Efficient triaging of advice and guidance referrals using teledermatology via the UK National Health Service e-Referral service platform: reporting positive outcomes from the COVID era.

BACKGROUND: Substantial increases in the implementation and use of dermatology advice and guidance (A&G) services has been a legacy of the COVID pandemic. OBJECTIVES: To evaluate the impact that a 45-month period of A&G use had on the health service outcomes in a university teaching hospital dermatology department. METHODS: A&G data for June in 2019, 2020, 2021 and 2022 were retrospectively analysed. Areas analysed included: total number of A&G requests; number of requests converted to referrals; percentage of discharges at first attendance; and referral-to-treatment (RTT) performance (defined as percentage of referrals seen by 18 weeks). RESULTS: A&G requests increased over the study period, from 45 requests in June 2019 to 1384 in June 2021. Increased request numbers were because of the COVID-19 pandemic, and then a subsequent change to the referral pathway. In January 2021, A&G became the obligatory referral route for all routine referrals to our department. The percentage of A&G requests converted to referral were 22.4%, 46.4%, 43.4% and 52.2% in June 2019, 2020, 2021 and 2022, respectively. Between 2019 and 2022 our discharges at first attendance decreased from 36.7% to 29.0%. RTT performance remained consistently above the national average; local RTT performances were 95.2% (2543/2671), 59.8% (782/1308), 90.1% (1697/1884) and 87.9% (1660/1888), in June 2019, 2020, 2021 and 2022, respectively, which compared favourably against RTT figures for England (90.2%, 56.5%, 78.2% and 65.1%). CONCLUSIONS: We highlight to other NHS dermatology departments the positive impact A&G triaging can have on outcomes, as observed for our service, reducing our discharges at first attendance and maintaining an RTT performance above the national average.

Chat GPT vs Clinician: challenging the diagnostic capabilities of A.I. in dermatology.

BACKGROUND: Chat Generative Pre-trained Transformer (Chat GPT) is an online language-based platform, designed to answer questions in a human-like way, using deep learning technology. OBJECTIVE: To examine the diagnostic capabilities of Chat GPT using real world, anonymised, medical dermatology cases. METHODS: Clinical information from 90 consecutive patients referred to a single dermatology emergency clinic between June to December 2022 were examined. Thirty-six patients were included. Anonymised clinical information was transcribed and input into Chat GPT 4.0 followed by the question "what is the most likely diagnosis?". The suggested diagnosis made by Chat GPT was then compared to the diagnosis made in dermatology. RESULTS: After inputting a clinical history and examination by a dermatologist, Chat GPT made a correct primary diagnosis 56% of the time (20/36). Using the clinical history and cutaneous signs from non-specialists, it was able to make a correct diagnosis 38% of the time (14/36). This was similar to the diagnostic rate of non-specialists 36% (13/36), although much lower than dermatologists (83%, 30/36). There was no differential offered by referring sources 27% of the time (10/36), unlike chat GPT which provided a differential diagnosis 100% of the time. Qualitative analysis showed Chat GPT offered responses with caution, often justifying reasoning. CONCLUSION: This study illustrates that whilst Chat GPT has a diagnostic capability, in its current form it does not significantly improve diagnostic yield in primary or secondary care.

Association of Clinical and Demographic Factors With the Severity of Palmoplantar Pustulosis.

