Lentigo maligna (LM) is an in situ melanoma arising on chronically sun-damaged skin predominantly on the head and neck. While surgery is the gold standard treatment for LM, imiquimod 5%, which is an immune-response modifier, is a well-reported off-licence treatment in both primary and adjuvant settings. Various treatment regimens have been published. We present our retrospective experience of using imiquimod to treat LM over 10 years at a UK tertiary melanoma centre. We report on indications, treatment regimes, side-effects and treatment efficacy. We identified 71 patients with LM treated with imiquimod with a mean age at diagnosis of 73.3 years. Ninety-three per cent were located on the head and neck. Forty-three per cent (n = 29/67) of patients were treated primarily (following punch biopsy diagnosis or incomplete excision with visible pigmentation remaining) and 57% (n = 38/67) with adjuvant treatment (excision with narrow or close margins, < 3 mm with no visible pigmentation). Invasive disease was seen in 17% of those treated primarily and 45% treated with adjuvant therapy. There were various treatment regimens, but the majority (55%) had treatment prescribed five times weekly for 11–12 weeks, with no significant difference in treatment regimens between the two treatment groups. Inflammation was recorded as none (20%), mild (21%), moderate (21%) and severe (20%). Side-effects were redness (40%), pain (17%), ulceration (7%) and systemic symptoms (6%). Fifty-nine per cent of the primary group had visible clearance; a previous study reported a 71% clinical response in this cohort. Three of the responders relapsed, with two progressing to LM melanoma within 8 years. Forty-eight per cent remained disease free, with a mean follow-up of 27 months. Of those treated with adjuvant therapy, 89% remained clinically disease free at mean follow-up of 19 months. Recurrence in the adjuvant group was reported as 5.6% (Lallas A, Moscarella E, Kittler H et al. Real-world experience of off-label use of imiquimod 5% as an adjuvant therapy after surgery or as a monotherapy for lentigo maligna. Br J Dermatol 2021; 185:675–7). Our limitations include a lack of post treatment biopsies. In 2021, an Australian study reported a practical guide on the use of imiquimod for LM (Guitera P, Waddell A, Paton E et al. A practical guide on the use of imiquimod cream to treat lentigo maligna. Australas J Dermatol 2021; 62:478–85). We propose the need for clearer UK guidelines describing the escalation and de-escalation of treatment in the event of no response and toxicity, respectively. We suggest using a patient application diary to ensure compliance and document changes in treatment and inflammation.

Amyopathic dermatomyositis (ADM) is a clinical subtype of dermatomyositis, which can be associated with malignancy and lung disease. We report a retrospective review of 21 cases of ADM presenting to a tertiary clinic. We discuss the clinical presentations, investigation, and cancer and lung associations. Patients were included if they met the European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) criteria for ADM. We identified 21 patients with ADM (16 women and five men). Mean age at diagnosis was 61 years (range 35–81). Clinical features were as follows: Gottron papules (n = 15; 71%), nailfold involvement (n = 16; 76%), heliotrope rash (n = 12; 57%), shawl sign (n = 11; 52%), Raynaud phenomenon (n = 9; 43%), scalp disease (n = 6; 29%) and calcinosis (n = 3; 14%). Antinuclear antibody (ANA) was positive in 76% of patients (n = 16) and 41% (n = 9) had myositis-specific antibodies. Four patients had a prediagnosed malignancy. One patient had prostate cancer detected on malignancy screen. One nerve sheath tumour was diagnosed within 1 year of ADM diagnosis and one cholangiocarcinoma within 3 years. Three patients were found to have mild lung fibrosis, but none was found to have severe interstitial lung disease. Patients were treated with corticosteroids (n = 16), hydroxychloroquine (n = 11), metho­trexate (n = 10), mycophenolate (n = 6), cyclophosphamide (n = 3), rituximab (n = 3), intravenous immunoglobulin (n = 3), mepacrine (n = 2), azathioprine (n = 1), ciclosporin (n = 1) and thalidomide (n = 1). In conclusion, in our study, a female preponderance and cutaneous findings involving extremities were seen in the majority of patients (95%), in keeping with other published data (el-Azhary RA, Pakzad SY. Amyopathic dermatomyositis: retrospective review of 37 cases. J Am Acad Dermatol 2002; 46:560–5). Our study further highlights the heterogeneity of cutaneous clinical presentation of ADM, which is broadly consistent with other reported cohorts [el-Azhary and Pakzad; Tang K, Zhang H, Jin H. Clinical characteristics and management of patients with clinical amyopathic dermatomyositis: a retrospective study of 64 patients at a tertiary dermatology department. Front Med (Lausanne) 2021; 8:783416]. We report high levels of hand and nail involvement, emphasizing the need for formal assessment of hands, including dermoscopy of nails. ANA was positive in 76% of patients; other reported data suggest that it is positive in 31.6–71% (el-Azhary and Pakzad; Tang et al.). Although previous studies have found myositis-specific antibodies in 87.5% (Tang et al.), only 42% in our cohort had positive antibodies; therefore, a high index of suspicion is required to detect cases and appropriately screen for associated morbidity (lung disease and malignancy). In addition, a third of patients had associated malignancy prediagnosed or within 3 years of diagnosis, highlighting the importance of baseline screening and ongoing follow-up.

