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Australasian Journal of Dermatology (2015) 56 (Suppl. 2), 1–87

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 16–19 May 2015 Adelaide, South Australia Registrars’ Training Session Evidence-based medicine – basic principles S. Zagarella, K. Chen Concord Hospital, Concord, New South Wales, Australia EBM is being added to the new curriculum, and will be examinable in future. It is a most important topic, as it deals with critical appraisal of published papers, a skill that is not intuitive, but must be learned and studied. This lecture will be added to a bank of resources for registrar study on this topic, in addition to Skin Schools on the topic, and a new module to be added to the College website. This lecture will introduce some important concepts including the hierarchy of evidence, sensitivity, specificity, OR, RR, Likelihood ratios, PPV, NPV etc. P values and confidence intervals are concepts that many people talk about every day, but perhaps do not understand as deeply as they think. Different types of studies will be discussed and the biases inherent in them.

Registrars’ Forum Assessment of delays to diagnosis of nodular melanoma compared to superficial spreading melanoma M. Cicchiello, M.J. Lin, J.W. Kelly Victorian Melanoma Service, Alfred Hospital, Melbourne, Victoria, Australia Introduction: Nodular melanomas (NMs) are aggressive tumours which contribute disproportionately to melanoma associated deaths. Their atypical clinical presentation may result in delays in diagnosis and missed opportunities for diagnosis. Method: 60 patients with primary cutaneous NMs were randomly identified from the prospectively maintained database of the Victorian Melanoma Service in the period between April 2008 and September 2012. This database includes all biopsy proven melanomas referred to the institution from a variety of general practitioners, dermatologists and surgeons in the community. 60 patients with primary cutaneous invasive superficial spreading melanomas (SSMs) were then identified from the database, using a matching process to account for the variables of age, sex and date of biopsy. A single interviewer conducted phone

interviews for all patients using a standardised questionnaire. Information on the pathway to melanoma diagnosis was compared for NMs and SSMs. Results: Patients with NMs had more consultations with doctors prior to biopsy compared to patients with SSMs. NMs were less likely than SSMs to be immediately biopsied on the first consultation (32% vs 57%, p = 0.01). Compared to patients with SSMs, patients with NMs were almost twice as likely to be falsely reassured by the first doctor they consulted that their melanoma was benign (27% vs 50%, p = 0.01). The maximum number of doctor visits prior to biopsy of a SSM was 3 (in 7% of SSM cases). In comparison, 33% of NMs were biopsied after 3 or more visits to a doctor, including 5% which required 6 visits to a doctor prior to biopsy.

Multiple Orf lesions in an immunocompetent patient treated successfully with imiquimod A. Ingham1,2, R. Manifold2, L. Gordon2 1 Department of Dermatology, Flinders Medical Centre, Adelaide, South Australia, Australia 2 Department of Dermatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia Orf in humans is caused by direct inoculation with parapoxvirus from infected sheep and goats. A recent study in Australian sheep found 0.03% are infected (1). We report a rare case of multiple orf in a healthy 16-year-old boy. He reported a one week history of erythematous haemorrhagic exophytic nodules arising on his left arm following a sheep shearing session a week prior on his property in rural New South Wales. The lesions had arisen within the locations of trauma from the shears to his forearm and hand and some up to 4 cm in size. The lesions were further traumatised by the patient’s attempts to remove burrs from his skin with a sewing needle. He was initially commenced on oral clindamycin as a diagnosis of MRSA abscesses was considered. Following dermatology consultation, an incisional biopsy was taken and histology was supportive of orf. He was treated with three weekly application of topical imiquimod with good effect. Our case highlights that multiple lesions of orf can arise in healthy hosts in instances of widespread trauma to the skin. Recognition of these lesions is important to ensure appropriate treatment is administered and adequate reassurance given to patient regarding self-resolution.

Reference 1.

Meat and Livestock Australia. Investigating incidence of Scabby Mouth during live export. Professional Agricultural Services Pty Ltd. October 2012. [cited 3 Dec 2014]. Available from www.mla .com.au.

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

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Australasian Journal of Dermatology (2015) 56

The off-label use of infliximab in dermatology: a review of 22 cases M. Abikhair1,2, M.S. Goh1,2, A.H. Chong1,2, R. Kelly1, H. Saunders1, P. Foley1,2, C. Baker1,2. 1 Department of Dermatology, St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia 2 Skin and Cancer Foundation Inc., Melbourne, Victoria, Australia Introduction: Infliximab, a chimeric monoclonal antibody against TNF alpha, is efficacious in multiple dermatological conditions.1,2 However the high cost of this medication and a lack of randomised controlled trials limit its accessibility. Currently on the Australian PBS funding system, infliximab is indicated for severe chronic plaque psoriasis only. Method: A retrospective clinical audit was performed, identifying 22 patients at our institution who received Infliximab for a non-PBS dermatological condition between 2004 and 2014. The most common indication for infliximab was severe, recalcitrant hidradenitis suppurativa (12 patients), followed by severe pyoderma gangrenosum (7), with three other conditions also identified. Completion of pre-treatment screening and objective scoring measures were reviewed. Results: All patients with hidradenitis suppurativa demonstrated improvement from baseline, with 75% having a documented life-changing response. Of the 7 patients with pyoderma gangrenosum, 6 demonstrated significant improvement permitting weaning of concurrent immunosuppression. Over half either completely healed or proceeded to surgical grafting. The mortality rate in our pyoderma cohort was consistent with previously published data and was attributable to advanced age and significant co-morbid illness.3 Conclusion: Our results support the benefit of this high cost medication in a cohort of severe and treatmentresistant patients.

been providing online educational and consultational services in dermatology to doctors Australia wide for over a decade. The site provides specific patient advice on cases submitted by treating doctors. Utilisation of this aspect of Tele-Derm National has grown steadily with over 800 cases submitted in the last 18 months alone. Additionally, TeleDerm National provides a unique educational opportunity for rural doctors, general practitioners, and medical students. Methods: Retrospective case analysis was performed on a random selection of submitted patient cases. The different types of patient presentations and their reason for submission for specialist opinion were analysed. The quality of clinical information provided was also evaluated. Additionally, the range of geographical locations and the characteristics of those towns and cities were explored. Results: There was approximately equal numbers of male and female patients submitted with almost a third being paediatric cases. Most cases were from the outpatient setting and of patients with ‘rash’ or dermatitis (66%). The average time from submission to Dermatologist reply was 5 1⁄2 hours. Clinical photos were provided in 83% of cases and 73% were assessed as good quality. Management advice was provided in 77% of cases. Reference to the online casebased learning modules was made in 21% of cases. Cases were submitted from locations Australia-wide. Conclusion: This study has identified the common dermatological complaints presenting to rural primary care doctors. The additional provision of professional development opportunities included in Telederm is unique and is used as an adjunct to advice provided to the rural doctors seeking advice for patient management.