Importance: Although palmoplantar pustulosis (PPP) can significantly impact quality of life, the factors underlying disease severity have not been studied. Objective: To examine the factors associated with PPP severity. Design, Setting, and Participants: An observational, cross-sectional study of 2 cohorts was conducted. A UK data set including 203 patients was obtained through the Anakinra in Pustular Psoriasis, Response in a Controlled Trial (2016-2019) and its sister research study Pustular Psoriasis, Elucidating Underlying Mechanisms (2016-2020). A Northern European cohort including 193 patients was independently ascertained by the European Rare and Severe Psoriasis Expert Network (2014-2017). Patients had been recruited in secondary or tertiary dermatology referral centers. All patients were of European descent. The PPP diagnosis was established by dermatologists, based on clinical examination and/or published consensus criteria. The present study was conducted from October 1, 2014, to March 15, 2020. Main Outcomes and Measures: Demographic characteristics, comorbidities, smoking status, Palmoplantar Pustulosis Psoriasis Area Severity Index (PPPASI), measuring severity from 0 (no sign of disease) to 72 (very severe disease), or Physician Global Assessment (PGA), measuring severity as 0 (clear), 1 (almost clear), 2 (mild), 3 (moderate), and 4 (severe). Results: Among the 203 UK patients (43 men [21%], 160 women [79%]; median age at onset, 48 [interquartile range (IQR), 38-59] years), the PPPASI was inversely correlated with age of onset (r = -0.18, P = .01). Similarly, in the 159 Northern European patients who were eligible for inclusion in this analysis (25 men [16%], 134 women [84%]; median age at onset, 45 [IQR, 34-53.3] years), the median age at onset was lower in individuals with a moderate to severe PGA score (41 years [IQR, 30.5-52 years]) compared with those with a clear to mild PGA score (46.5 years [IQR, 35-55 years]) (P = .04). In the UK sample, the median PPPASI score was higher in women (9.6 [IQR, 3.0-16.2]) vs men (4.0 [IQR, 1.0-11.7]) (P = .01). Likewise, moderate to severe PPP was more prevalent among Northern European women (57 of 134 [43%]) compared with men (5 of 25 [20%]) (P = .03). In the UK cohort, the median PPPASI score was increased in current smokers (10.7 [IQR, 4.2-17.5]) compared with former smokers (7 [IQR, 2.0-14.4]) and nonsmokers (2.2 [IQR, 1-6]) (P = .003). Comparable differences were observed in the Northern European data set, as the prevalence of moderate to severe PPP was higher in former and current smokers (51 of 130 [39%]) compared with nonsmokers (6 of 24 [25%]) (P = .14). Conclusions and Relevance: The findings of this study suggest that PPP severity is associated with early-onset disease, female sex, and smoking status. Thus, smoking cessation intervention might be beneficial.

Loss-of-Function Myeloperoxidase Mutations Are Associated with Increased Neutrophil Counts and Pustular Skin Disease.

The identification of disease alleles underlying human autoinflammatory diseases can provide important insights into the mechanisms that maintain neutrophil homeostasis. Here, we focused our attention on generalized pustular psoriasis (GPP), a potentially life-threatening disorder presenting with cutaneous and systemic neutrophilia. Following the whole-exome sequencing of 19 unrelated affected individuals, we identified a subject harboring a homozygous splice-site mutation (c.2031-2A>C) in MPO. This encodes myeloperoxidase, an essential component of neutrophil azurophil granules. MPO screening in conditions phenotypically related to GPP uncovered further disease alleles in one subject with acral pustular psoriasis (c.2031-2A>C;c.2031-2A>C) and in two individuals with acute generalized exanthematous pustulosis (c.1705C>T;c.2031-2A>C and c.1552_1565del;c.1552_1565del). A subsequent analysis of UK Biobank data demonstrated that the c.2031-2A>C and c.1705C>T (p.Arg569Trp) disease alleles were also associated with increased neutrophil abundance in the general population (p = 5.1 × 10-6 and p = 3.6 × 10-5, respectively). The same applied to three further deleterious variants that had been genotyped in the cohort, with two alleles (c.995C>T [p.Ala332Val] and c.752T>C [p.Met251Thr]) yielding p values < 10-10. Finally, treatment of healthy neutrophils with an MPO inhibitor (4-Aminobenzoic acid hydrazide) increased cell viability and delayed apoptosis, highlighting a mechanism whereby MPO mutations affect granulocyte numbers. These findings identify MPO as a genetic determinant of pustular skin disease and neutrophil abundance. Given the recent interest in the development of MPO antagonists for the treatment of neurodegenerative disease, our results also suggest that the pro-inflammatory effects of these agents should be closely monitored.

