EBV-related lymphoproliferative disease in Wiskott-Aldrich Syndrome patient

Case: Wiskott-Aldrich Syndrome (WAS) is a rare X-linked inborn error of immunity caused by mutations in the WAS gene. It is classically characterized by immunodeficiency, eczema, and micro-thrombocytopenia. It has been known since the 1960s that patients with WAS have an increased risk of lymphoproliferative disease though the exact incidence remains unknown in the American population. Limited case reports have discussed EBV-related lymphoproliferative disease in patients with WAS. We present a case of a 9-year-old boy with known WAS complicated by eczematous rash, thrombocytopenia, recurrent ear infections, and monoclonal gammopathy who was found to have submandibular EBV-associated lymphoid hyperplasia with associated lung and retroperitoneal lymphadenopathy. Family had been offered treatment with hematopoietic stem cell transplant but declined multiple times in the past. Earlier in the year, he presented with possible MIS-C with negative SARS-CoV-2 PCR. He presented to our hospital with mastoiditis and lymphadenopathy. Physical examination showed severe eczema on hands and tender right mastoid. Laboratory evaluation showed thrombocytopenia, elevated IgG of 6290, IgA of 744, IgE of 827, low IgM of 41, and 14% response to pneumococcal titers. He was empirically treated with intravenous antibiotics. ENT performed right postauricular incision and drainage and the culture grew Hemophilus influenza. Throughout his hospital stay, his submandibular lymphadenopathy became more prominent despite treatment. Core needle biopsy of right submandibular lymph node was suggestive of EBV-associated lymphoid hyperplasia. EBV PCR and antibodies were both positive. CT chest, abdomen, and pelvis revealed multifocal pulmonary lymphadenopathy and a diffuse, bilateral nodularity as well as retroperitoneal and mesenteric lymphadenopathy. He was given four doses of weekly Rituximab, which successfully decreased EBV viremia below linear detectability. Immunoglobulin replacement therapy (IgRT) was initiated. Bronchoalveolar lavage and lung biopsy were performed and are results are currently pending. Discussion(s): We present a case of a 9-year-old boy with known WAS awaiting transplant who was found to have submandibular EBV-associated lymphoid hyperplasia with associated lung and retroperitoneal lymphadenopathy. While lymphoproliferative disease is a known complication of WAS, EBV-related lymphoproliferative disease in WAS patients has only been reported as case reports and remains a rare but known complication of patient with WAS.Copyright © 2023 Elsevier Inc.

LANGERHANS CELL HISTIOCYTOSIS IN A CHILD WITH MULTISYSTEMIC LESIONS ASSOCIATED WITH INFECTED POLIOMYELITIS AND SARS-COV-2, FEATURES OF DIAGNOSTICS. CLINICAL CASE.

Langerhans cell histiocytosis (LCH) is an abnormal clonal proliferation of Langerhans cells. The prognosis varies depending on the form of the disease and organ damage. Any organs and systems can be involved in the pathological process in various combinations. A poor response to standard therapy and an unfavorable prognosis are characteristic of patients with a multisystem form of LCH and involvement of organs at risk. Skin lesions are a classic sign of LCH. Purpose - to describe the complexity and duration of diagnosis of LCH with multisystem damage in a boy aged 2 years and 2 months, infected with poliomyelitis and coronavirus. Clinical case. The first clinical manifestations of LCH in the child debuted with an eczematous-seborrheic rash on the scalp with spread to the limbs and trunk. The child was treated for toxicoderma, hemorrhagic vasculitis at the place of residence for 6 months. The boy lost 1.5 kg of body weight in 1 month. At the time of hospitalization, seborrheic-eczematous rashes on the skin with a hemorrhagic component, trophic-inflammatory changes in the nails of the hands, signs of protein-energy deficiency, stomatitis, gingivitis, hepatosplenomegaly, polyserositis, diabetes insipidus, osteolytic foci of the frontal bones were found. Results of the tests: anemia, thrombocytopenia, hypoproteinemia and hypoalbuminemia, coagulation disorders. The patient had the onset of lower flaccid paraparesis, muscle hypotonia. The boy was diagnosed with a number of infectious complications, including poliomyelitis (a derivative of vaccine poliovirus type 2), COVID-19. The child received LCH-III cytostatic therapy with a positive effect. The research was carried out in accordance with the principles of the Helsinki Declaration. The informed consent of the patient was obtained for conducting the studies.Copyright © 2023 Institute of Physics of the Russian Academy of Sciences. All rights reserved.