Kimura’s disease arising from nodular prurigo C. Kalai1, R. Brand2 1 Skin & Cancer Foundation, Carlton, Victoria, Australia 2 Mercy Hospital, Mt Lawley, Western Australia, Australia

References 1.

Sockolov et al (2009). Non-psoriatic uses of monoclonal antibody therapy. Journal of Dermatological Treatment. 2009; 20: 319–327. 2. Rott, Mrowietz (2007). The use of infliximab in Dermatology. JDDG. 2007; 5: 655–60. 3. Saracino et al (2011). Pyoderma Gangrenosum requiring inpatient management: a report of 26 cases with follow up. AJD. 2011; 52: 218–21.

Telederm National: a decade of teledermatology L. Byrom1,3, L. Lucas2, V. Sheedy2, K. Madison2, G. Castrisos3, C. Alfonzo3, F. Chiu3, J. Muir1,2,3 1 Dermatology Department, Mater Misericordiae Health Service, Brisbane, Queensland, Australia 2 Australian College of Rural and Remote Medicine, Brisbane, Queensland, Australia 3 University of Queensland, Brisbane, Queensland, Australia

Kimura’s disease is a chronic inflammatory disorder of unknown aetiology that most commonly presents as subcutaneous masses in the head and neck region or painless lymphadenopathy. Although the pathophysiology is unknown, Kimura’s disease is hypothesized to be a Type 1, immunoglobulin E (IgE)-mediated hypersensitivity reaction.1 A 68-year-old gentleman with longstanding prurigo nodularis on a background of renal disease, diabetes and anxiety develops multiple painless subcutaneous nodules. Biopsies showed Kimura’s disease arising from prurigo nodules, suggesting another possible aetiology of Kimura’s disease.

Reference 1.

Ohta N, Fukase S, Suzuki Y, Ito T, Yoshitake H, Aoyagi M. Increase of Th2 and Tc1 cells in patients with Kimura’s disease. Auris. Nasus. Larynx 38(1): 77–82.

Introduction: Tele-Derm National is an initiative of the Australian College of Rural and Remote Medicine and has © 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 Scar outcomes in dermatologic surgery B. Kim1,2, J. Norman1,2, M. Sgarioto1,2, D. Hewitt1,2, R. Paver1,2, P. Fernandez-Penas1,2 1 Skin and Cancer Foundation Australia, Westmead, New South Wales, Australia 2 University of Sydney, Camperdown, New South Wales, Australia Introduction: The trauma inflicted on the skin and the foreign bodies introduced from suture materials may alter the process of wound healing. It is important to identify measures to reduce the risk of surgical complications. Method: A total of 212 patients were recruited from March 2011 to February 2014. Patients were assessed by two dermatologists. Surgical site, closure type, defect size, scar length, suture type and size were recorded. Patients were followed-up at 6 weeks and 6 months for complications including abscess formation, granuloma formation, scar spreading, suture spitting and hypertrophic scar formation. Results: The mean age of patients was 66 years. Dermatologic surgery was performed most frequently on the face (49.5%), followed by the trunk (31.8%).

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long-term antibiotics. Excision revealed impressive lymphoplasmacytic infiltration of mainly IgG4 + plasma cells accompanying CD4+ lymphocytes and storiform fibrosis. His serum IgG and IgG4 were normal. To date he has no other signs or symptoms of IgG4-RD or recurrence of the lump. Tokura et al1 recently classified IgG4-related skin diseases into 7 subtypes. These were divided into primary eruptions and secondary eruptions without mass formation by plasma cells.1 High levels of circulating IgG4 are seen in up to 60–70% of patients. Biopsy of the affected organ reveals the features seen in the case presented herein. In most cases several organs such as the pancreas, salivary and lacrimal glands are also involved. Oral glucocorticoids produce a therapeutic response in most patients.

Reference 1.

Tokura Y, Yagi H, Yanaguchi H, Majima Y, Kasuya A, Ito T, & Hashizume H. (2014). IgG4-related skin disease. British Journal of Dermatology 171(5): 959–67.

Complications at six weeks were: scar spreading (5.6%), suture spitting (10.8%), granuloma (8.5%), hypertrophic scarring (2.4%), and abscess formation (4.7%). At six months, complications included scar spreading (9.9%), suture spitting (4.7%), hypertrophic scarring (1.4%).

Think UV, not heat! C. Wong, R. Nixon Occupational Dermatology Research and Education Centre, Skin and Cancer Foundation Inc, Carlton, Victoria, Australia

Using bivariate analysis, the risk of granuloma formation was greater with increasing defect size length, width, and scar length (p < 0.05) at 6 weeks. The risk of suture spitting was related to the operating surgeon (p < 0.05). We could not find any factor related to scar spreading. On the other hand, at 6 months, scar spreading, the only complication that appeared in more than 5% of the patients, was most likely to occur with the larger suture size (p < 0.05), correlated with increased scar length (p < 0.05), more likely to occur on the trunk (p < 0.05) and depended on the operating surgeon (p < 0.01).

Introduction: Australia has the highest incidence of skin cancer in the world, a preventable disease caused primarily by exposure to ultraviolet radiation (UVR) in sunlight. Health promotion strategies play a significant role in sun protection.

Localised IgG4-related skin disease, a rare clinical entity P. Sobarun1, A. Yung1, D. Lamont2, P. Emanuel3 1 Department of Dermatology, Waikato Hospital, Hamilton, New Zealand 2 Department of Pathology, Waikato Hospital, Hamilton, New Zealand 3 Department of Pathology, Auckland District Health Board, New Zealand IgG4-related disease (IgG4-RD) is a recently defined clinical syndrome characterized by infiltration of tissues by IgG4+ plasma cells. We describe a 74-year-old man who developed a lump on the medial aspect of his left arm at the insertion site of a PICC line. His history was significant for psoriasis, psoriatic arthritis and ongoing prosthetic hip infection requiring

Method: A cross-sectional study was performed using questionnaires completed at corporate skin checks in Melbourne, Victoria. This was conducted on 668 participants during 2011 to 2013. Results: Over a quarter (n = 170, 25.4%) of participants did not understand that sunburning was related to high levels of UVR, which occur in summer. Almost a fifth (n = 122, 18%) associated the heat of February with highest UVR. Understanding these concepts is important for Australians residing in cooler parts of southern Australia, as UVR levels may be high and yet the temperature may be relatively cool. Conclusion: From a public health perspective, there needs to be more emphasis on UVR in sun awareness campaigns in order to prompt sun protective behaviours. It is also vital for dermatologists to have an understanding of UVR concepts and incorporate such patient education into their routine skin assessments, as well as communicating the complex message regarding obtaining adequate solarinduced Vitamin D, providing advice on the early detection of skin cancers and recommending routine selfexamination.

