Technology-enhanced learning interventions on skin of colour dermatology for dermatology trainees and fellows: are they effective or sustainable?

Recent shifts towards synchronous online learning and raised awareness of ethnic inequalities in health have resulted in the establishment of frequent 'one-off' technology-enhanced learning (TEL) initiatives on diversity issues. There is little established evidence regarding the efficacy or sustainability of such interventions. We designed a prospective cohort pilot study including 14 dermatology registrars and fellows and delivered a TEL programme focusing on central centrifugal cicatricial alopecia and keloid scarring. Information was collected on the existing competence and confidence of our cohort about managing these conditions, as well as the short-term and long-term impact of our intervention. Following our programme, participant knowledge improved transiently, but was not sustainable 6 weeks later. Over half of participants were not confident in adopting newly acquired knowledge on skin of colour into practice. Results demonstrate a disparity between how effective one-off education initiatives are perceived vs. actual benefit. More systemic solutions may be warranted.

Cutaneous lupus associated with pembrolizumab therapy for advanced melanoma: a report of three cases.

Checkpoint blockade immunotherapy has revolutionized the treatment of advanced melanoma, with impressive survival benefits attained through upregulation of the anticancer immune response. Blockade of regulatory checkpoint molecules can, however, also result in aberrant immune activation leading to undesirable inflammation and autoimmunity. Although many genetic determinants have been described in patients with primary autoimmune diseases, it is uncertain whether patients developing autoimmune skin disease as an adverse effect of anti-PD-1 therapy share the same genetic risks. Furthermore, it is also unclear whether treatment with these agents can result in the unveiling of underlying 'silent' autoimmunity resulting in chronic inflammatory disease. We report three cases of cutaneous lupus associated with pembrolizumab therapy for advanced melanoma. One patient had a previous diagnosis of histologically proven discoid lupus erythematosus, well-controlled without treatment for over 2 years, which flared on first exposure to pembrolizumab. The remaining two patients had no previous history of autoimmune disease; both developed cutaneous eruptions, histologically and immunohistologically, in keeping with subacute cutaneous lupus following treatment with pembrolizumab. Our report bolsters what is currently an exceedingly small body of evidence documenting the development of cutaneous lupus in the setting of pembrolizumab therapy. Our third case specifically documents an otherwise unreported severe reflare of previously diagnosed, quiescent discoid lupus erythematosus in the setting of pembrolizumab, vividly highlighting the potential for autoimmune and specifically, lupus reactivation in the setting of anti-PD-1 therapy.

Infective Exacerbation of Pasteurella multocida.

An 89-year-old lady presented with a one-day history of shortness of breath as well as a cough productive of brown sputum. Her medical history was significant for chronic obstructive pulmonary disease (COPD). She was in severe type one respiratory failure and blood tests revealed markedly raised inflammatory markers; however her chest X-ray was clear. On examination there was bronchial breathing with widespread crepitations and wheeze. She was treated as per an infective exacerbation of COPD. Subsequent blood cultures grew Pasteurella multocida, a common commensal in the oropharynx of domesticated animals. The patient was then asked about any contact with animals, after which she revealed she had a dog and was bitten on her left hand the day before admission. We should not forget to enquire about recent history of injuries or animal bites when patients present acutely unwell. She made a complete recovery after treatment with penicillin.

A teenager with lumbar striae distensae (when a bruise is not a bruise).

A 14-year-old boy was referred to a paediatric clinic after a recent diagnosis of coeliac disease, which was well controlled on a gluten-free diet. During the consultation, the mother raised concerns regarding marks that had developed over her son's back over the past 6 months. On examination, a number of horizontal, coloured bruise-like marks were noted over the lower back. The appearance was suspicious of bruising and possible non-accidental injury, although a history of trauma or injury was denied. Blood tests including a coagulation screen were arranged which were normal and the patient was followed up twice during a 6-month period. He remained well but the bruising was persistent. It was concluded that these were striae associated with pubertal growth. This case summarises the importance of careful surveillance of bruising in children and illustrates the association between striae and pubertal growth which may be confused with non-accidental injury.