Upskilling haematological services for WGS and germline assessments through a regional skin biopsy training programme

NHS England Genomics introduced whole genome sequencing (WGS) with standard-of- care (SoC) genetic testing for haemato-oncology patients who meet eligibility criteria, including patients with acute leukaemia across all ages, and exhausted SoC testing. Alongside, the role of germline mutations in haematological cancers is becoming increasingly recognised. DNA samples are required from the malignant cells (somatic sample) via a bone marrow aspirate, and from non-malignant cells (germline sample) for comparator analysis. Skin biopsy is considered the gold-standard tissue to provide a source of fibroblast DNA for germline analysis. Performing skin punch biopsies is not within the traditional skillset for haematology teams and upskilling is necessary to deliver WGS/germline testing safely, independently and sustainably. A teaching programme was designed and piloted by the dermatology and haematology teams in Sheffield and delivered throughout the NHS trusts in North East & Yorkshire Genomic Laboratory Hub. The training programme consisted of a 90-min session, slides, video and practical biopsy on pork belly or synthetic skin, designed to teach up to six students at one time. To disseminate best practice, the standard operating procedure and patient information used routinely in Sheffield were shared, to be adapted for local service delivery. From January 2021 to December 2022, 136 haematology staff from 11 hospitals, including 34 consultants, 41 registrars, 34 nurses and 8 physician associates, across the NEY GLH region completed the skin biopsy training programme. Feedback from the course was outstanding, with consistently high scores in all categories. Practical components of the course were especially valued;98.6% (71/72) trainees scored the practical element of the programme a top score of 5 out of 5, highlighting that despite the challenges of delivering face-to- face teaching due to COVID-19, teaching of practical skills was highly valued;training in this way could not have been replicated virtually. Costs of the programme have been approximately 16 000, including consultant input and teaching/educational materials. Recent support has been provided by a separately funded Genomic Nurse Practitioner (GNP), with succession planning for the GNP to take over leadership from the consultant dermatologist. Plans are in place to use the remaining budget to disseminate the programme nationally. Our training programme has shown that skin biopsy can be formally embedded into training for haematology consultants, trainees, nursing team, and physician associates. Delivery of training can be effective and affordable across regional GLHs with appropriate leadership and inter-speciality coordination, and ultimately sustainable with specialist nursing staff, including GNPs.

Utilization and effect of telehealth for the treatment of haemangioma before and after COVID

Many patients treated at Stanford for haemangiomas must travel from the rural Central Valley or Central Coast to receive care. Because of COVID-19, there was an increased use of telehealth which shifted the management of haemangiomas. Our study aimed to identify the implications of this change and its impact on access to care for patients who live far away. Using the Stanford Research Repository, we established two cohorts of patients seen at Stanford dermatology clinics with a haemangioma diagnosis: one from 2018 and one from 2022. We took a random sample of 50 patients from each and collected data on haemangioma treatment prescriptions, age at diagnosis, age at dermatology encounters, and distance travelled to clinic. We subdivided the 2022 cohort into in-person visits and telehealth appointments. While no patients utilized telehealth in the 2018 cohort, 69% of patients in the 2022 cohort utilized telehealth for their first Dermatology visit. In the 2022 cohort, 52% of patients utilized telehealth for at least one dermatology appointment. The average age at presentation for the 2018, 2022 in-person, 2022 telehealth groups were 121 , 208 , and 116 days, respectively. Average age at diagnosis was significantly younger for the telehealth cohort compared to the 2022 in-person cohort, and there was an increase in prescriptions for treatment in the telehealth cohort. These results show that increased telehealth utilization as a result of the pandemic has allowed patients to be seen by a dermatologist at an earlier age and receive a prescription for treatment for haemangiomas.

Dermatologists' perceptions of using teledermatology to manage hidradenitis suppurativa

The COVID-19 pandemic has led to rapid adoption of teledermatology. Hidradenitis Suppurativa (HS) is a chronic inflammatory condition that requires recurrent clinical evaluation and may be subjected to privacy concerns amongst patients when managed over teledermatology. We assessed dermatologists' perceptions of teledermatology in managing HS. Participants were invited to completed a survey electronically via a secure online platform. The survey was disseminated to members of the Asia Pacific Hidradenitis Suppurativa Foundation and through word of mouth, over February to June 2022. Demographics and survey responses were collated. Associations between demographics and attitudes towards teledermatology for HS were evaluated by multivariable ordered logistic regression. 100 responses were obtained comprising of 76 (81.7%) dermatologists and 17 dermatology trainees (18.3%). Older physicians tended to express sentiments that it was difficult to accurately assess disease severity for HS.There was increased tendency for physicians to perceive difficulty in managing HS compared to AD (assessed as a control cohort) - in terms of photography of sensitive areas (adjusted OR 4.71 (95% confidence interval: 2.44-9.07);p value < 0.001), accurate assessment (adjusted OR 2.66 (95% confidence interval: 1.48-4.79);p value 0.001), privacy issues from examination of private body areas (adjusted OR 2.75 (95% confidence interval 1.36-5.56);p value 0.005). This study, is the first, to our knowledge that assess physician attitudes towards the use of teledermatology in managing HS patients, and compares differential perspectives of its use on HS and AD patients. Physicians' efforts should be focused on streamlining patient selection and optimizing consult environments for patients with HS.Copyright © 2023