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

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Australasian Journal of Dermatology (2015) 56

Illness perception in association with psychological functioning in patients with discoid lupus erythematosus P. Chen1, E. Broadbent3, C. Coomarasamy2, P. Jarrett P1,4 1 Department of Dermatology, Counties Manukau District Health Board, Otahuhu, Auckland, New Zealand 2 Ko Awatea, Centre for Research, Knowledge and Information Management, Counties Manukau District Health Board, Auckland, New Zealand 3 Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand 4 Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand Psychological distress is common in patients with Discoid Lupus Erythematosus (DLE). Patients’ perceptions of their illness may better predict functional outcomes than clinician-based assessments. This study compared patients’ perception of DLE with physician ratings of severity and to assess their relationships with patient depression and Quality of Life (QoL). 24 patients completed psychological questionnaires; the Brief Illness Perception Questionnaire, Patient Health Questionnaire and dermatology life quality index and drawing pictures of their faces. Cutaneous lupus disease area severity index (CLASI) was measured. Sixteen patients screened positive for depression, six of whom had severe depression. Disease severity was significantly associated with depression (r = 0.41, p = 0.05). There was no association between the patients’ perception of the extent of their skin lesions measured by spot area compared to the disease activity and damage scores, respectively (r = 0.32 p = 0.13, r = 0.14, p = 0.5), however there was a trend for patients with higher severity to draw more spots (r = 0.42, p = 0.06). Those who drew larger faces had higher depression scores (r = 0.53, p = 0.008). Those who had higher perceived control over their DLE had higher QoL, lower depression and better disease control. Patients with more severe inflammatory disease measured by the CLASI were more likely to be depressed. Patients’ perception of their disease differs from the dermatologists CLASI assessments and this has implications for management. Drawings and questionnaires may be a useful way to understand patients’ views of the disease, and a starting point for discussion around QoL and distress. Pulsed dye laser treatment at 2 weekly compared to 3 monthly intervals in infants with capillary malformations B.C. Swan, S. Robertson, E. Ma, A. Tuxen, L. Bingham, L. Ly, B. Welsh, V. Morgan, P. Bekhor Laser Unit, Department of Dermatology, Royal Children’s Hospital, Melbourne, Victoria, Australia

(PDL) treatment at 6–12 weekly intervals under general anaesthetic (GA) in early life remains the treatment of choice. The safety of repeated GA in infants is controversial, but prior to 3–6 months old, PDL treatment can be performed without GA. Shortening the PDL treatment interval can reduce the course duration to 3 months or less, and has, in adults, been shown to be more effective. We investigated the effectiveness and safety of PDL treatment in infants at 2 weekly intervals (without GA) compared to three monthly. Method: We performed a prospective pilot study of 9 infants less than 8 weeks old with CM. Using 595 nm Vbeam PDL, the entire CM was treated, then half of the CM was randomly allocated to 2 weekly and other half to 3 monthly intervals for further 2 treatments. Three month posttreatment photographs were evaluated by an independent, blinded dermatologist. Complications were recorded. Results: Three patients had greater improvement on the 2 weekly treated side compared to 4 patients with greater improvement on the 3 monthly treated side including 3 with excellent results. Two patients showed equal improvement on both sides. There were no significant adverse reactions. Conclusion: This pilot study suggests that infants may be treated with PDL without GA at 2 weekly intervals without adverse effects. While preliminary data would suggest a better outcome with 3 monthly intervals, further larger studies are warranted for statistical significance. Two weekly PDL intervals for treatment of CM in infants needs consideration as this shortens treatment duration and minimises GA.

Perianal ulceration misdiagnosed as pyoderma gangrenosum R.B. Saunderson, A.B. Watson Department of Dermatology, John Hunter Hospital, Newcastle, New South Wales, Australia Pyoderma gangrenosum is a diagnosis of exclusion and misdiagnosis can result in substantial complications for patients with other causes of cutaneous ulceration. We present the case of a 70-year-old female with severe perianal ulceration with a diagnosis of pyoderma gangrenosum, which worsened with immunosuppressive therapy. Extensive investigations revealed the cause to be herpes simplex virus type 1. A review of the literature was undertaken and revealed the misdiagnosis of pyoderma gangrenosum is not uncommon and alternative diagnoses need to be considered prior to commencement of immunosuppressive therapy. With increased utility of immunosuppressive therapy, herpes simplex virus is increasingly recognised as a cause of severe perianal ulceration.

Introduction: Capillary malformations (CM) affect 0.3% newborns and have a psychosocial impact. Pulsed dye laser © 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015

La Roche Posay Sponsored Symposium: Targeting the Human Skin Microbiome in Patients with Atopic Dermatitis Targeting the human skin microbiome in patients with atopic dermatitis T.A. Luger Department of Dermatology, University of Münster, Münster, Germany Atopic dermatitis (AD) is a multigenic chronically relapsing inflammatory skin disease characterized by eczema and pruritus. The prevalence of atopic dermatitis (AD) in developed countries is increasing and currently is ranging from 20% to 25% in children and 2–3% in adults. Recent progress has been achieved in our understanding about the complex mechanisms underlying the pathophysiology of atopic dermatitis, involving an impaired epidermal barrier function, an abnormal function of both innate as well as adaptive immune responses and an altered microbiome of the skin. The human body in particular epithelia, which represent the barrier to the environment are colonized by a variety of microorganisms and there is a well-established symbiotic relationship between host and microbes. The term microbiome refers to the totality of microorganisms, their genomes and interactions in a defined environment and is considered as being an important part of the human metabolic system. The human body contains 10 times more bacterial cells than human cells. The human microbiome consists of about 5–10,000 species and the total of bacteria in the human organism, is 1–3% of body weight. In the past studies on the microbiome of the gastrointestinal tract provided evidence of a relation between the microbiome and obesity. Initial investigations of the skin microbiome show an enormous inter-and intra-individual diversity. Thus actinobacteria are predominant in seborrheic areas of the skin, while proteobacteria mainly occur in dry skin areas and firmicutes mostly are located in moist areas. The composition of the skin microbiome is influenced by many different factors such as environment, age, gender, metabolic-, and inflammatory diseases. In patients with atopic dermatitis, a marked change in the skin microbiome diversity has been shown as a function of the disease severity. Thus, the diversity of the microbiome decreases during disease exacerbation in favor of colonization with pathogenic microbes such as staphylococcus aureus. Interestingly, the changes in the skin microbiome can already be observed before disease exacerbation occurs. Upon successful topical or systemic treatment an increase of the diversity associated with a decrease of S. aureus has been observed. Resident bacteria of the skin such as S. epidermidis by releasing antimicrobial peptides as well via stimulating the skin immune system are able to control the colonization with pathogenic microbes such as S. aureus.