Teledermatology in the provision of biologics through COVID-19 in a rural dermatology practice-A retrospective review.

COVID-19 compounded existing barriers to healthcare for rural patients. We completed a retrospective chart review of patients receiving Pharmaceutical Benefits Scheme subsidised biologics at a Modified Monash Model 3 dermatology practice during the pandemic and examined factors contributing to successful continuation of care, particularly teledermatology. Our experience is instructive in the provision of medical dermatology to regional patients.

A Rare Case of Delayed Hypersensitivity Following COVID-19 Booster Necessitating Treatment With Dupilumab.

Following vaccination, patients can develop symptoms of eczema flare, which could range from mild skin irritation and urticaria to diffuse skin involvement. Delayed immunologic reactions have been described in association with the novel mRNA COVID-19 vaccines and boosters. We report the case of an 83-year-old female who presented with widespread pruritic urticarial indurated papules on the arms, legs, and palms, sparing the face six months following the booster vaccine. She denied constitutional symptoms, new medications, recent illnesses, or new personal care products. Punch biopsy demonstrated acanthosis, spongiosis, and superficial and mild dermal perivascular lymphocytic infiltration with occasional eosinophils compatible with a dermal hypersensitivity reaction. The patient was admitted to the hospital due to the need for systemic steroids as well as IV antibiotics secondary to a superimposed bacterial skin infection in the setting of severe itching and skin injury; she was discharged on oral steroids with follow-up to dermatology and rheumatology. Delayed hypersensitivity reactions typically peak within four days following vaccination and may be observed with COVID-19 vaccines or boosters. However, reports remain limited, and people's history of eczema should not preclude them from receiving a COVID-19 vaccine that is both safe and effective.

Safety and tolerability of losmapimod for the treatment of FSHD

Evaluate the safety and tolerability of losmapimod in the treatment for FSHD. FSHD is a relentless, variably progressive disease leading to accumulation of disability over decades. Fulcrum is developing losmapimod, a small molecule p38 alpha/beta MAPK inhibitor, to treat FSHD. Losmapimod has been generally well-tolerated in more than 3,600 subjects across multiple clinical studies, including >100 subjects with FSHD. Fulcrum has assessed losmapimod in FSHD in one completed phase 1 study (FIS 001-2018) and two ongoing Phase 2 studies in the open label extension period (FIS 001-2019 and FIS 002-2019). Subjects aged 18-65 years with genetically confirmed FSHD1, clinical severity score 2-4, and MRI-eligible muscles for biopsy were exposed to losmapimod 7.5 or 15 mg twice daily PO for 14 days and up to 76 weeks. In study FIS 001-2018, 6 subjects were exposed to 7.5 mg and 11 subjects to 15 mg twice daily dosing for 14 consecutive days. In studies FIS 001-2019 and FIS 002-2019, 14 and 77 subjects respectively, received at least one dose of losmapimod 15 mg twice daily for up to 76 weeks. A total of 108 subjects with FSHD1 have been exposed to losmapimod, with approximately 131 patient-years of exposure. Fifty-seven subjects have been exposed to losmapimod for 12 to 18 months, and 30 have been exposed for over 18 months. Most adverse events (AEs) observed during the studies were considered of mild to moderate in severity. The most common AEs were alanine aminotransferase (ALT) increase, headache, dizziness, dry skin, eczema and gastrointestinal disorders. The majority of AEs resolved with continued dosing. Dosing has been paused for 14 days in four subjects (3 in FIS 001-2019 and 1 in FIS 002-2019) subjects due to COVID-19 infection. There were no reported drug related SAEs, deaths, discontinuations due to AEs, or clinically significant changes in vital signs, clinical laboratory results, or ECG parameters. Losmapimod given as up to 15 mg twice daily in >100 subjects with FSHD1 for up to 76 weeks has been generally well-tolerated, consistent with that previously reported in other patient populations. Therefore, the benefit-risk profile of losmapimod for the treatment of FSHD remains favorable.Copyright © 2022

Prevalence of Occupational Hand Eczema among Healthcare Workers and its Associated Risk Factors in a Tertiary Hospital in Sarawak During Covid-19 Pandemic.