COVID-19 severity in allergic patients with or without allergen immunotherapy

Background: SARS-CoV- 2 impacts on the immune response in a variable way. In pilot study we showed last year that in allergic patients allergen immunotherapy (AIT) seemed to reduce COVID-19 severity. Here we present final results. Method(s): in cooperation with allergists, dermatologists and ENTs we conducted a Latin-American registry of patients with allergic disorders, including urticaria, who got COVID-19. Apart from demographic data, COVID-19 severity, allergic diseases, comorbidities and compliance with underlying allergy/asthma treatment we collected data on AIT. Result(s): Of the 1095 registered patients, 54% female, 89.4% were confirmed and 10.6% highly suspected COVID-19 cases. IgE-mediated allergy was confirmed (81%) or clinically suspected (16%);while 3.2% had only urticaria. 630/1095 (57.5%) received AIT;in both groups (yes or no AIT) median age was 30-39y. For COVID-19 severity, see table. Compared to allergic patients without AIT, receiving AIT reduced the Risk Ratio (RR) for severe disease with lower respiratory symptoms or worse (COVID-4- 7) to 0.78 (.95 CI 0.6703-0.9024), p = 0.0017) and for critical COVID-19 in need of oxygen therapy or worse to 0.65 (.95 CI 0.42-0.9992, p = 0.048). There was only one fatality in the no-AIT group. There was no difference between groups in co-morbidities, public or private practice or allergic disease;AIT patients tended to be younger. Conclusion(s): These data seem to favor the outcome of COVID in allergic patients receiving AIT, but more in-depth analysis is needed.

Working Group for Myositis within the Swedish Rheumatism Association

The Swedish Rheumatism Association, our umbrella Organization: In Sweden, there are approximately one million people with different rheumatic diseases, and about 1400 of them have a myositis diagnosis. In addition to several local associations, there are 3 nationwide diagnostic groups for systemic inflammatory diseases: Working group for systemic lupus erythematosus (SLE), Working group for Systemic Sclerosis and Working group for Myositis. Goals and vision: We form opinion and influence politicians and decision-makers at all levels in issues that are important to us, such as access to rapid care and opportunities for rehabilitation. Knowledge and Education: We educate: * Representatives who can share knowledge based on their own experience and to provide support and help for people living with rheumatic disease. * Volunteers for patient schools. * Patient Research Partners since 2008. Research and fundings: : * We are the single largest private funder of Swedish rheumatology research. * Patient Research Partners should become obvious members in research projects. Working group for Myositis was established in 2020 and most of our activities have been on-line. The number of members is growing as we spread out the information. We will continue with our on-line events and together with our experts arrange our first patient conference in 2022. We are a member of the Swedish Rare Disease Association and European Network ERN ReCONNET. We have now three Patient Research Partners with myositis and we will continue to participate in international research projects, such as IMACS, Rehabilitation & exercise SIG. Our mission is to give support to myositis patients and their families, share knowledge of their disease, facilitate meeting with others with the same diagnosis for an exchange of experiences or just for fun. Our goals are to: * Inform through newsletters, patient meetings, website and webcasts. * Arrange lectures by myositis experts. * Arrange annual patient conference. * Raise awareness for the disease in society and inform healthcare professionals within primary care units. * Contribute to that all patients receives equally good care all over the country. * Inform about research results, ongoing studies and update information on new treatments and drugs. * Contribute to that all newly diagnosed patients have access to patient education and written information material about myositis. * Contribute for opportunities for rehabilitation, such as training in warm water pools and access to rehabilitation facilities in warm climate. * Collaborate with the Youth organization of the Swedish Rheumatism Association for Juvenile Dermatomyositis and provide support for parents, children and adolescents. * Collaborate with the myositis organizations in other countries. Our Webinars: The experts who have shared their knowledge on our webinars are: Ingrid Lundberg, Professor;Maryam Dastmalchi, MD, Rheumatologist;Helene Alexanderson, PhD, Associate professor, PT;Malin Regardt, PhD, OT;Balsam Hanna, Specialist Rheumatology;Dag Leonard, MD, Rheumatologist;Antonella Notarnicola, MD, Rheumatologist;Fabricio Espinosa, Rheumatologist, PhD candidate;Kristofer Andreasson, PT, PhD candidate;Jonatan Sjogren, OT;Lars Nordelv, CBT Therapist, also a patient;Helena Andersson, MD, Rheumatologist;Hanna Brauner, PhD, Dermatologist. Among the topics our webinars have covered so far are: Diagnostic criteria of myositis, new research findings, existing treatments and ongoing studies, Physical activity and its effects on depression, safety of high-intensity interval training, Occupational therapy, Patient Reported Outcomes, Myositis Associated Antibodies and how to deal with anxiety, cardiac involvement and osteoporosis in myositis, clinical findings and treatments for Antisynthetase syndrome skin involvement in Dermatomyositis, Covid-19 and vaccination.

