Could virtual dermatology services widen healthcare inequity for patients with chronic skin conditions: are we READHY?

Advances in technology have resulted in increasing adoption of virtual dermatology services across the National Health Service. This has accelerated dramatically during the COVID-19 pandemic. Providing remote consultation alternatives empowers many patients to manage their health away from traditional in-person services. However, there is concern that universal implementation of such services may potentially widen healthcare inequalities for some patient groups. Reliably identifying at-risk groups is challenging. Co-design of health services has been proposed as a method to ensure equality and appropriateness of provision for all patients accessing a service by including them in the design process. In this study we profile the digital health literacy of patients with chronic skin conditions with the aim of using this information to redesign virtual services to support their long-term skin health. The Multidimensional Readiness and Enablement Index for Health Technology (READHY), comprising the eHealth Literacy Questionnaire (eHLQ), Health Literacy Questionnaire (HLQ) and Health Education Impact Questionnaire (heiQ), was used to assess patient skills, confidence and experience in using technology to manage their health. Consecutive patients under long-term follow-up in two specialist clinics supporting chronic skin conditions (organ transplant surveillance and biologics monitoring) completed questionnaires either in person or over the telephone. Between July and November 2021, 99 of 128 (77.3%) of patients invited to participate took part. Overall, these patients showed high levels of self-management skills, determination not to let health problems control their life and good support from family and healthcare professionals. In the domains related to digital skills, the responses were diverse. A cluster analysis identified multiple groups of patients with varying combinations of higher or lower level of digital health literacy, social and healthcare support, as well as capabilities in handling health condition and emotional responses. These preliminary data have provided important information for optimizing a co-design process aimed at tailoring services to support patients with chronic skin diseases. In particular, it has identified patient groups with distinct differences in terms of digital health literacy. Recognition of these groups and their differing profiles in terms of barriers to accessing virtual healthcare will be a key consideration in ensuring equitable representation in the service co-design process. It provides opportunities to target support to those patients with lower digital health literacy skills so that they may benefit from virtual services or adaptation of these services to address their specific needs. Alternatively, it allows recognition of patient groups who have higher digital health literacy and may safely benefit from alternative approaches to service provision such as patient-initiated follow-up.

Is a hybrid skin cancer surveillance service for organ transplant recipients feasible? Lessons from the pandemic

Organ transplant recipients (OTRs) are highly vulnerable to SARS-CoV-2 infection and routine transplant consultations were converted primarily to virtual (VC) rather than face to face (F2F) from the outset of the pandemic. A similar strategy was adopted in our tertiary OTR dermatology clinic, but the implications of this on safe and effective skin cancer surveillance are uncertain. We audited clinical and patient experiences of our hybrid service with the aim of identifying the benefits and limitations of this approach, and improvements required to optimize a future hybrid VC-F2F model for skin cancer surveillance. All OTRs consultations held between 1 April 2020 to 31 March 2021 were identified through electronic patient records. Data collected included proportions and reasons for VC and F2F consultations, teledermatology requests, VC to F2F conversion rate, rates of skin cancer diagnoses and adherence to established follow-up protocols. All patients were invited to complete an online service evaluation. In total, 554 encounters (80.3% VC, 19.7% F2F) were recorded in 247 OTRs (42% with previous skin cancer). Of routine F2F consultations, this was patient preference in 17 of 109 (16%) and clinician-based risk assessment for the remainder. In 108 (25%) VCs, photographs were requested and received for 63%, of which 82% were adequate for diagnosis. Overall, 12% of VCs were converted to F2F and in 19 of 45 (42%) OTRs this was due to suspected skin cancer, which was confirmed in nine of 19 (47%). All other skin cancers were diagnosed in routine F2F consultations. Surveillance in 167 of 192 (87%) assessable OTRs adhered to established follow-up protocols. Of patients who responded to the online survey, 74% felt that there were benefits to VCs, but 41% expressed concern about the lack of skin examination and 57% reported little/no confidence in self-monitoring. Despite this, 59% expressed a preference to continue hybrid VC-F2F surveillance, with VC as routine and F2F consultation when required. Our audit provides preliminary evidence supporting the effectiveness, safety and patient acceptability of a VC-F2F hybrid model for the delivery of OTR skin cancer surveillance. We did not identify major delays in skin cancer diagnosis, although not all patients have yet been seen F2F. Certain aspects of service delivery will require optimization. In particular, despite routine skin cancer education, many patients expressed concerns about self-monitoring. Programmes specifically tailored to address this need will be required, as will information technology support for some OTRs. With this information we are redesigning our service to incorporate a VC-F2F model for routine skin cancer surveillance and are evaluating the incorporation of a patient-initiated follow-up pathway.

Severe epidermolysis bullosa acquisita in a patient with graft-versus-host disease: causal or coincidental?