Shellac, the purified resin produced from the female lac bug (Kerria lacca), has its application within a wide range of industries, including healthcare, food, wood treatments and cosmetics. Shellac 20% alcohol is included in the British Society for Cutaneous Allergy/European Society of Contact Dermatitis extended facial series based on frequency of reactions exceeding the 0.3% threshold. However, the source of primary sensitization remains difficult to characterize through patch testing as relevance is not always clear and the test preparation has an irritant potential. We present a series of 28 patients from 2013 to 2022 with positive or irritant reactions to shellac, to elucidate its reaction pattern and relevance within our outpatient population. Cases with confirmed shellac positivity (‘+’ reactions and higher) or irritant reactions using a test preparation with alcohol 20% (Chemotechnique MB Diagnostics, Vellinge, Sweden) on days 2 and 4 of patch testing in a cosmetic series were retrieved between 2013 and 2022 from a total of 5458 people tested. Data collected from records included degree of positivity, irritancy, relevance, coexisting allergens, primary anatomical site and previous history of atopy. Data were processed using Microsoft Excel. We report 21 positive reactions, 14 (67%) of which were weak. Eleven (52%) positive reactions were deemed of current relevance, seven (33%) of doubtful relevance, one (5%) of past relevance and one (5%) a crossreaction to fragrance. Seven (25%) patients had documented irritant reaction to shellac. Nickel and colophony were the most common coexisting allergens in shellac-positive patients (positive in five and four cases, respectively). Nine (43%) cases with positive reaction had coexisting positivity of fragrance markers (which included one or more of geraniol, citral, Evernia furfuracea, turpentine, propolis, colophony, abitol, isoeugenol, cinnamyl alcohol, Jasminum officinale, jasmine absolute, majantole or benzaldehyde), indicating a higher prevalence than existing rates from studies in the general population. Fourteen (67%) positive cases documented the face as the primary site of disease, and 16 (76%) had a personal history of atopy. Our results indicate a significant association between shellac positivity and coexisting fragrance allergy, suggesting a role as a marker of fragrance allergy due to cross-reaction. When comparing irritant reactions to the proportion of positive reactions, this was higher than in previous US population-based reports (five irritant cases vs. 64 positive cases of a total cohort of 612 cases) but significantly lower than in a recent German population-based study (90 irritant cases vs. 76 positive cases of a total cohort of 2167), in all instances using the alcohol 20% preparation.