Lesions in lockdown: mobile dermoscopy in virtual dermatology clinics

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.

Teledermatology and the Montgomery rule of consent

The Montgomery vs. Lanarkshire case of March 2015 is one of the most important UK judgments on informed consent. The ruling dictated that any intervention should be based on a shared decision, whereby patients are aware of all options and supported in making an informed decision. There is debate over whether patients requiring a procedure after a store-andforward teledermatology consultation need a preoperative face-to-face (F2F) appointment to comply with this consent. We evaluated patient experiences of our skin cancer teledermatology pathway, whereby patients had a telephone consultation before a surgical appointment and their first visit to the hospital was for the procedure. On average, we receive 9000 2-week-wait referrals a year. In March 2020, following the UK's nationwide lockdown, our dermatology department had 700 new referrals pending without any opportunity of F2F appointments. To meet this demand and the subsequent restrictions of the COVID-19 pandemic, we established a teledermatology service. Patients attended a community hub where a detailed history was taken and lesions photographed by a medical photographer, including dermoscopic images. Clinical images were subsequently reviewed by a consultant dermatologist. For those requiring surgical procedures, preoperative telephone consultations were conducted. Patients requiring complex procedures and those with likely highgrade malignant melanoma were offered F2F appointments. During the telephone consultation, the planned procedure was explained, with risks, benefits and alternative treatments discussed. The first 50 patients were sent a survey comprising eight questions pertaining to their experience of the new pathway. Over a 4-week period, 34 responded. Mean age was 67 years (range 29-93). Ninety-seven patients felt photographs were taken in a timely manner. All patients reported that appropriate safety and social distancing precautions were taken. All patients described an overall positive experience, felt that sufficient information was provided throughout the pathway and were happy to engage with this service should they require a similar procedure in the future. In this cohort of patients, their first visit to hospital was for a procedure. There are many benefits in reducing F2F hospital attendances. As well as reducing footfall during the pandemic, there is less lost work time and cost of travel for patients or their relatives, more efficient use of hospital facilities and reduced carbon footprint. Our survey suggests that preoperative telephone consultations are liked by patients and appropriate in meeting the requirements of Montgomery consent for a teledermatology service.

Palmoplantar inflammation with a broad differential diagnosis made clear upon patch testing

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.

Teleconsultations in paediatric dermatology: a UK-wide clinician survey

The COVID-19 pandemic catapulted dermatology services into a digital era, with the rapid introduction of teleconsultations. Potential benefits include widening access to healthcare and environmental sustainability. Barriers to successful teleconsultations include reduced diagnostic accuracy and technical issues. National Health Service operational planning guidance recommends that >= 25% of consultations are delivered remotely (https://www.england.nhs.uk/wp-content/uploads/ 2021/03/B0468-implementation-guidance-21-22-prioritiesand- operational-planning-guidance.pdf). Yet there is a lack of data regarding the acceptability and effectiveness of paediatric dermatology teleconsultations. We conducted a survey to explore clinicians' experience of teleconsultations in paediatric dermatology, focusing on paediatric eczema, to inform a future clinical trial. The survey was created using an online platform (Microsoft Forms) and piloted by paediatric dermatologists. It was circulated via email to members of the British Society for Paediatric Dermatology, the British Association of Dermatologists and the UK Dermatology Clinical Trials Network (DCTN). It remained open for 7 weeks from July to September 2021. Descriptive analysis was undertaken using Microsoft Excel. There were 120 responses, the majority from consultant dermatologists (59%). Prior to COVID-19, the most commonly provided teleconsultation service was advice and guidance (A+G) to general practitioners (GPs;55% responses). The majority of responders (63%) conducted no teleconsultations. Teleconsultations accounted for < 25% of all consultations in 98% responses. Since the pandemic there has been a marked shift in practice. Forty-nine per cent of responders now conduct > 25% of consultations as teleconsultations. Only 8% provide no teleconsultations. Teleconsultations are now being offered for new consultations [n = 62 (80%)], followup consultations [n = 101 (84%)] and A+G for GPs [n = 96 (80%)]. The most common format is telephone consultations with photographs (72%). For follow-up of paediatric eczema, the most effective format was felt to be telephone consultations with photographs [n = 52 (43%)], followed by video consultations with photographs [n = 32 (27%)]. Over half of responders (54%) felt that teleconsultations were less effective than face-to-face appointments for follow-up of paediatric eczema. Seventeen (21%) responders felt they could accurately assess eczema severity using a video vs. 27 (34%) using photographs. Reported barriers to teleconsultations included poorquality images, technical problems, reduced diagnostic accuracy and impaired communication. Importantly, the issue of safeguarding children was a concern. The majority of clinicians felt that teleconsultations were beneficial for reducing footfall in hospitals and minimizing time missed from school. Our results demonstrate variation in clinician opinion on the effectiveness of teleconsultations and the optimal format for paediatric eczema follow-up appointments. As part of a UK DCTN-themed research call award, we plan to conduct a patient survey, qualitative patient interviews and a health economics analysis of teleconsultations for paediatric eczema. This feasibility work will help to inform a future clinical trial.