Background: Occupational hand eczema (OHE) is common among healthcare workers (HCWs), especially during the coronavirus disease 2019 (COVID-19) pandemic. Aims: Our study aimed to determine the prevalence of OHE among HCWs and to identify its associated risk factors. Methods: We conducted a cross-sectional study. A self-administered questionnaire study was done. It was followed by a clinical assessment of subjects with skin changes on their hands to determine the likely cause and its severity. Descriptive analysis and inferential analysis were performed to determine the prevalence of OHE and its associated risk factors. Results: A total of 1004 HCWs with a mean age of 34.58 years old were recruited. Of these, 50.1% were nurses, another 24.6% were doctors. A 1-year prevalence of 42.3% and a point prevalence of 16.5% were reported. Dry skin (n = 368, 86.6%) and itching (n = 274, 64.5%) were the common symptoms. Risk factors that were significantly associated with OHE were atopic eczema, allergic rhinitis, frequent hand washing and caring for children under four years old, whereas HCWs who frequently use alcoholic disinfectant and moisturizer hand cream showed lower odds of OHE. No significant association was found between age, gender, profession, involvement in COVID-19 care, number or duration of glove usage and occurrence of hand eczema. Conclusions: We report a high prevalence of OHE among HCWs during the current COVID-19 pandemic. Education and effective preventive measures are paramount to prevent and improve occupational dermatosis.

Evaluation of skin damage owing to protecting measures against COVID-19 among health staff in the west of Iran

Background So far, studies have not been performed regarding skin damage owing to protective measures against coronavirus disease 2019 (COVID-19) by health staff in Iran. Therefore, the present study was performed to assess skin damages owing to protecting measures against COVID-19 among health workers in Hamadan City located in the west of Iran. Materials and methods This cross-sectional study was conducted on 273health staff working in hospitals affiliated to Hamadan University of Medical Sciences. The inclusion criteria were health personnel working in hospitals involved in the care and treatment of patients with COVID-19 in the city of Hamadan. The authors used a researcher-developed questionnaire to gather data. All the analyses were done using Stata version 14-2. P value less than 0.05 was considered as significant. Results The most common skin signs and symptoms of COVID-19 in health staff were dryness, redness, and itch, representing in 83.78, 53, and 40.99% of hospital staff, respectively. All participants used hand disinfectants, with a frequency in the range of 1-5 times in 29.33% and more than 20 times in 19.79% of them. Using a mask for more than 6h in daily practice was significantly associated with skin dryness (P=0.007), skin redness (P=0.001), scaling (P=0.019), and skin pain (P=0.005). Conclusion The findings showed that the prevalence of skin damages related to using protective equipment is high, and simple interventions may help preserve health workers to care for patients infected by COVID-19.

Characteristics of skin damage among healthcare workers during COVID-19 pandemic: an epidemiological survey.

Objective: To investigate epidemiological features of skin damage among front-line healthcare workers fighting against COVID-19 pandemic. Method(s): A self-designed questionnaire was released on an online survey website "wenjuan.com", and sent to the front-line medical staff caring for patients with confirmed COVID-19 in 6 infectious disease wards of the General Hospital of Central Theater Command of PLA via WeChat from March 10th to 20th, 2020. Then, the questionnaires were collected, a database was established, and statistical analysis was performed on the incidence, types and epidemiological characteristics of skin damage among the medical staff. Result(s): A total of about 550 medical staff were surveyed, 404 questionnaires were collected, of which 391 were valid, and 303 cases had skin damage. The survey showed that females, hand cleaning frequency > 10 times per day, wearing three-level protective equipment for more than 6 hours per week were risk factors for skin damage, and frequent use of a hand cream could reduce skin problems. Among the respondents, the incidence of skin damage was significantly higher in the females (79.81%, 249/312) than in the males (38.35%, 54/79;chi2 = 4.741, P = 0.029), and higher in the groups with hand cleaning frequency of 10-20 times per day (79.73%, 118/148) and > 20 times per day (85.71%, 84/98) than in the group with hand cleaning frequency of 1-10 times per day (69.66%, 101/145;chi2 = 9.330, P = 0.009). The incidence of skin damage was significantly lower in the group wearing protective equipment for 1-5 hours per week (64.04%, 73/114) than in the groups wearing protective equipment for 6-10 hours per week (81.48%, 66/81), 11-15 hours per week (95.24%, 20/21), 16-20 hours per week (81.82%, 36/44), 21-25 hours per week (86.49%, 32/37), and > 25 hours per week (80.85%, 76/94;chi2 = 19.164, P = 0.002). Among the 391 respondents, the skin damage related to disinfection and protective equipment mainly manifested as dry skin (72.89%), desquamation (56.78%), skin pressure injury (54.48%), skin maceration (45.01%), and sensitive skin (33.50%);acne (27.11%) was the related skin disease with the highest incidence, followed by facial dermatitis (23.27%), eczematous dermatitis (21.48%), folliculitis (18.92%), dermatomycosis (11.00%), urticaria (9.21%), etc. Conclusion(s): There was a high incidence of skin damage related to protective equipment among the front-line healthcare workers fighting against COVID-19, and strengthening skin protection could markedly reduce the incidence of skin damage.Copyright © 2020 by the Chinese Medical Association.