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Plenary Session 1 Melasma: differential diagnosis and pathogenesis A.G. Pandya Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA Melasma (sometimes referred to as chloasma or the mask of pregnancy) is a common, acquired disorder of hyperpigmentation affecting millions of people worldwide. The differential diagnosis for melasma is wide, and includes acquired nevoid disorders, reactions to medications, interface dermatoses, lichenoid dermatoses and age-related skin changes. It is imperative to make a correct diagnosis of melasma prior to embarking on treatment. The pathogenesis of melasma is not well understood, but recent studies have discovered new signaling pathways that may play a role in melasma and which could be targeted with new therapeutic agents. While the role of ultraviolet light in causing melasma is well known, recent studies have pointed to visible light as an etiologic factor as well.

Preadolescent acne: The argument for early intervention A.C. Yan Section of Dermatology, Division of General Pediatrics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, USA The prevalence of preadolescent acne is increasing at a time when the age of acne onset is decreasing. These observations are in concert with the decreasing age of puberty seen in children. Children with early acne are also at greater risk for later more severe acne. Emerging evidence suggests that the specific microbiome of patients acne may influence the severity of acne that develops. Specifically, it is an individual patient’s immunologic response to resident propionibacteria that determines the degree of inflammatory acne. It is therefore not unreasonable to conceive that early intervention for acne in preadolescence might alter the trajectory of acne severity in those so affected.

References 1. Eichenfield et al. Pediatrics. 2013;131:S163. 2. Davis et al. Pediatr Dermatol. 2013:30(6):689–694. 3. Goldberg et al. Pediatr Dermatol. 2011;28(6):645–648. 4. Lucky et al. J Peds. 1997;130(1):30–39.

In the future, the exploration of the skin microbiome will enable entirely new approaches for the treatment of infectious and inflammatory skin diseases. © 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

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Melanoma Symposium Reflectance confocal microscopy as a diagnostic aid in determined invasion in lentigo maligna clinical presentations G. Carlos1,2,3, P. Luk3,4, R.A. Scolyer1,3,4, P. Guitera1,2,3 1 Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia 2 Sydney Melanoma Diagnostic Centre, Royal Prince Alfred Hospital Sydney, New South Wales, Australia 3 Melanoma Institute Australia, Sydney, New South Wales, Australia 4 Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia Australia has the highest incidence of lentigo maligna (LM) in the world and it represents the most prevalent in-situ form of melanoma. Location, extension and polymorphic clinical presentations of these lesions represent a diagnostic and management challenge for clinicians and pathologists. Often Wood’s lamp and dermoscopy are insufficient for accurate demarcation of peripheral margins. Reflectance confocal microscopy (RCM) may improve the accuracy of diagnosis and margin mapping. In order to treat wider areas, reduce recurrence and improve cosmesis, radiotherapy and imiquimod have been proposed as alternatives to surgery. The challenge of these treatments is the risk of inadequately treating a micro-invasive component. The aim of this study was to determine whether RCM is a reliable tool to detect invasion in LM. RCM is able to access large lesions in vivo non-invasively. On the other hand, in RCM it is difficult to determine the exact site of the cells (junctional or dermal) on a en face field of view, due to a partially disrupted dermoepidermal junction. From 2007 to 2014, 213 patients with clinically suspicious lesions for LM or LM melanoma (initial diagnosis or recurrence) were retrieved from a confocal database of the Sydney Melanoma Diagnostic Centre and Melanoma Institute Australia. On review of the RCM images, 39 of 213 (18%) patients had atypical cells extending into the dermis. Fifteen out of these 39 patients had invasive melanoma confirmed on histopathological examination. Pathology correlation of RCM findings and data on false negative and false positive cases will be analysed and presented. Topical and intralesional therapies for locoregional metastasis of cutaneous melanoma D.J Deshpande1, D.L. Damian2, M Carlino3, P. Fernandez-Peñas1 1 Department of Dermatology, Westmead Hospital, Westmead, New South Wales, Australia 2 Discipline of Dermatology, University of Sydney at Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia 3 Westmead Institute for Cancer Research (WICR),Westmead Hospital, Westmead, New South Wales, Australia Melanoma is well known to be an immunogenic tumour and locoregional melanoma provides a unique opportunity

to use topical and intralesional immunotherapy in an attempt to induce tumour specific immune responses. We review the management options for this scenario. Treatment modalities for these patients are determined by the site and volume of local-regional disease and the presence of distant metastatic disease. Topical immunotherapeutic agents such as diphencyprone and imiquimod may be indicated for superficial lesions unsuitable for or resistant to surgery or radiation therapy. Intralesional therapies such as Rose Bengal and Talimogene laherparepvec (T-Vec) are an option for thicker cutaneous or subcutaneous metastases, and the observation that untreated bystander lesions often resolve after Rose Bengal suggests an immune contribution to its mechanism of action. The role of these local therapies remains to be determined particularly given the activity of BRAF/MEK inhibitors and the newer immunologically active systemic agents such as ipilimumab and anti-PD1 agents. Possible future approaches may involve combination topical and systemic therapy in order to maximise rates of durable tumour response in this patient group.