Implementing patient-initiated follow-up in dermatology: a local departmental experience

As part of the National Health Service's response to the COVID-19 pandemic (https://www.england.nhs.uk/outpatienttransformation- programme/patient-initiated-follow-up-givingpatients- greater-control-over-their-hospital-follow-up-care/), and in line with the personalized care agenda (https://www.bad. org.uk/shared/get-file.ashx?itemtype=document&id=7237), 'patient-initiated follow-up' (PIFU) is being implemented across secondary care. This has been introduced by the National Outpatients Transformation Team and the aim of this initiative is to encourage self-management in patients and facilitate shared decision-making, together with supporting clinical waiting list reviews. The expected benefits include flexible personalized pathways and better access to specialist care when needed, thus benefiting general practitioners and the department. It replaces the old-style 'open appointment', which was rigid, without a clear pathway and not accurately recorded, impacting on demand and capacity planning. The British Association of Dermatologists has adapted this guidance and produced a document to support the roll out of this initiative throughout dermatology departments in England.4 It is important that clinicians appropriately assess which patients are suitable for PIFU. Criteria for selection include a low risk of urgent follow-up;confident to take responsibility of their care by understanding the condition, symptoms and when to seek advice;and understanding how to re-access care. Our experiences in setting up and using the PIFU pathway are shared. In our trust, it was first rolled out in dermatology and urology, two specialities with a high number of follow-ups. For dermatology, we included clinics in the main department and across all four community sites. In order to set up this service, engagement was sought with key stakeholders (service managers, administrative teams and clinicians). A Standard Operating Procedure was created to classify the pathway, agreed processes for the administrative and secretarial team, and written information for patients and general practitioners. Education sessions were given on how to use PIFU, assess patient suitability and measure outcomes. From September 2021 to November 2021, 548 patients have been added onto a PIFU and, as of December 2021, 11 have used it to re-access care. A staff survey has been done and has shown overall positive feedback, with 68% having a positive experience and only 8% having a negative experience. Seventy-six per cent of staff feel it is better for patients and doctors/administrators, and 95% would recommend it to other departments. The only negative issues have been an increase in workload for the secretaries who send out the written information. We aim to obtain patient feedback once more have re-accessed care, which we hope to present alongside our experiences on the benefits and challenges of implementing PIFU.

A virtual multidisciplinary clinic service for the diagnosis and treatment of severe perianal skin disease in hidradenitis suppurativa and Crohn disease

Patients with hidradenitis suppurativa (HS) often present to our tertiary service with severe perianal disease that is extremely debilitating. We are able to provide a holistic service for our patients through our perianal virtual clinic (PVC), a weekly service comprising dermatologists, colorectal surgeons, gastroenterologists and a gastroenterology clinical nurse specialist. Virtually, we discuss and optimize the management of patients who have a diagnosis of either HS or gastrointestinal/ cutaneous Crohn disease (CD), or both. Through discussion of the medical management, review of pelvic magnetic resonance imaging scans and the discussion of surgical treatment in detail with our colleagues, we are able to streamline treatment for these complex patients. We provide a review of the activity in this service over the last 2 years, from January 2019 to December 2020. As part of the clinical work in our tertiary hidradenitis clinic, we routinely treat patients with significant perianal HS. These patients have discharging sinus tracts and fistulating disease in apocrine gland-bearing areas. A proportion have gastrointestinal or cutaneous CD. From a medical perspective, these patients have often failed multiple therapeutic interventions, and surgery can provide a useful adjunct to treatment. Surgical intervention involves extensive laying open and debridement of disease, including biopsy, and seton control of anal fistulae. Perianal skin cancer can be identified at the time ofsurgery, a complication known to affect those with chronic inflammation and those on immunosuppressive drugs. In the last 2 years, following surgery, one patient has been diagnosed with cutaneous squamous cell carcinoma (SCC), one with SCC in situ and one with extramammary Paget disease. In reviewing the activity of the PVC, we discussed 26 patients with HS and severe perianal disease in 2019 and 42 patients in 2020, despite interruption to the service due to the COVID-19 pandemic in 2020. This increase in activity reflects our expanded service and the severity and complexity of the patients referred. We identify those that may benefit from early surgery and also take referrals of patients with both HS and CD that may need optimization of medical therapy. In total, eight patients were admitted under the joint care of the colorectal and dermatology teams for surgery in 2019 and seven in 2020. The PVC has become an important one-stop service in the optimization of complex treatment for patients with perianal HS and/or CD referred to our tertiary service.