Knowledge and Practices of Disinfectants and Sanitizers Use during COVID-19 Pandemic in Jordan

Background: The use of antimicrobials has been expanded during the COVID-19 pandemic. This study aims to assess the knowledge and practices of disinfectants and sanitizers use among Jordanian people during the (COVID-19) pandemic. Methods: A web-based cross-sectional descriptive questionnaire was distributed across Jordan between August and September 2020. The questionnaire consisted of three sections inquiring about demographics and general characteristics of the surveyed sample, evaluating the respondents' knowledge about disinfectants, as well as respondents' practices. The questionnaire was completed by 403 literate adult respondents. Results: Our results indicate that Jordanian adults have used disinfectants increasingly during the COVID-19 outbreak. Knowledge of our study sample was considerably affected by gender (p=0.044), income (p=0.001), and profession (p<0.001). 80.8% of those participants reported skin-related side effects due to disinfectant use during the pandemic. The most used disinfectants were ethanol, followed by soap and water. Generally, study respondents showed positive practices toward the use of disinfectants during the time of the pandemic with few high-risk practices reported. Interestingly, the positive practices applied by Jordanian adults were minimally and not significantly affected by the knowledge about antimicrobials' safe and effective use. Conclusions: There is an urgent need for a structured effort to increase public awareness regarding the safe and effective use of disinfectants against SARS-CoV-2 transmission. © 2023 DSR Publishers/The University of Jordan.

CASE REPORT: Immigrants and evolving food allergies

Case report Background: We present a case of coconut allergy as a rare evolving food allergy among immigrants. Case presentation: A 3-year-old girl, on treatment for asthma, was referred to the allergy clinic due to possible reactions to salmon and coconut. Due to COVID restrictions, the initial consultation was conducted by telephone. Reportedly, she developed hives and wheeze after eating salmon and coconut products. During the face-to-face review, it was noted that the child's paternal side of the family was of ethnic minorities. The patient had cradle cap as a baby, and coconut oil was applied for treatment as advised by family back home. During a hospital-based coconut challenge, she developed puffy eyes, and on subsequent consumption of coconut macaroon, she developed hives. The child was diagnosed with coconut allergy. Face-to-face assessment and food cultural awareness are essential for clinical diagnosis. Discussion(s): Allergy is a multifactorial illness affected by epigenetic, environmental factors, eczema during infancy and food culture. Studies suggest that the risk of allergy can be highest in immigrants to culturally stable food, particularly with delayed early taste during weaning. The dual allergen hypothesis proposes that early cutaneous exposure to food protein through damaged skin barrier can lead to sensitisation and allergy and that early oral exposure to food induces tolerance. Conclusion(s): Further research on understanding the interaction between epigenetics of the allergic disease and the environment is needed as is an understanding of how the movement of populations and different culture habits can affect the incidence of food allergy. In the meantime, is promoting healthy skin barrier and early food introduction enough to prevent food allergies.