Graft-versus-host disease (GvHD) is common after haematopoietic cell transplantation (HCT). Mucocutaneous manifestations are variable and may simulate autoimmune bullous dermatoses. However, the association of GvHD with autoimmune disorders, including bullous dermatoses, is also well recognized. We describe a patient with GvHD in whom severe and relapsing epidermolysis bullosa acquisita (EBA) was diagnosed 3 years after transplant and propose a causal association with GvHD. A 66-year-old woman developed GvHD following allogeneic HCT for acute myeloid leukaemia in 2016. This affected her gastrointestinal tract and skin but improved with oral corticosteroids and ciclosporin. In 2019 she presented with a widespread rash consisting of large, tense, haemorrhagic blisters. Histological features were in keeping with EBA. Direct immunofluorescence was also consistent with EBA, demonstrating linear positivity for IgG and C3 confined to the blister base, as was detection of collagen VII antibodies on indirect immunofluorescence. She was admitted and treated with high-dose oral steroids, ciclosporin and intravenous immunoglobulin (IVIg) with eventual resolution of blistering. Although further IVIg administration was planned as an outpatient, this coincided with the start of the COVID-19 pandemic and she elected not to attend and also stopped all medication. Despite this, her EBA remained quiescent until September 2021 when she was readmitted with a severe deterioration in blistering and significant dysphagia due to an oesophageal stricture, with a weight of 31.7 kg. Once again, she responded rapidly to oral prednisolone and IVIg. Dapsone was considered but precluded by G6PD deficiency and there were clinical and adherence concerns about using mycophenolate mofetil. Upon discharge she was again nonadherent to medication and failed to attend for planned IVIg. She flared and was admitted for a third time in December 2021, requiring gastrostomy for nutritional support;her weight at this time was 26.4 kg. Her EBA is currently well controlled on prednisolone and IVIg. EBA is a rare, acquired blistering disorder secondary to autoantibodies targeting type VII collagen. Previous studies have found circulating basement membrane zone (BMZ) antibodies in 24% of chronic GvHD patients, possibly generated in response to chronic BMZ damage (Hofmann SC, Kopp G, Gall C et al. Basement membrane antibodies in sera of haematopoietic cell recipients are associated with graft-versushost disease. J Eur Acad Dermatol Venereol 2010;24: 587-94). Corresponding clinical manifestations are rare, with bullous pemphigoid the most frequently reported. EBA is much less common with four previously reported cases [Brassat S, Fleury J, Camus M, et al. (Epidermolysa bullosa acquisita and graftversus- host disease). Ann Dermatol Venereol 2014;141: 369-73 (in French)]. As a fifth case of EBA, our patient provides further evidence of a likely pathophysiological relationship between GvHD and autoimmune subepidermal bullous dermatoses, and highlights the significant challenges of managing these vulnerable patient groups during the COVID-19 pandemic.

Melanized (dematiaceous) fungal infections simulating skin cancer in African organ transplant recipients

Fungi are the most frequent skin infections in organ transplant recipients (OTRs) and usually present as superficial mycoses. Deeper infections are much less common, potentially more serious and the incidence is higher in the first few months post-transplant. We report two African OTRs with deep fungal infections caused by dematiaceous (melanized, pigmented or black) fungi, who both presented with suspected skin malignancies. A 60-year-old Nigerian man developed a painful, ulcerated, amelanotic, bleeding nodule on his right fourth toe 2 months after renal transplantation. Clinical differential diagnoses included Kaposi sarcoma (KS), amelanotic acral melanoma and subungual squamous cell carcinoma (SCC). However, histology showed pseudoepitheliomatous hyperplasia, extensive mixed inflammation, multinucleated giant cells and pigmented septate hyphae with rounded 'budding' forms. Periodic acid-Schiff, Grocott and Masson-Fontana stains were positive, and Alcian blue stain was negative, consistent with infection by a dematiaceous fungus. Fungal 18S polymerase chain reaction (PCR) was positive and culture identified Nigrograna mackinnonii. Treatment with oral itraconazole was supervised virtually during the COVID-19 pandemic. After 6 months there was minimal response and he opted for amputation of the digit. A 61-year-old Nigerian man presented 2 months after renal transplantation with a 2-cm diameter nodule on his left thigh at the site of a previous burn. This failed to respond to antibiotics. Magnetic resonance imaging was suggestive of possible malignancy, but surgery was deferred because of the COVID-19 pandemic. Two months later the lesion was 5 cm in diameter and verrucous with an 8-cm sessile, purplish plaque on his right forearm. Atypical KS, lymphoma and chronic burns-associated SCC were all considered. However, histology from both lesions was similar to the first patient. Fungal culture and 18S PCR confirmed infection with the dematiaceous fungus Alternaria alternata. At his request, the right thigh lesion was excised. The lesion on his forearm has partially responded to 8 months of ongoing oral itraconazole. In our African OTR cohort, KS is more common than deep fungal infection. However, despite this suspicion of skin malignancy, both patients had phaeohyphomycoses caused by dematiaceous fungi. Characterized by the presence of melanin in their cell walls, > 130 species of these plant pathogens and soil saprophytes are implicated in human disease, particularly in immunocompromised individuals. Although localized skin diseases (phaeohyphomycoses, chromoblastomycosis and mycetoma) are the most common manifestations, rare disseminated, central nervous system and pulmonary infections may prove fatal. Although uncommon, deep fungal infection should be considered in atypical skin lesions in OTRs;histology, tissue culture and fungal PCR are critical to confirming this diagnosis.