Teledermatology reporting experiential teaching model for dermatology registrars: a qualitative study

Teledermatology was introduced into the UK dermatology training curriculum in August 2021. National surveys of dermatology trainees in the UK undertaken in 2019 and 2020 demonstrated a vital learning gap in teledermatology (Lowe A, Pararajasingam A, Goodwin R. A UK-wide survey looking at teaching and trainee confidence in teledermatology: a vital gap in a COVID-19-induced era of rapid digital transformation? Clin Exp Dermatol 2020;45: 876-9). Feedback received elucidated that registrars were desirous of observing dermatology consultants during teledermatology reporting, particularly undertaking this themselves under direct supervision. To bridge the gap, we set up a regional virtual teledermatology reporting teaching programme for registrars in our deanery, applying Kolb's experiential learning model and using our local asynchronous teledermatology service. Our aim was for trainees to participate directly in teledermatology reporting for skin lesions under consultant supervision, developing confidence in triaging patients, providing appropriate advice to general practitioners (GPs), and for discharging benign lesions. Teaching was delivered through eight interactive sessions with a focus on skin lesions, over a 12-month period from August 2020 to August 2021, by a senior consultant dermatologist with an interest in teledermatology and skin cancer. Eight dermatology registrars from four different hospital trusts participated, using MS Teams as the virtual platform. Registrars logged in and selected a new referral awaiting review. Screen sharing enabled registrars and the supervising consultant to view the accompanying clinical history and images and engage in a brief discussion. Trainees decided to either accept or reject, directing accepted referrals into urgent suspected cancer, urgent or routine. Where appropriate, advice regarding treatment that GPs could prescribe in the community was given. Qualitative feedback was collected pre- and postprogramme, using e-mailed questionnaires. A 5-point Likert scale was used to assess confidence levels in the following domains: assessing and diagnosing;triaging;discharging skin lesions;giving advice regarding benign skin lesions;and overall confidence in teledermatology. Responses ranged from 1 (strongly agree) to 5 (strongly disagree). The response rate was 100% (n = 8). Trainee confidence was compared using a nonparametric Mann-Whitney U-test. A significant improvement post-teaching was demonstrated in all domains. Most (87%) rated the programme as being extremely relevant to their training. Our study is limited by a relatively small sample size of residents. Nevertheless, results demonstrate that this model is effective in increasing trainee confidence in using teledermatology for the reporting of skin lesion referrals in actual practice, thus equipping registrars with the skills needed to keep pace with changing service demands in an increasingly digital ecosystem.

Dermatologists' Perceptions of the Use of Teledermatology in Managing Hidradenitis Suppurativa: Survey Study

Background: The field of teledermatology has expanded tremendously and has been used for conditions including hidradenitis suppurativa (HS). However, due to the sensitive location of lesions, HS may be considered less suitable for teledermatology. Objective: We sought to assess dermatologists' experiences and perceptions toward using teledermatology for HS relative to atopic dermatitis (AD) as a comparison. Methods: A survey was disseminated electronically to practicing dermatologists in the Asia-Pacific region between February and June 2022. Differences in attitudes and perceptions between HS and AD were compared using random-effects ordered logistic regression, controlling for demographics. Results: A total of 100 responses were obtained comprising of 76 (81.7%) dermatologists and 17 (18.3%) dermatology trainees;62.6% (62/98) of physicians were uncomfortable with using teledermatology for HS. Multivariable regression confirmed increased perceived challenges with managing HS using teledermatology compared to AD. These challenges include the need for photography of hard-to-reach or sensitive areas (odds ratio [OR] 4.71, 95% CI 2.44-9.07;P<.001), difficulties in accurate assessment of severity (OR 2.66, 95%CI 1.48-4.79;P=.001), and inability to palpate lesions (OR 2.27, 95% CI 1.23-4.18;P=.009). Conclusions: This study confirms the relative reluctance of dermatologists to use teledermatology for HS and complements existing data showing mixed levels of willingness from patients. The use of teledermatology for HS may need to be optimized to overcome these challenges, including increasing security features, selection of patients with milder or limited diseases, and selecting patients with an established and strong doctor-patient relationship. ©Valencia Long, Ellie Ci-En Choi, Zhaojin Chen, Moonyza Akmal Ahmad Kamil, Murlidhar Rajagopalan, Erin McMeniman, Nisha Suyien Chandran.