Making stressed melanoma self-destruct D.S. Hill1,2, K.A. Beaumont1, S.M. Daignault3, A. Anfosso1, P.E. Lovat2, W. Weninger1,4,5, N.K. Haass1,3,4 1 The Centenary Institute, Newtown, New South Wales, Australia 2 Dermatological Sciences, Newcastle University, Newcastle upon Tyne, UK 3 The University of Queensland Diamantina Institute, Translational Research Institute, Woolloongabba, Queensland, Australia 4 Discipline of Dermatology, University of Sydney, Camperdown, New South Wales,, Australia 5 Department of Dermatology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia Introduction: Melanoma drug resistance is, in part, due to tumour heterogeneity. We have demonstrated that melanomas are composed of differentially cycling tumour cells in a subcompartment-specific distribution. Further, we have shown that treatment with endoplasmic reticulum (ER) stress-inducing drugs, fenretinide (synthetic retinoid) or bortezomib (Velcade®) induces cell cycle arrest and apoptosis of metastatic melanoma cells. This study investigates the effect of ER stress-inducing agents on the dynamics of cell division and death of individual melanoma cells within the complex tumour microenvironment, and to develop combination strategies that increase the efficacy of ER stress-inducing agents for melanoma therapy. Methods: Melanoma cells were grown as 3D spheroids and implanted into a collagen matrix to mimic tumour architecture and microenvironment. Cutting-edge technology was applied for real-time cell cycle imaging (FUCCI) and for ER-stress detection (F-XBP1ΔDBD-venus reporter). Results: Bortezomib induced ER stress, delayed proliferation, and combination with fenretinide increased apoptosis

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 in 2D and 3D culture. Real-time cell cycle imaging revealed that bortezomib induced both G1 and G2 cell cycle arrest, but preferentially killed G2-phase cells. Consequently, pretreatment with temozolomide or fenretinide, causing G2-arrest, sensitised melanoma cells to bortezomib. In contrast, pretreatment with MEK-inhibitors, causing G1-arrest, inhibited bortezomib cytotoxicity in all melanoma cells, as did selective BRAF-inhibitors in BRAF-mutant melanoma cells. Conclusion: Bortezomib combined with fenretinide or temozolamide is a strategy worth exploring for the treatment of BRAF-inhibitor insensitive or resistant melanoma. Importantly, melanoma cells arrested in G1 are protected from bortezomib cytotoxicity, which excludes MAPK pathway inhibitors as combination partners.

Paediatric Dermatology Symposium Bullous pemphigoid in infants: characteristics, diagnosis and treatment A. Schwieger-Briel1, C. Moellmann1, E. Schmidt2, H. Ott2,3, J.S. Kern1 1 Departments of Dermatology and Pediatrics, Medical Center – University of Freiburg, Freiburg, Germany 2 Department of Dermatology, University of Luebeck, Luebeck, Germany 3 Catholic Children’s Hospital Wilhelmstift, Hamburg, Germany Background: Bullous pemphigoid (BP) in infants is a rare but increasingly reported autoimmune blistering skin disease. Autoantibody reactivity is usually poorly characterized. Current guidelines do not address specific aspects of the infantile form of BP. Methods: Detailed characterization of a current case series of five infants with BP from our departments. Comprehensive analysis of all reported cases (1–12 months) with respect to clinical and laboratory characteristics, treatment and outcome. Results: In total 81 cases were identified. The mean age was 4.5 months. Moderately severe and severe disease was seen in 84% of cases. Immunofluorescence microscopy was comparable with BP in adults. Where analyzed, the NC16A domain of bullous pemphigoid 180 kDa antigen / collagen XVII (BP180) was identified as the major target antigen. BP180 NC16A ELISA values in our cohort were significantly higher than in a control cohort of 28 newly diagnosed adult patients. 50% of patients were treated with systemic corticosteroids, 20% with a combination of systemic corticosteroids and dapsone or sulfapyridine and 10% with topical corticosteroids alone. 14% of patients needed a combination of multiple immunosuppressants. All but one patient reached remission. Relapses were rare.

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genesis and diagnostic criteria are comparable to adult BP, yet BP180 NC16A ELISA levels seem to be significantly higher in infants. The overall disease outcome is favorable. Based on the results of this study we propose a treatment algorithm for infantile BP.

Prevalence of methicillin-resistant Staphylococcus aureus in children with atopic dermatitis, and comparison to the general paediatric population: a longitudinal study C. Chaptini1, S. Quinn2, G. Marshman1 1 Department of Dermatology, Flinders Medical Centre, Adelaide, South Australia, Australia 2 School of Medicine, Flinders University, Adelaide, South Australia, Australia Background: Given the increasing rate of methicillinresistant Staphylococcus aureus(MRSA) skin infections in the population, such infections might also be increasing in patients with atopic dermatitis(AD). There are limited studies on MRSA prevalence in the AD population, and no previous studies in Australia. Objectives: This study investigated the prevalence of MRSA and MSSA in the paediatric AD population. It also examined the rate of MRSA in children with AD, compared to the general paediatric population, and investigated risk factors for MRSA. Methods: This is a longitudinal, retrospective study to investigate, using logistic regression, the change of prevalence of MRSA and MSSA in skin swabs of patients with AD, aged 0–18 years, admitted to a large teaching hospital in South Australia from 1999–2014(n = 289). Additionally, skin and soft-tissue isolates positive for Staphylococcus aureus, obtained from paediatric inpatients from 2010– 2014(n = 343), were analysed to investigate the proportion of MRSA in patients with AD, compared to those without AD. Results: In total 78.5% of AD patients had MSSA and 7.0% had MRSA. In each successive age period, the prevalence of MRSA increased OR = 2.01(1.22–3.34), p = 0.007, so that compared to 1999–2002, patients in 2011–2014 were approximately 16 times more likely to have MRSA (p = 0.012). There was an association between increasing number of hospital admissions and MRSA, OR = 1.08(1.02, 1.14). MRSA rates are lower in those with AD compared to those without AD, OR = 0.567(0.214–1.500), p = 0.253. Conclusion: The prevalence of MRSA in AD is clearly on the rise. This study provides reassurance for local practitioners that most skin infections in children with AD are methicillin-sensitive.

