adverse drug reaction to vaccination. A punch biopsy was obtained from the edge of an ulcer, which revealed microthrombi within blood vessels, an ischemic epidermis, and fat necrosis of subcutaneous tissue. The patient experienced slow healing of ulceration with topical clobetasol propionate 0.05%, neomycin sulphate and nystatin ointment, and compression bandaging treatment. To our knowledge, this is the first reported case of cutaneous thrombosis associated with skin necrosis following Oxford/AstraZeneca vaccination. Recently there have been concerns related to reports of thrombotic events at atypical sites (including cerebral and splanchnic vascular beds) associated with thrombocytopenia following Oxford/ AstraZeneca vaccination (Greinacher A, Thiele T, Warkentin TE et al. Thrombotic thrombocytopenia after ChAdOx1 nCov-19 vaccination. N Engl J Med 2021;384: 2092-101). These findings extend the range of atypically located thromboses associated with COVID-19 vaccination and reinforce the necessity for physicians to be vigilant for signs and symptoms related to thromboses at atypical sites in recently vaccinated patients.

A quality improvement project evaluating patient and clinician experience of video consultations in outpatient dermatology

The COVID-19 pandemic has brought about unprecedented changes to healthcare delivery. Balancing infection-control practices with the provision of safe specialist care has led to the introduction of video consultations (VCs). Consequently, NHS England has collaborated with Attend Anywhere® (AA) to offer a VC platform to National Health Service trusts. We present the first evaluation of a VC platform in dermatology, at a time when minimizing the substantial indirect impact of the pandemic on patients' lives is vitally important in improving long-term accessibility to dermatology care for vulnerable groups. We are performing a quality-improvement project to evaluate patient and clinician experience of using AA in a U.K. dermatology secondary care outpatient centre during the current pandemic (at the time of writing, June 2020). The clinician survey and final outcomes will be assessed in September 2020. Prospective online surveys for patients and clinicians were designed. The patient survey was integrated into the platform to initiate automatically at the end of each VC. Seventeen questions qualitatively and quantitatively assessed several domains, including patient satisfaction and views on potential long-term use of the platform. Similarly, 12 questions were designed to evaluate clinicians' opinions about the platform, its use for training, ease of organizing prescriptions and potential future use. Data were recorded using a 5-point scoring system (ranging from 'strongly agree' to 'strongly disagree'). Key themes from patient and clinician free-text responses were categorized according to common properties. In total, 149 patient responses have been collected over a 4-week period to date. Patients included were of all ages: < 18 years (27%), 18-30 years (26%), 31-69 years (31%) and > 70 years (14%). Fifty-five per cent of consultations were first attendances (45% follow-ups), 31% for a lesional skin problem and 33% for systemic treatment monitoring. The main findings were that 91% had a 'very good' or 'good' overall experience of AA, with 90% feeling that they were able to communicate everything they wanted and 87% feeling comfortable being examined over a VC. Eighty-seven per cent would choose VC over telephone consultation during the current pandemic. Sixty per cent would choose VC over face-toface consultation after the pandemic. A common theme from free-text responses was that subgroups of patients who would find hospital attendances difficult had greater satisfaction with AA, including patients with physical or cognitive impairment, on long-term systemic/biological medication and who are carers for family members. We demonstrate that AA is a patientfriendly platform that can have a pivotal role in the short and long term in the dermatology outpatient setting.

Video Consultations in a Paediatric Dermatology Clinic: A Quality Improvement Project Evaluating Patient and Clinician Experience

Adapting the delivery of dermatology care to meet the challenges of the COVID-19 pandemic has led to the introduction of remote methods of healthcare delivery. Video consultation (VC) is a method of making dermatology accessible remotely whilst minimising the risk of infection transmission. Understanding the current and future role of VC in the delivery of dermatology paediatric consultations is of crucial importance to optimise the delivery of safe and efficient care. We performed a quality improvement project to evaluate patient and clinician experience of VC in a UK paediatric dermatology secondary care outpatient setting from June 2020 to September 2020. Prospective online surveys for patients and clinicians were designed and integrated into the video platform to automatically initiate at the end of each VC. 46 responses were collected: 55% of consultations were first attend, 45% follow-up, 59% for a rash and 22% for monitoring of birthmarks. The main findings were that 91% of parents had a 'very positive or 'positive' overall experience of VC and 94% would choose VC over a telephone consultation during the current pandemic. A common theme from free text responses from parents and clinicians were that subgroups of patients who would find hospital attendances difficult had greater satisfaction with VC (e.g. children with physical disabilities, parents who are carers for other family members). We demonstrate that VC is a patient-and clinician-friendly tool that can have a crucial short-and long-term role in the delivery of paediatric dermatology care in the outpatient setting.