Mental health of patients with psoriasis during the COVID-19 pandemic: a cross-sectional study in a tertiary setting

Patients with psoriasis are at increased risk of depression. Furthermore, psoriasis is linked to social isolation, stress-related disorders and suicidality. The COVID-19 pandemic and social distancing represent potential stressors for patients, which may disproportionately affect the wellbeing of this vulnerable population. Our aim was to investigate whether the pandemic increased the affective burden of patients with psoriasis. We surveyed 194 patients with dermatologist-confirmed psoriasis attending our tertiary service. Ninety-three patients had completed questionnaires [Hospital Anxiety and Depression Scale (HADS);Quick Inventory of Depressive Symptomatology Self- Report (QIDS-SR);Sheehan Suicidality Tracking Scale;Dermatology Life Quality Index (DLQI)] before March 2020 in a pre-existing study. From May to October 2020, we recruited a different patient sample (n = 101) who completed the same questionnaires. We analysed separately data from 22 patients, who completed the survey both before and during the pandemic. Cases of depression and anxiety were defined as having a HADS subscale score of >= 8. Analysis was performed in R. Ninety-three patients completed the survey before the pandemic [49 5% female;mean (SD) age 42 (18) years] and 101 during the pandemic [38% female;mean (SD) age 52 (16) years;74% shielding]. Patient proportions across treatment groups did not differ before vs. during the pandemic (73 1% vs. 78 2% on biologics;P = 0 8). Depression, anxiety and suicidality were highly prevalent at both timepoints. However, there were no significant differences in depression [31% vs. 40%;adjusted odds ratio (aOR) 1 2, 95% confidence interval (CI) 0 6-2 5], anxiety (39% vs. 47 5%;aOR 1 7, 95% CI 0 8-3 5) or suicidal ideation prevalence (13% vs. 20%;aOR 2 19, 95% CI 0 8-5 9] before vs during the pandemic. During the pandemic, depression was not associated with living alone (P = 0 45) or shielding (P = 0 13). In the paired analysis, depression scores did not differ during compared with before the pandemic (QIDS-SR 9 4 x 5 8 vs. 8 8 x 6 1;P = 0 56). DLQI changes did not correlate with changes in QIDS-SR (r = 0 08, P = 0 7). At follow-up, three patients (14%) reported 12-month passive suicidal ideation;no patient reported 12- month active suicidality. Depression and the prevalence of anxiety are high in patients with psoriasis. Suicidal ideation rates appear to be higher than the rates in the general population during the COVID-19 pandemic. However, we did not observe a significant increase in the psychological burden or shielding of our patients during the pandemic compared with previous levels. Our findings are consistent with recent research on psoriasis-related quality of life during the COVID- 19 pandemic and may reflect population-specific resilience mechanisms. They also highlight the importance of continued monitoring of psychiatric comorbidity in this population, independently of acute stressors. Future research should address the long-term pandemic impact on patients.

Current Knowledge on Psoriasis During the Covid-19 Pandemic

Psoriasis is a chronic inflammatory disease associated with a de-fective epidermal barrier, in which the immune system is already activated in lesional sites of the skin, and it is thus possible that affected individuals can have different immunologic rates of viral response. This is especially impor-tant in the era of the novel coronavirus disease (COVID-19) that is affecting the entire world. Patients with psoriasis are often receiving systemic therapy which includes immunosuppressive and biologic therapy, so this new infec-tious disease has raised concerns among dermatologists regarding psoriasis treatment. Some of the risk factors of psoriasis are obesity, diabetes mellitus, and hypertension - all of which are diseases linked with negative outcomes and higher severity of COVID-19. Psoriasis is mediated by inflammatory cells and proinflammatory cytokines such as IL-17, IL-23, IFN-gamma, and TNF-alpha, and patients with skin diseases have been shown to be more susceptible to CO-VID-19 infection, but with a less severe disease course. As an anti-inflamma-tory agent, vitamin D could play a significant role in the future as a possible treatment for reducing the risk and severity of psoriasis and COVID-19. It has been suggested that patients treated with biologic therapy should continue treatment, as it has not been shown to cause severe complications of the CO-VID-19 disease. Preventive measures, including vaccination, should be taken to minimize the risk of infection and severity of the clinical outcome.Copyright © 2022, Croatian Dermatovenerological Society. All rights reserved.

Virtual clinics in teledermatology: an opportunity for all?