Conclusions: Presentation of infantile BP is often severe with blistering of hands and feet present in all cases. Patho© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

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Assessment of pharmacists’ knowledge about use of topical corticosteroids in atopic dermatitis: pre- and post-continuing professional development education S.D. Smith1,2,3, A. Lee2,3, A. Blaszczynski4, G. Fischer2,3 1 The Dermatology and Skin Cancer Centre, Gosford, New South Wales, Australia 2 Department of Dermatology, Royal North Shore Hospital, Sydney, New South Wales, Australia 3 The Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia 4 School of Psychology, University of Sydney, Sydney, New South Wales, Australia Dr S Smith, Dr A Lee, Professor A Blaszczynski and Assoc Prof G Fischer equally contributed to the construction of this review article. Background: Topical corticosteroids (TCS) are the standard of care in paediatric atopic dermatitis (pAD). TCS phobia is commonly cited by parents as a major impediment to treatment adherence. Parents frequently state that information provided by pharmacists is a significant factor in TCS-phobia. Objectives: To assess pharmacists’ beliefs and sources of information on the safety of TCS in treatment of pAD and to determine whether their beliefs can be modified by re-education. Methods: Pharmacists attending a continuing professional development conference were assessed before and after a lecture presenting evidence-based information on the use of TCS in pAD. Responses recorded in real-time by electronic key pad. Results: The mean response rate was 86% of 292 surveyed. Of responders, 64% recognised that treatment adherence was a major reason for treatment failure in pAD. The posteducation session assessment demonstrated a major shift in attitude compared to the pre-education assessment. As a result of education the pharmacists would instruct parent/ patients to apply until eczema is clear (92% vs 27% pre- and post-education, p < 0.0001). The proportion that would instruct patients to use TCS sparingly dropped from 54% to 8% (p < 0.0001). The belief that cutaneous atrophy was a common side effect dropped from 46% to 7% (p < 0.0001). A belief held by 56% that side-effects from TCS would occur even if used appropriately, dropped to 11% post-education (p < 0.0001). Conclusions: There are significant gaps that exist in Australian pharmacists’ knowledge of the use and safety of TCS in pAD which have the potential to contribute to poor treatment compliance. These attitudes appear modifiable through targeted, evidence-based education delivered by a dermatologist.

Adverse effects of topical corticosteroids in paediatric eczema: Australasian Consensus Statement E. Mooney1, M. Rademaker2, D. Orchard1 on behalf of the consensus group on Topical Corticosteroid Use in Paediatric Eczema 1 Department of Dermatology, Royal Children’s Hospital, Melbourne, Victoria, Australia 2 Department of Dermatology, Waikato Hospital, Hamilton, New Zealand Atopic eczema is a chronic inflammatory disease affecting about 30% of Australian/New Zealand children. Severe eczema costs over AUD $6,000/year per child in direct medical, hospital and treatment costs as well as time off work for caregivers and untold distress for the family unit. In addition, it has a negative impact on a child’s sleep, education, development and self-esteem. The treatment of atopic eczema is complex and multifaceted but a core component of therapy is to manage the inflammation with topical corticosteroids (TCS). Despite this, TCS are often under-utilised by many parents due to corticosteroid phobia and inaccurate concerns regarding adverse effects. This has lead to extended and unnecessary eczema exacerbations for children. Contrary to popular perception, topical corticosteroid use in paediatric eczema does not cause atrophy, hypopigmentation, hypertrichosis, osteoporosis, purpura or telangiectasia when used appropriately as per guidelines. In rare cases, prolonged and excessive use of potent TCS has contributed to striae, short-term HPA axis alteration and ophthalmological disease. TCS use can also exacerbate perioroficial rosacea. Topical corticosteroids are very effective treatments for eczema. When they are used to treat active eczema and stopped once the active inflammation has resolved, adverse effects are minimal. TCS should be the cornerstone treatment of atopic eczema in children.

SCALP syndrome: a rare clinical entity S. Strathie Page, A. Halbert Princess Margaret Hospital, Perth, Western Australia, Australia SCALP syndrome is a relatively newly coined syndrome consisting of a collection of different conditions: sebaceous nevus syndrome, aplasia cutis, limbal dermoids, giant congenital melanocytic naevi and CNS malformations. There have only been three previous reports of this condition in the literature. We describe the fourth case of this condition and review the other previous cases described.

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 Neonatal autoimmune blistering diseases – a systematic review of literature C.Y. Zhao1,2, N.Y.Z. Chiang1,2, D.F. Murrell1,2 1 Dermatology, St George Hospital, Sydney, New South Wales, Australia 2 Medicine, University of New South Wales, Sydney, New South Wales, Australia Introduction: Neonatal autoimmune blistering disease (AIBD) is rare. To the best of our knowledge, this is the first systematic review of neonatal AIBD, aimed at fostering a better understanding of neonatal AIBD’s clinical presentation and prognosis. Method: The literature was searched using MEDLINE, Embase, PubMed, LILACS and reference lists of identified papers. Inclusion criteria were: all time periods and languages; neonates were defined as 92% coverage), 20 mj, clearance rates of up to 95% were consistently achieved during follow ups at 6 and 12 months. This treatment has been adopted as the field treatment of choice in patients with moderate to severe AK in our group practice.

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A novel hybrid ablative and non-ablative fractional resurfacing treatment for clinical efficacy with enhanced patient experience C. Robb and J. Pozner 1 Skin and Allergy Centre, Tennessee, United States of America 2 Sanctuary Plastic Surgery Boca Raton, Florida, United States of America Introduction: Intrinsic aging and long-term ultraviolet light exposure results in visible signs of skin aging, including wrinkles, discolorations, and dullness. Ablative fractional resurfacing is a well-established treatment that vaporizes aged tissue with less thermal injury, albeit with longer downtimes. Conversely, non-ablative fractional resurfacing causes a thermal injury and tissue coagulation with shorter downtimes. A novel hybrid fractional laser combines both ablative and non-ablative wavelengths within a single pass to maximize clinical results and minimize downtimes. This is the first demonstration of treatment with a hybrid fractional laser providing an excellent safely profile, clinical efficacy, and enhanced patient experience. Methods: Retrospective study of patients treated with a novel hybrid fractional laser (Halo™, Sciton, Inc.) delivering both ablative 2940 nm and non-ablative 1470 nm wavelengths within a single pass. To monitor skin responses, healing progression, and clinical results, photographs and complexion analysis images (Visia, Canfield Scientific, Inc.) were collected daily for five days post-laser treatment, and at the thirty-day follow up. Results: Treatment was safe, with no adverse events reported. No to moderate pain scores were recorded (visual analog scale 0–10); 1–3 for shallow, low coverage treatments and 3–5 for deep, high coverage treatments. Healing progression photographs illustrated that regardless of treatment parameters, subjects were consistently healed at five days post-treatment. Before and after photographs demonstrated improvement in wrinkles, dyschromia, laxity, skin texture, and pore size. Complexion analysis images showed a significant percent decrease in skin discolorations after a single treatment. Conclusions: The development of a novel hybrid fractional laser technology combining ablative and non-ablative wavelengths provides a breakthrough treatment. Delivering coincident or adjacent wavelength pulsing, together with tunable ablation, coagulation, depth, and coverage offers individualized treatment parameters. The ablative intraepidermal response is synergistic with the non-ablative dermal coagulation wound healing to produce exceptional resurfacing results with an enhanced patient experience. Consistent, efficacious clinical results were achieved with a single treatment. Hybrid fractional laser treatment improved wrinkles and dyschromia resulting in bright, reflective, more youthful skin. Patients experienced the clinical resurfacing results of an ablative treatment with the downtime of a non-ablative treatment.