Allergic contact dermatitis to the elastic bands of an N95 mask

Case report Introduction: In the wake of the COVID-19 pandemic, occupational contact dermatitis related to the use of personal protective equipment (PPE) has become increasingly prevalent. While most cases are irritant in nature, allergic contact dermatitis (ACD) remains an important cause of occupational dermatitis. We report a case of ACD to rubber accelerators in the elastic bands of an N95 mask. Informed consent was obtained from the patient for this report. Case Report: A 27-year-old healthcare worker presented with a progressive pruritic eruption over her face and neck, 1 week after she began wearing N95 masks at work. She had only worn disposable surgical masks. She had no medical history apart from hand dermatitis, which was well controlled with topical medications. Examination revealed linear eczematous plaques along her lateral cheeks and posterior neck, corresponding to contact areas between the mask bands and her skin. Patch tests revealed a positive reaction to several rubber accelerators, including Thimerosal, 2-Mercaptobenzothiazole (MBT), and Methylisothiazolinone. We performed another patch test to several N95 mask straps, to which the patient developed an eczematous reaction to the elastic bands of 2 N95 mask types with elastic bands. Clarification with the manufacturer confirmed the use of rubber accelerators similar in properties to MBT in the production of these masks. A diagnosis of allergic contact dermatitis to rubber accelerator was made. The patient's dermatitis resolved with topical corticosteroids and the avoidance of N95 masks with elastic bands. Discussion and Conclusion(s): The use of facial PPE such as masks is a recognised cause of occupational dermatitis among healthcare workers. A variety of dermatoses are associated with the use of facial PPE, with contact dermatitis being the most common. However, while the majority of contact dermatitis are irritant in nature, ACD remains an important and preventable cause of occupational dermatitis. Commonly implicated allergens associated with mask use include preservatives and adhesives used in their production, as well as metals in the nose clip. Although less common, mask elastic bands have also been reported to be a potential source of ACD, with rubber accelerators being identified as potential allergens. However, there is often a lack of declaration of such chemicals used in the production of PPE. Given the need for continued use in the occupational setting, early identification and avoidance of allergens are key. Failure to do so may result in the progression of skin lesions, ultimately affecting the patients' quality of life and work performance. With the ubiquitous use of masks in the current climate, we wish to highlight the need for greater awareness of rubber accelerators as potential allergens, and their presence in the elastic bands of frequently used PPE.

Acute encephalitis following COVID-19 vaccines: A case series

Case report Background: Neurological adverse effects (NAE) as headache and dizziness are commonly reported with COVID-19 vaccines but are transient and self-limited. However, few serious NAE have been recently described which can be fatal. Here we report two rare cases of encephalitis related to COVID-19vaccination BNT162b2 (Pfizer) and mRNA-1273 (Moderna) and the inherent challenges in their diagnosis. Method(s): We report two cases of acute encephalitis notified to the department of pharmacovigilance in the University Hospital of Monastir Results: Case n'1: Three weeks after receiving her first dose of mRNA-1273, a 35-year- old female, with a medical history of hypothyroidism and eczema was admitted to the intensive care unit as she had confusion and a febrile tonic-clonic seizure complicated with a status epilepticus and dysautonomia. CSF investigations were nonspecific, and the MRI head did not detect any abnormality. Common causes were excluded by an extensive workup (neoplastic, neuro-vascular, autoimmune and infectious causes). She received cefotaxime and acyclovir without any recovery. However, a spectacular recovery was noticed when receiving methylprednisolone. Case n'2: Three days after receiving her first dose of BNT162b2, a-40- year- old female, with a medical history of rheumatoid arthritis was admitted to the medical care unit as she had experienced a three-day history of headache, memory disturbance, severe cognitive disorders and 4 febrile tonic-clonic seizures. MRI head showed signs of bitemporal encephalitis and CSF investigations was with no findings. Extensive laboratory studies ran out alternative causes as neoplastic, autoimmune and infectious diseases. A twenty-one- day acyclovir regimen was administrated with no recovery. As the cognitive deficit is getting more severe, she got intravenous immunoglobulin therapy with a spectacular improvement. Conclusion(s): Based on the Naranjo Algorithm, this adverse NAR can be possibly (score = 6) induced by COVID-19 vaccines. The dramatic improvement after receiving either corticoids or immunoglobulin therapy supports an immune-mediated mechanism behind this acute presentation. Cases of acute encephalitis secondary to H1N1 influenza and poliomyelitis vaccines have been previously reported but those related to COVID-19 vaccines are still not yet elucidated due to the unproven causality. Further prospective studies are needed to evaluate the causal association between vaccine and NAE occurring vaccination.