The COVID-19 pandemic has been a catalyst in the slow-moving transition to telemedicine services: dermatology has been particularly affected by this move to 'teledermatology' and the use of virtual clinics. However, the COVID-19 pandemic has also exposed and exacerbated pre-existing health inequalities. Dermatological services are prone to inequalities in service access, disease burden and equity. There are 13 million general practice consultations for skin conditions every year (https://www.not tingham.ac.uk/research/groups/cebd/documents/hcnaskinc onditionsuk2009.pdf), yet only 611 dermatology consultants provide specialist care (https://www.statista.com/statistics/ 594431/dermatologists-in-the-united-kingdom-uk-by-staffgrade/). Teledermatology with the adoption of virtual clinics has the potential to increase accessibility to dermatology patients in geographically isolated areas. However, access and use of virtual clinics for dermatology patients poses several challenges. In 2018, five million people in the UK were noninternet users (https://www.ons.gov.uk/peoplepopulationa ndcommunity/householdcharacteristics/homeinternetandsoc ialmediausage/articles/exploringtheuksdigitaldivide/2019-03-04). A geographical divide exists in the UK concerning knowledge and application of basic digital skills, with the North, the Midlands and Wales falling short in a national average of 79%. The Department for Work and Pensions has impairment listings on a range of skin conditions that are most likely to be disabling (https://www.gov.uk/governme nt/publications/medical-guidance-for-dla-and-aa-decision-ma kers-adult-cases-staff-guide). Yet, 22% of all disabled people lack internet access. Ethnic disparities on the use of pre-existing online healthcare infrastructure like NHS Direct already exist (Cook EJ, Randhawa G, Large S et al. Who uses NHS Direct? Investigating the impact of ethnicity on the uptake of telephone based healthcare. Int J Equity Health 2014;13: 99). Cultural factors and those living in overcrowded housing lack the privacy needed for dermatological consultations. With austerity measures, people are unable to afford internet access or goodquality computers to make video calls to talk about their skin problems, making teledermatology an unsuitable alternative. The digital divide also exists across an age gradient, with older people more likely to report not using the internet. Dermatology patients tend to be elderly, with the median age of patients referred being 51 years. With virtual clinics projected to be significant in the future delivery of dermatology services, it would be prudent to mitigate the risks of digital exclusion for our most vulnerable patients and tackle the persisting inequalities.

Washing the great unwashed: a history of British public hand hygiene

British and European public attitudes towards hand hygiene have evolved over time. Early examples of soap-like products date from Babylon around 5000 years ago, later probably passing along the silk route to Europe. A mixture of fats boiled with ashes were found in clay cylinders. In the fourth century BC, Hippocrates propagated ancient Chinese and Greek theories that epidemics spread via noxious 'miasma' particles. In the Roman Empire, Galen advocated health by balancing four humours (blood, yellow bile, black bile and phlegm). The Romans brought public bathhouses to Britain after invading in 55BC adding a social aspect to cleanliness, also bringing fresh water in aqueducts. Emily Cockayne's book Hubbub: Filth, Noise & Stench in England documents daily life in England from 1600 to 1770. Diarist Samuel Pepys reportedly rubbed himself 'clean' using a cloth. King Louis XIV of France reportedly took two baths during his reign, the first during his recovery from a convulsive episode. In the Middle Ages, 'cleanliness' focused on keeping up appearances. It was believed that white linen garments absorbed the body's impurities and cleaned the skin. People wore visible starched white collars and cuffs, to signal cleanliness and social superiority. British public attitudes changed during the nineteenth century, driven by discoveries showing a relationship between hygiene and health. Bulwer- Lytton disparagingly referred to the 'great unwashed' lower classes in his 1830 novel Paul Clifford. However, in 1837, Buckingham Palace did not have a bathroom. Bathing was mostly inaccessible, labourers would usually bath in sweat and were cleaned only on admission to hospitals or poor houses. In 1845, English dermatologist Sir Erasmus Wilson published a lay handbook called Healthy Skin. This was wildly popular and disseminated the health benefits of sanitation and clean skin. Public washhouses proliferated. By the 1920s handwashing was common practice in Western countries. Soap manufactures Lever Brothers launched a 'clean hands' campaign advising children to wash their hands 'before breakfast, before dinner and after school'. After the Second World War, bathrooms became widespread and home plumbing made village washhouses redundant and unappealing. Handwashing practices among healthcare workers have remained low, averaging 39%. Hand hygiene was at the forefront in tackling the COVID-19 pandemic. The public were advised to wash their hands frequently, for at least 20 s each time. Will this be a landmark in handwashing history.