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

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References 1.

2.

3.

4.

5.

Cohen JL, Ross EV. Combined fractional ablative and nonablative laser resurfacing treatment: a split-face comparative study. J Drugs Dermatol. 2013 Feb;12(2):175–8. Orringer JS, Rittié L, Hamilton T, Karimipour DJ, Voorhees JJ, Fisher GJ. Intraepidermal erbium:YAG laser resurfacing: impact on the dermal matrix. J Am Acad Dermatol. 2011 Jan;64(1):119– 28. doi: 10.1016/j.jaad.2010.02.058. Laubach HJ, Tannous Z, Anderson RR, Manstein D. Skin responses to fractional photothermolysis. Lasers Surg Med 2006;38:142–9. Paithankar DY, Clifford JM, Saleh BA, Ross EV, Hardaway CA, Barnette D. Subsurface skin renewal by treatment with a 1450-nm laser in combination with dynamic cooling. J Biomed Opt. 2003 Jul;8(3):545–51. Laubach H, Chan HH, Rius F, Anderson RR, Manstein D. Effects of skin temperature on lesion size in fractional photothermolysis. Lasers Surg Med. 2007 Jan;39(1):14–8.

Medication-induced pigmentation: A novel treatment for an age-old problem M. Rodrigues1,2,3, P. Bekhor1,2 1 The Royal Children’s Hospital, Melbourne, Victoria, Australia 2 The Skin and Cancer Foundation Inc, Melbourne, Victoria, Australia 3 St Vincent’s Hospital, Melbourne, Victoria, Australia Medication-induced pigmentation has long been a challenging management problem. It often renders the patient depressed at the prospect of living with dyspigmentation. While the pigmentation may spontaneously fade over months, it may never completely disappear. The Q-switched laser has been reported to hasten resolution of medicationinduced pigmentation, however the newly developed, picosecond technology has not been studied for this indication to date. We present a split-lesion case series comparison of three patients with minocycline-induced pigmentation on the face. In all cases, the patients underwent treatment with both Q-Switched Neodymium: yttrium aluminum garnet (QS Nd:YAG) and picosecond Alexandrite (755 nm) laser (PicoSure™). In all cases, after a single treatment, the PicoSure™ treated side demonstrated complete clearance while the QS Nd:YAG treated side revealed only partial clearance.

Non-Melanoma Skin Cancer Symposium Scalp basal cell carcinoma: a review of 2202 cases M. Cho1, J. Lee2, C. James3, G. Marshman4, S.C. Huilgol1,5 1 Department of Dermatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia 2 Queen Elizabeth Hospital, Adelaide, South Australia, Australia 3 Adelaide Pathology Partners, Mile End, Adelaide, South Australia, Australia 4 Department of Dermatology, Flinders Medical Centre, Bedford Park, South Australia, Australia 5 Adelaide Skin & Eye Centre, Kent Town, South Australia, Australia Introduction: Basal cell carcinoma (BCC) is most common in men and the elderly. However, increases in the incidence in women, younger age groups and in aggressive scalp subtypes in younger women have been reported.1 Method: Retrospective audit of all scalp BCCs from 3 pathology laboratories in Adelaide, SA, from January 2009 to December 2013. Data subsets included: age, gender, procedure type, size, histological subtype, presence of perineural invasion, and completeness of excision. Results: A total of 2,202 BCCs were included, with the majority in men (62.1%) and those older than 60 years (78.4%). Nodular BCC (55.4%) was the most prevalent subtype, followed by mixed (30.3%) and superficial subtypes (7.95%). Aggressive histological subtypes were associated with larger lesions, increased risk of perineural invasion, incomplete excision and subtype discordance between the initial biopsy and excision. Subtype concordance between biopsy and excision was 56.4% with higher rates with punch biopsy. The incomplete excision rate was 16.4%. Conclusion: Most scalp BCC were in men and the elderly with no evidence to suggest women, including those in younger age groups, were at higher risk of developing aggressive BCC subtypes. Punch biopsy was best at subtype classification prior to definitive treatment. Incomplete excision rates were relatively high with worse outcomes in aggressive BCC subtypes.

Reference 1.

Katz TM, Silapunt S, Goldberg LH et al. Analysis of 197 female scalp tumors treated with Mohs micrographic surgery. Journal of the American Academy of Dermatology 2005; 52: 291–4.

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 Management of squamous cell and basal cell carcinomas of the head and neck with perineural invasion A. Gupta1, M. Veness2, B. De’Ambrosis3, D. Selva4,5, S.C. Huilgol1,5 1 Department of Dermatology, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia 2 Westmead Cancer Care Centre, University of Sydney, Sydney, New South Wales, Australia 3 University of Queensland and South East Dermatology, Carina Heights, Brisbane, Queensland, Australia 4 Department of Ophthalmology & Visual Sciences, University of Adelaide and South Australian Institute of Ophthalmology, Adelaide, South Australia, Australia 5 Adelaide Skin and Eye Centre, Adelaide, South Australia, Australia Introduction: Perineural invasion (PNI) occurring in nonmelanoma skin cancers (NMSC) is associated with an increased risk of locoregional recurrence and reduced disease-free survival. This necessitates early and accurate diagnosis, appropriate risk-stratification, and a clear management strategy. The diagnosis of PNI is based on careful clinical assessment, imaging and histopathology. Surgery, preferably with margin control, and definitive or adjuvant radiotherapy (ART) are established treatment strategies for PNI. There remains clinical uncertainty regarding the role of ART in incidental PNI. This review synthesises current literature to ascertain clinicopathologic features that impart higher risk to individuals with PNI in NMSC, in order to provide treatment algorithms, including identification of patient subsets that are most likely to benefit from ART. This includes those with extratumoural PNI, involvement of larger-calibre nerves, tumour invasion beyond dermis, recurrent tumour, or diffuse intratumoural spread. The management options presented are stratified by histological subtype, and a new classification of PNI into low-, medium-, and high-risk groups.