BackgroundPatients with psoriatic disease(PsD) [psoriasis(PsO) and psoriatic arthritis(PsA)] are at greater risk of non-alcoholic fatty liver disease(NAFLD) and NAFLD-associated fibrosis/cirrhosis compared with the general population and other inflammatory arthritis(1) independent of disease-modifying medications [biological(b)DMARDs or methotrexate(MTX)][2]. Conversely, using these medications in patients with significant NAFLD might accelerate progression to fibrosis/cirrhosis[1]. The Leeds Teaching Hospitals NHS Trust(LTHT) NAFLD screening pathway is not validated in PsD and may underestimate prevalence of NAFLD in PsD[3].Objectives:1.To assess the prevalence of NAFLD in our PsD population2.To determine the effectiveness of the LTHT NAFLD pathway for identifying PsD patients at risk of fibrosis/cirrhosisMethodsThis audit included consecutive patients from the Leeds Specialist Spondyloarthritis and Dermatology departments who underwent screening for NAFLD fibrosis/cirrhosis using the LTHT pathway. Briefly, patients are first screened using ELF and FIB4 scores. ELF>9.5 and FIB4 >1.45 triggers referral for fibroscan and hepatology opinion. A fibroscan >10 was considered indicative of clinically significant NAFLD. We compared baseline demographics (age, sex, BMI, diabetic status), biochemistry (ALT, AST, platelet count, albumin, hepatitis B and C), and NAFLD screening tests (ELF, FIB4 and fibroscan +/- liver ultrasound and biopsy) with the final hepatology diagnosis (NAFLD/ fibrosis/ cirrhosis/ other). We compared results from our PsD patients and patients with other inflammatory arthritis (Other IA).ResultsOverall 110 patients were included; 86.4% (95/110) PsD, and 14.6% (15/110) Other IA. Regarding demographic and clinical variables, age, sex, BMI, AST, ALT, platelets and albumin were similar between all groups. Other IA patients were more likely to be male and taking bDMARD monotherapy. No PsO patients were taking bDMARDs and over half were on no DMARD(Table 1). ELF scores were higher in the PsO group, possibly because the P3NP peptide (part of the ELF score) may be elevated in active skin PsO. Contrastingly, FIB-4 scores were higher in PsA compared with all other groups. Higher FIB4 scores, but not ELF scores, were associated with a fibroscan score >10 and a diagnosis of NAFLD fibrosis/cirrhosis in PsA (p=0.05 and p=0.09 respectively).ConclusionPsA patients had higher rates of significant fibrosis/cirrhosis compared with patients with Other IA. FIB-4 was better than ELF at identifying PsA patients requiring a fibroscan to exclude significant fibrosis/ cirrhosis. Findings will now be validated in a larger prospective cohort study.References[1]Prussick RB, et al.J Clin Aesthet Dermatol.2015;8:43-45.[2]Prussick RB, et al.Br J Dermatol.2017;179:16-29.[3]LTHT Pathways – Suspected NAFLD/ ALD.http://lhp.leedsth.nhs.uk/leedspathways/DEtail.aspx?id=25.Table 1.Summary of demographic and clinical data for the cohortPsA(n=59)PsO(n=36)Other IA(n=15)Age(years)52(±15)48(±13)49(±15)Sex(% male)58(34/59)47(17/36)80(12/15)BMI(kg/m²)33(±5)31(±7)33(±7)Diabetes(%) Yes21(12/58)11(4/36)20(3/15) No67(39/58)81(29/36)73(11/15) Impaired Glucose Tolerance13(7/58)9(3/36)7(1/15)DMARDs MTX32(19/59)39(14/36)20(3/15) bDMARD9(5/59)067(10/15) MTX + bDMARD36(21/59)07(1/15) Other2(1/59)3(1/36)0 None22(13/59)58(21/36)7(1/15)ALT57(±32)37(±26)89(±45)AST42(±22)31(±16)63(±41)Hepatitis B or C1(1/59)00ELF >9.5(%)46(22/48)70(23/33)36(4/11)FIB-4 >1.3(%)38(19/50)20(7/35)27(3/11)Fibroscan median liver stiffness >10(%)31(15/48)83(5/6)25(3/12)Liver US Cirrhosis/fibrosis10(4/41)15(2/13)8(1/13) NAFLD73(30/41)77(10/13)77(10/13) Other17(7/41)00 Normal liver08(1/13)15(2/13)Biopsy Cirrhosis/fibrosis46(5/11)00 NAFLD46(5/11)00 Other000 Normal9(1/11)00Diagnosis (%) Cirrhosis/fibrosis12(7/59)6(2/36)7(1/15) NAFLD66(39/59)19(7/36)80(11/15) Other5(3/59)75(27/36)0 Normal15(9/59)013(2/15) Awaiting diagnosis1(1/59)00Acknowledgements:NIL.Disclosure of InterestsNone Declared.

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