Genome-wide association study in frontal fibrosing alopecia identifies four susceptibility loci including HLA-B*07:02.

Frontal fibrosing alopecia (FFA) is a recently described inflammatory and scarring type of hair loss affecting almost exclusively women. Despite a dramatic recent increase in incidence the aetiopathogenesis of FFA remains unknown. We undertake genome-wide association studies in females from a UK cohort, comprising 844 cases and 3,760 controls, a Spanish cohort of 172 cases and 385 controls, and perform statistical meta-analysis. We observe genome-wide significant association with FFA at four genomic loci: 2p22.2, 6p21.1, 8q24.22 and 15q2.1. Within the 6p21.1 locus, fine-mapping indicates that the association is driven by the HLA-B*07:02 allele. At 2p22.1, we implicate a putative causal missense variant in CYP1B1, encoding the homonymous xenobiotic- and hormone-processing enzyme. Transcriptomic analysis of affected scalp tissue highlights overrepresentation of transcripts encoding components of innate and adaptive immune response pathways. These findings provide insight into disease pathogenesis and characterise FFA as a genetically predisposed immuno-inflammatory disorder driven by HLA-B*07:02.

Clinical and genetic differences between pustular psoriasis subtypes.

BACKGROUND: The term pustular psoriasis indicates a group of severe skin disorders characterized by eruptions of neutrophil-filled pustules. The disease, which often manifests with concurrent psoriasis vulgaris, can have an acute systemic (generalized pustular psoriasis [GPP]) or chronic localized (palmoplantar pustulosis [PPP] and acrodermatitis continua of Hallopeau [ACH]) presentation. Although mutations have been uncovered in IL36RN and AP1S3, the rarity of the disease has hindered the study of genotype-phenotype correlations. OBJECTIVE: We sought to characterize the clinical and genetic features of pustular psoriasis through the analysis of an extended patient cohort. METHODS: We ascertained a data set of unprecedented size, including 863 unrelated patients (251 with GPP, 560 with PPP, 28 with ACH, and 24 with multiple diagnoses). We undertook mutation screening in 473 cases. RESULTS: Psoriasis vulgaris concurrence was lowest in PPP (15.8% vs 54.4% in GPP and 46.2% in ACH, P < .0005 for both), whereas the mean age of onset was earliest in GPP (31.0 vs 43.7 years in PPP and 51.8 years in ACH, P < .0001 for both). The percentage of female patients was greater in PPP (77.0%) than in GPP (62.5%; P = 5.8 × 10-5). The same applied to the prevalence of smokers (79.8% vs 28.3%, P < 10-15). Although AP1S3 alleles had similar frequency (0.03-0.05) across disease subtypes, IL36RN mutations were less common in patients with PPP (0.03) than in those with GPP (0.19) and ACH (0.16; P = 1.9 × 10-14 and .002, respectively). Importantly, IL36RN disease alleles had a dose-dependent effect on age of onset in all forms of pustular psoriasis (P = .003). CONCLUSIONS: The analysis of an unparalleled resource revealed key clinical and genetic differences between patients with PPP and those with GPP.

Coloured sweat in two brothers: First report of familial chromhidrosis.

The uncommon diagnosis of chromhidrosis is most frequently made in young adults. This sweat gland disease, although benign, may impact significantly on the patient's quality of life. We describe the first report of familial chromhidrosis of pseudo-eccrine type (pseudochromhidrosis) occurring in two brothers aged 9 and 12 years. The classification and causality of chromhidrosis is described and approaches to assessment and management are outlined.

Unilateral Beau's lines associated with a fractured olecranon.

We report a case of unilateral Beau's lines developing after an olecranon fracture of the right elbow. Unilateral Beau's lines are an uncommon phenomenon but have been previously reported after trauma to the wrist, hands, forearm and elbow.

Clinical improvement in Darier's disease with photodynamic therapy.