Pharm Aco Kin Etics, Safety, and Tolerability of Upadacitinib in Children with Atopic Dermatitis

BACKGROUND: Upadacitinib is a Janus kinase inhibitor that has been approved for the treatment of adults and adolescents with moderate to severe atopic dermatitis (AD). The objective of this study was to characterize the pharmacokinetics (PK), safety, and tolerability of upadacitinib in children with severe atopic dermatitis. METHOD(S): This is an open-label, multiple-dose study. AD patients (n = 35) were enrolled into four cohorts (Cohort 1, 6 to <12 years, low dose;Cohort 2, 6 to <12 years, high dose;Cohort 3, 2 to <6 years, low dose;Cohort 4, 2 to <6 years, high dose). The low and high doses were selected based on body weight to provide comparable plasma exposure in pediatrics to 15 mg and 30 mg QD doses in adults, respectively. All patients continued on the low dose after the PK assessment on Study Day 7. Safety and exploratory efficacy parameters are assessed in the study. RESULT(S): Geometric mean Cmax and AUC over 0-24 hours at steady state were 33.1 ng/mL and 249 ng.h/mL, respectively, in Cohort 1, 95.5 ng/mL and 523 ng.h/mL, respectively, in Cohort 2, 35.2 ng/mL and 264 ng.h/mL, respectively, in Cohort 3, and 101 ng/mL and 625 ng.h/mL, respectively, in Cohort 4. Upadacitinib was generally safe and well tolerated. The most common AEs were COVID infection, headache, and abdominal discomfort. No new safety risks were identified compared to the known safety profile for upadacitinib. In the 29 subjects with available interim efficacy results at week 12, 34.5% achieved validated Investigator's Global Assessment scale for AD score of 0 or 1 and 69.0% achieved Eczema Area and Severity Index by at least 75% at Week 12 with treatment of upadacitinib. CONCLUSION(S): The findings supported the use of current dosing regimens for further investigation of upadacitinib in upcoming phase 3 clinical trials in pediatric AD patients.

Occupational dermatitis virtual clinic for healthcare workers: clinics to increase training opportunities to dermatology registrars who are working from home

During the COVID-19 pandemic, there has been a demand from frontline healthcare workers (HCWs) wanting dermatological advice for occupational dermatitis due to increased infection-prevention measures. Various dedicated occupational skin disease clinics in the UK have been set up to help these HCWs, from virtual clinics to drop in clinics (O'Neill H, Narang I, Buckley D et al. Occupational dermatoses during the COVID-19 pandemic: a multicentre audit in the UK and Ireland. Br J Dermatol 2021;184: 575-7). These clinics provide an opportunity for dermatology registrars to enhance their training in contact dermatitis and teledermatology. In a nationwide survey conducted in January 2020, it was felt that dermatology trainees lacked confidence in handling teledermatology referrals (Lowe A, Pararajasingam A, Goodwin RG. A paradigm shift in trainee confidence in teledermatology and virtual working during the COVID-19 pandemic: results of a follow-up UK-wide survey. Clin Exp Dermatol 2021;46: 544-7). At our institution, a virtual telephone clinic has been set up with occupational health input. A standardized pro forma is given and each person sends photos with an occupational health referral to an encrypted email service. By having this additional information beforehand, a history can be taken in the telephone clinic and appropriate management advice given. There is a dermatology consultant who is on hand to help with any queries that the trainee may have. Medications are sent out to the patient and a letter is copied to the patient, as well as the general practitioner, which details the consultation. The patients are usually discharged from the service;however, if the patients need to be seen a face-to-face appointment is given. In these clinics, various occupational dermatoses have been seen and managed. The most common diagnosis was irritant contact dermatitis of the hands due to increased handwashing and alcohol gel use, and most of these patients have a previous diagnosis of atopy (O'Neill et al.). Other occupational dermatoses seen include allergic contact dermatitis, acne and flare-up of atopic eczema. Owing to the COVID-19 pandemic, some dermatology registrars may be working from home. By doing these clinics, training opportunities in dermatology can continue with registrars still seeing patients virtually and managing the conditions. Teledermatology is being introduced in the new dermatology curriculum from August 2021. This service is also appreciated by the HCWs with these patients being seen promptly and getting their conditions managed, maintaining wellbeing in staff.