Two-week wait skin cancer referrals to a paediatric dermatology clinic: a service evaluation

Skin cancer in children is rare. Data from the USA indicate that paediatric melanoma accounts for approximately 1% of melanomas and up to 5% of all childhood cancers, and its incidence is declining. Paediatric nonmelanoma skin cancer (NMSC) is also rare and often associated with genetic conditions or iatrogenic risk factors such as prolonged immunosuppression. In the UK, suspected cancers are referred from primary care via the '2-week wait' (2WW) pathway. National Institute for Health and Care Excellence guidance (NG12) provides criteria to guide recognition and referral, aimed at improving cancer outcomes through early detection and diagnosis. Melanoma and squamous cell carcinoma are diagnosed in approximately 6% of all 2WW skin cancer referrals;however, the vast majority of these are in adults. We evaluated all urgent paediatric dermatology referrals made via the 2WW skin cancer pathway over a 21- month period (August 2019-May 2021). In total, 172 referrals were made. Fifty-two per cent were female and mean age at time of referral was 10 years (range 2 months-17 years). The mean wait time from referral to clinical review was 9.9 days (range 1-28). Skin biopsy was arranged in 27 (15.6%) patients;nine (33.3%) of these biopsies were completed by paediatric dermatologists and 18 (66.6%) were referred to plastic surgery. There were no confirmed cases of skin cancer. Referrals were deemed inappropriate in 22% of cases. Of these, 15 (41%) were misdirected referrals and the remainder included nonlesional dermatology, including cutaneous infections (24%) and inflammatory conditions (22%). The histological diagnoses are outlined in the Table. As 2WW referrals rise, services must plan efficient and cost-effective pathways for the provision of care. Referral rates for any suspected cancer are disproportionately high in young people, including for melanoma. Signs of a 'changing mole' are less sensitive in a paediatric cohort where melanoma is more likely to present as an amelanotic or nodular lesion. Over a 21-month period, we did not identify a paediatric skin cancer among patients referred on a 2WW pathway. The service burden related to 'stopping the clock' and patient tracking is considerable and has not been formally costed. As we attempt recovery following the COVID-19 pandemic, we plan to introduce greater use of teledermatology triage to address this issue. (Table Presented).

Melanoma of unknown primary: a case series and review of the literature

Melanoma of unknown primary (MUP) was originally defined in 1963 as melanoma in the subcutaneous tissue, lymph nodes or visceral organs without the presence of a cutaneous, ocular or mucosal primary. The incidence of MUP is reported to be between 1% and 8% of all melanomas. MUP can be divided into lymph node involvement only and organ metastases. The aetiology of MUP is elusive. Possibilities proffered include an unrecognized melanoma, a previously excised melanoma that was misdiagnosed as benign, a primary melanoma that has completely regressed or the de novo malignant transformation of an aberrant melanocyte within a lymph node. We report our experience in a single tertiary referral centre. A database of all melanomas diagnosed between January 2018 and December 2021 was analysed for MUP. The total number of melanomas diagnosed in that timeframe was 298. Six patients (three males, three females) were identified as having MUP, with an incidence of 2%. Median age was 63.3 years (range 45-84). One (17%) presented with primary dermal metastatic deposits, 67% (n = 4) presented with isolated lymph node metastases, 0% presented with visceral metastases and 17% (n = 1) presented with isolated brain metastases. All six patients were reviewed by dermatology and ophthalmology. Fifty per cent (n = 3) were reviewed by ENT. One (17%) was referred to gynaecology. No primary melanoma was identified in any of the patients. All patients underwent a positron emission tomography-computed tomography (CT) scan to investigate for further metastases, and all underwent dedicated brain imaging via CT and magnetic resonance imaging. All patients underwent surgical resection of their MUP, and all were reviewed by medical oncology, with 83% (n = 5) undergoing treatment with immunotherapy. There have been no associated deaths to date. In five patients (83%) the MUP was diagnosed in 2021, and one (17%) was diagnosed in 2018. Recent studies have shown the impact of the COVID- 19 pandemic on the presentation of cutaneous melanoma, including an increased Breslow thickness at the time of presentation vs. a similar period pre-COVID-19. Our data indicate an increased rate of MUP presenting after the onset of the COVID-19 pandemic;however, given the low number overall, no conclusions can be drawn. There is no current literature regarding the increased rate of MUP since the COVID-19 pandemic. Further studies are required to investigate this. Recommendations for the evaluation of those with MUP include a full skin examination by a dermatologist and ocular examination to exclude primary melanoma. Patients should undergo imaging of the brain, thorax, abdomen and pelvis to assess disease burden. Referral to otorhinolaryngology can be considered to assess for mucosal melanoma of the nasopharynx. Gynaecology referral should be considered for those with inguinal lymphadenopathy. MUP is rare. Guidelines for the investigation of MUP are currently lacking and are needed to ensure the delivery of consistent evidence-based care for patients.