We report a patient with Darier's disease successfully treated with photodynamic therapy. She had previously been recalcitrant to treatment with emollients, topical corticosteroids and retinoids. Photodynamic therapy was trialled with significant clinical improvement in her cutaneous symptoms and signs that was maintained for over 27 months.

The cutaneous biochemical redox barrier: a component of the innate immune defenses against sensitization by highly reactive environmental xenobiotics.

Contact allergy to environmental xenobiotics is a common and important problem, but it is unclear why some chemicals are potent sensitizers and others weak/nonsensitizers. We explored this by investigating why similar chemicals, 2,4-dinitrochlorobenzene (DNCB) and 2,4-dinitrothiocyanobenzene (DNTB), differ in their ability to induce contact hypersensitivity (CHS). DNCB induced CHS in humans, whereas at similar doses DNTB did not. However, following DNCB sensitization, DNTB elicited CHS in vivo and stimulated DNCB-responsive T cells in vitro, suggesting that differences in response to these compounds lie in the sensitization phase. In contrast to DNCB, DNTB failed to induce emigration of epidermal Langerhans cells in naive individuals. Examination for protein dinitrophenylation in skin revealed that DNCB penetrated into the epidermis, whereas DNTB remained bound to a thiol-rich band within the stratum corneum. DNTB reacted rapidly with reduced glutathione in vitro and was associated with a decrease in the free thiol layer in the stratum corneum, but not in the nucleated epidermis. By contrast, DNCB required GST facilitation to react with gluthathione and, following penetration through the stratum corneum, depleted thiols in the viable epidermis. Chemical depletion of the thiol-rich band or removing it by tape stripping allowed increased penetration of DNTB into the epidermis. Our results suggest that the dissimilar sensitizing potencies of DNCB and DNTB in humans are determined by a previously undescribed outer epidermal biochemical redox barrier, a chemical component of the innate immune defense mechanisms that defend against sensitization by highly reactive environmental chemicals.

Investigation of mechanisms underlying the T-cell response to the hapten 2,4-dinitrochlorobenzene.

T-cell mediated contact sensitization by small molecular weight xenobiotics results in significant morbidity and absences from work. To be recognized by T-cells, xenobiotics must act as haptens, becoming protein-bound. At present, the requirement for processing and presentation of xenobiotics, the nature of the T-cell responses to them and the mechanisms that confer individual susceptibility in humans are unclear. We have investigated the T-cell response to the hapten 2,4-dinitrochlorobenzene (DNCB) which can sensitize all immunocompetent people. Fourteen healthy adults were sensitized with DNCB; 11 demonstrated positive T-cell responses to the chemical in vitro. Responding cells were of both CD4+ and CD8+ subsets, of Th1 and Tc1 phenotypes, producing high levels of IFN-gamma and low levels of IL-10. DNCB-specific T-cell clones were raised from 2 subjects, which in the presence of fixed and unfixed autologous Epstein-Barr virus transformed B cells as antigen-presenting-cells (APC), demonstrated that the chemical requires metabolic processing by the APC in order to initiate the T-cell response. Intracellular-reduced glutathione is consumed in detoxication of DNCB, leaving residual non-detoxified DNCB free to bind to proteins. The results suggest that DNCB forms multiple haptens with intracellular and extracellular proteins leading to Th1 and Tc1 responses in individuals exposed to this compound.

Peroxisome proliferator-activated receptors and their relevance to dermatology.

Peroxisome proliferator-activated receptors (PPARs) are members of the nuclear hormone receptor superfamily and are expressed in a variety of tissues including skin and cells of the immune system. They act as ligand-dependent transcription factors which heterodimerize with retinoid X receptors to allow binding to and activation of PPAR responsive genes. Through this mechanism, PPAR ligands can control a wide range of physiological processes. Based on their effects in vitro and in vivo PPAR agonists and antagonists have the potential to become important therapeutic agents for the treatment of various skin diseases. PPARs can also be activated directly by phosphorylation to have ligand-independent effects. This review will discuss the physiology of PPARs relating this to skin pathology and their role as a target for novel therapies.