Access to phototherapy during the COVID-19 pandemic

As the COVID-19 pandemic hit, many phototherapy centres stopped treating patients completely or limited services to very urgent patients only. As the duration of the pandemic became evident and owing to the need to offer alternatives to systemic immunosuppressive drugs for many patients with inflammatory skin disease, we adapted our service to treat increasing patient numbers. Offering treatment over extended hours and Saturday morning, and reorganizing waiting areas and the flow of how patients entered and exited the unit allowed social distancing. This also provided time for the cleaning of equipment between patients. A survey confirmed that patients felt very safe attending treatment. Our unit has also offered a home phototherapy service since 2016 - initially four units and expanded to eight in 2018. To allow continued access for our cohort of vulnerable, shielding patients, we drew up a compelling business case and submitted a funding application to the Trust's emergency COVID-19 budget, successfully obtaining funding for an additional 10 units. Our existing Waldman home units are no longer manufactured, but we were able to source three units from existing stock and seven additional Daavlin 7 Series units from Scott Medical. The home phototherapy service offers treatment for a wide range of inflammatory skin diseases, including psoriasis, eczema, urticaria, polymorphic light eruption, pruritus and pityriasis lichenoides chronicus. In 2020, despite staff redeployment and before the arrival of the new units, patients receiving home phototherapy included 16 patients with psoriasis who were shielding or could not travel to hospital. Eighty-one per cent of patients achieved clear or minimal residual disease activity within 30 exposures or less by the end of their course, which is comparable to our hospital-based service. Rates of symptomatic erythema (E2) were 1% of total number of exposures delivered in this patient group with no episodes of E3 or E4. Our in-hospital erythema rate for 2020 was 2 2%. There were very high levels of patient satisfaction. This highlights the importance of home phototherapy and provides additional evidence that it is safe and effective. The expansion in our service brought about by the COVID-19 pandemic will allow us to extend this service to more patients in the future.

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.

Does the accuracy of clinician diagnosis of COVID-19 compared to RT-PCR in adults depend on the number and severity of comorbidities?

Background: Due to the high transmissibility of SARS-Cov-2, the virus causing COVID-19, accurate diagnostic methods are essential for effective infection control, but the gold standard method of real-time polymerase chain reaction (RT-PCR) is costly, slow, and test capacity has at times been insufficient. Method(s): Diagnosis data were retrieved from registers, based on positive RT-PCR or ICD-10 codes set by clinicians. Through linkage to a population-representative adult cohort in Sweden, we assessed the accuracy of clinician diagnosis against RT-PCR, stratified by number and severity of comorbidities. Result(s): A total of 42,621 subjects were included. Of these, 6,560 had COVID-19. Clinician diagnosis was found in 5,705 subjects, while 3,936 had a positive RT-PCR and 3,081 got diagnosed with both methods. Of those with at least one comorbidity, sensitivity for clinician diagnosis ranged from 69% (95% CI 44-86) for those with two "severe" comorbidities (diabetes and chronic obstructive pulmonary disease) to 84% (95% CI 73-91) for those with two "moderately severe" comorbidities (asthma and hypertension). Specificity was > 90% for all comorbidity groups. Youden's index increased slightly with the number of comorbidities in both "severe" and "moderately severe" categories, but for those with "light" comorbidities (eczema, rhinitis, sleep disorders), it was the lowest with >=2 comorbidities (69% (95% CI 66-72)). Youden's index was 71% (95% CI 70-72) for those with no comorbidities and 71% (95% 69-73) for the whole cohort. Conclusion(s): Clinicians identify non-cases to a high degree, but RT-PCR is needed for adequate sensitivity, regardless of comorbidity.

Case report of an antimelanoma differentiationassociated protein 5 antibody-associated amyopathic dermatomyositis

