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.

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.

No abstract

Keloids and hypertrophic scars remain a frustrating and common entity posing continued challenges. A case of an 8-yearold girl with a painful keloid scar on the right arm subsequent to a history of varicella zoster virus inspired us to review the available evidence on the best treatment modality, given her substantial needle phobia. There is a plethora of treatment options available in the pursuit of their notoriously difficult elimination; however, none is more accessible, cheap or patient centric than topical treatments. 1 We searched the MEDLINE and Embase databases and the Clinical Trials Registry from inception to 7 January 2022. The findings are summarized in a PRISMA flow diagram (https:// doi.org/10. 6084/m9.figshare.19874242.v1). The studies exhibited a high degree of heterogeneity in designs and methods with notable variation in outcome measurement across studies, and therefore meta-analysis was not performed. The Cochrane Risk of Bias tool (Figure 1) emphasizes further the impact of selection, performance and detection bias, alongside the prevalence of incomplete outcome data.