Autoantibodies against melanoma differentiation-associated protein 5 (MDA5) associated with dermatomyositis have recently been described in Asians with rapidly progressive respiratory disease. Here we report the case of a middle-aged white woman with anti-MDA5 antibody-associated amyopathic dermatomyositis with interstitial lung disease (ILD), which is stable with minimal immune suppression. A 55-year-old woman was referred to a virtual dermatology clinic during the COVID-19 pandemic suspected of having widespread eczema involving the chest, face, arm and hands on the background of atopy. On direct questioning, she admitted to having constitutional symptoms, exertional dyspnoea, joint pain and symptoms of proximal muscle weakness. On clinical suspicion of possible connective tissue disorder, she was urgently reviewed in the hospital, where she was found to have a photodistributed rash involving cutaneous ulceration and violaceous plaques. Hand examination showed mechanic's hand mimicking hand eczema, ragged nail cuticles and acute tenosynovitis in the left index finger. Her upper and lower limb muscle power was normal and respiratory examination revealed bi-basal fine end-expiratory crepitation. Her repeated biochemical, haematological and muscle enzymes remained normal. Skin biopsy taken from photosensitive rash over the wrist showed hypergranulosis, Civatte body formation, colloid bodies and dyskeratotic keratinocytes, in keeping with severe lichenoid eruption. Superficial dermis showed patchy red-cell extravasation, perivascular chronic infiltration, dermal oedema and serum on the surface, in keeping with ulceration secondary to severe inflammatory processes. There were no eosinophils and eccrine coils were free of inflammation, raising the suspicion of a drug eruption. Her antinuclear antibody and double-stranded DNA were repeatedly negative. Myositisspecific antibody panel was performed owing to a high clinical suspicion of photosensitive dermatoses, both clinically and histologically. Histology revealed positive anti-MDA5 antibodies;repeated positive testing confirmed this. Although lung function was normal, computed tomography revealed evidence of ILD. We made a diagnosis of anti-MDA5 antibodyassociated amyopathic dermatomyositis with ILD. Her malignancy screening was negative. The patient was started on lowdose prednisolone and hydroxychloroquine 200 mg twice daily, with topical steroid applications, which resulted in remarkable clinical improvement. Anti-MDA5 associated dermatomyositis has characteristic cutaneous lesions consisting of skin ulceration and tender palmar papules, mechanic's hands, inflammatory arthritis and rapidly progressive ILD, which is frequently fatal. Although our patient had ILD, she was relatively stable on minimal immunosuppression. It is important for clinicians to have an increased awareness of this disease as it could have a highly variable clinical presentation in the white population.

Occupational dermatoses during the second COVID-19 pandemic wave: an audit of 401 healthcare workers

Healthcare workers (HCWs) assessed by dermatologists during the first wave of the COVID-19 pandemic had high rates of irritant hand dermatitis, facial dermatitis and acne triggered by wearing personal protective equipment (PPE) (Ferguson FJ, Street G, Cunningham L et al. Occupational dermatology in the time of the COVID-19 pandemic: a report of experience from London and Manchester, UK. Br J Dermatol 2021;184: 180-2). We report data from a tertiary National Health Service trust during the second COVID-19 wave in winter 2020-21. At its peak, the Trust had 835 COVID-positive inpatients and 263 intensive care unit (ICU) beds - one of the largest ICUs in Europe. Building on the published experience of dermatology units, we ran 30 dermatology pop-up clinics over 3 weeks in allocated rest areas across the Trust: 08.00-09.00 h and 13.00-14.00 h on weekdays, from 18 January 2021. HCWs requiring formal dermatology referral were provided with letters to their line managers. In 3 weeks, 401 HCWs were assessed: 327 females and 74 males (mean age 35 2 years). The most frequently seen occupation was nurses (n = 130;32 4%) followed by doctors (n = 74;18 4%). On average, staff spent 9 5 h in PPE per shift. Consistent with the existing literature, the most common diagnosis was irritant hand dermatitis (n = 186;46 4%). There was an increased incidence of acne (n = 171;42 6%) vs. the first wave, where the reported incidence was 17% in a multicentre study (O'Neill H, Narang I, Buckley DA et al. Occupational dermatoses during the COVID-19 pandemic: a multicentre audit in the UK and Ireland. Br J Dermatol 2021;184: 575-7). Less common in the second wave was facial eczema (n = 50, 12 5%) and pressure injury (n = 30;7 5%). Thirty-one (16 7%) of the HCWs with hand dermatitis required the prescription of potent topical corticosteroids, suggesting at least moderate symptoms. The majority received emollient samples. It was rare for HCWs to require formal referral (n = 11;2 7%). In our cohort, at least four (1 0%) HCWs required time off work owing to their skin problems. Our data support previous reports of increased occupational dermatoses in HCWs during the COVID-19 pandemic. We highlight the sheer scale of the issue, with 401 HCWs presenting for dermatological assessment in only 3 weeks in one trust. Compared with our experience during the first wave, acne exacerbated or precipitated by masks is increasingly common, which may be due to emollient use to prevent facial eczema or injury when wearing masks.