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In-transit squamous cell carcinomas: an Australian case series J.H.Y. Ma1,2, A. Wu1, C. James3, J. Ibbetson4, M. Veness5, P. Salmon6, C. Ooi1, W. Weightman7, I. McColl8, I. Hamann9, N. Grieve10, S. Ozluer11, M. Nikitins12, Y. Caplash13, T. Edwards14, N. Marshall14,15, D. Selva16, S.C. Huilgol1,17 1 Department of Dermatology, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia, Australia 2 Department of Medicine, Flinders Medical Centre, Bedford Park, South Australia 5042, Australia 3 Adelaide Pathology Partners, Adelaide, South Australia, Australia 4 Surgical Pathology Division, SA Pathology, Adelaide, South Australia, Australia 5 Head and Neck Cancer Service, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia 6 Dermatologic Surgical Unit, Skin Cancer Institute, Tauranga, Bay of Plenty 3110, New Zealand 7 Department of Dermatology, Queen Elizabeth Hospital, University of Adelaide, Woodville, South Australia, Australia 8 John Flynn Hospital, Tugun, Queensland, Australia 9 Mid North Coast Dermatology, Port Macquarie, New South Wales, Australia 10 Dermatology SA, Norwood, South Australia, Australia 11 Southport Dermatology, Southport, Queensland, Australia 12 Sach Day Surgery, Adelaide, South Australia, Australia 13 Department of Plastic and Reconstructive Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia 14 Adelaide Plastic Surgery Associates, Adelaide, South Australia, Australia 15 Department of Plastic and Reconstructive Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia 16 South Australian Institute of Ophthalmology, University of Adelaide, Adelaide, South Australia, Australia 17 Adelaide Skin & Eye Centre, Kent Town, South Australia, Australia Background: In transit metastases from cutaneous squamous cell carcinoma (SCC) are rare and are more common in the immunosuppressed. Objective: To determine characteristics of tumours and patients with in-transit SCC metastases and patient outcomes. Methods: Histological confirmation and chart review of cases from Australian clinicians. Results: In 23 cases, median age was 70 years (range 52–99). 83% of patients were male. 70% were immunocompetent. Tumor site was on the head and neck in 96% of cases. The median time to presentation with in-transit SCC from treatment of the original tumor was 7 months in immunocompetent patients and 5 months in immunocompromised patients. Management strategies included surgery (100%), adjuvant radiotherapy (74%), adjuvant chemotherapy (13%) and reduction of

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

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immunosuppression (4%). Median follow up was 19 months (range 1–106). At follow up, 44% of immunocompetent patients were deceased compared to 57% for immunosuppressed patients. Limitations: This was a retrospective review with small sample size. Conclusion: The authors propose new clinical and histological criteria for the diagnosis of in-transit SCC metastases. In-transit SCC may be more aggressive in immunosuppressed patients. Recommended management is excision with adjuvant radiotherapy.

Pigmentary Diseases Symposium Common and uncommon dermatoses in darker skin S. Vaishampayan Department of Dermatology, Base Hospital, Lucknow Cantt (UP) Pin, India

Approach to hypopigmentation or depigmentation in children S. Vaidya St Peters Dermatology and Dermatology SA, Adelaide, South Australia, Australia Hypopigmentation or depigmentation of the skin is a frequently encountered problem in childhood, being totally benign or representing the first sign of a multisystem disorder. It can be due to a wide variety of congenital and acquired diseases. Classification provides an approach to a clinical condition in which the causes are heterogeneous and histological examination of the skin is rarely diagnostic.1 Medical history, clinical examination, Wood’s light investigation, histological analysis of the skin and a multidisciplinary consultation can contribute to a correct and early diagnosis of the different types of hypopigmentation.2 The present paper represent a systematic clinical approach to the differential diagnosis of those skin disorders. References

It is a well-known ‘secret’ that clinical appearance of many dermatoses, sometimes vary between people with skin of colour and Caucasians. Doctors trained in a particular region may face difficulty in diagnosing some of these when patients from other race seek their consultation. Dermatophytosis, Lichen planus, Psoriasis, Leprosy, Acne vulgaris, Rosacea, Ichthyosis etc are some of the common dermatoses seen on day to day basis. I will try to present characteristic or typical clinical presentations of these common dermatoses as well as also will show uncommon presentations of these common dermatoses. I will also try to demonstrate few rarer or uncommon dermatoses like – lichenoid psoriasis, mycosis fungoides, hypomelanosis of Ito, porphyrias etc in patients with skin of colour.

Vitiligo – an approach to treatment M. Rodrigues1,2,3 1 St Vincent’s Hospital, Melbourne, Victoria, Australia 2 The Royal Children’s Hospital, Melbourne, Victoria, Australia 3 The Skin and Cancer Foundation Inc., Melbourne, Victoria, Australia Vitiligo is an acquired chronic pigmentary disorder affecting 0.5–2% of the world’s population, with equal incidence in men and women. This depigmenting condition is thought to be autoimmune though the exact aeitopathogenesis remains unclear. This cosmetically challenging and often psychologically devastating condition necessitates a thorough understanding of topical, physical and surgical treatments available for affected patients. An approach to the treatment of vitiligo and different treatment modalities will be discussed as well as the latest discoveries and potential future therapies.

1.

Practical Classification of Childhood Hypopigmentation Disorders. Acta. Derm. Venereol. 2010; 90: 6–11. 2. Hypomelanoses in Children. J. Cutan. Aesthet. Surg. 2013; April– June, 6(2): 65–72.

Management of post-inflammatory hyperpigmentation A.G. Pandya Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA Postinflammatory hyperpigmentation (PIH) is a common, acquired, transient excess of skin pigment that follows inflammation or injury to the skin. Those with Fitzpatrick skin types IV-VI are the most susceptible. PIH typically manifests as macules or patches at the site of previous trauma or inflammation. Lesions range from light brown dark gray depending on whether the excess melanin resides in the epidermis or dermis. Inflammatory mediators, such as IL-1α, endothelin-1, and reactive oxygen species, increase the synthesis of melanin after inflammation. Hyperpigmentation is particularly difficult to treat with follicular, basal layer, or basement membrane involvement. Pigment incontinence leads to dermal melanophages which are isolated from the effects of treatment, helping to explain the long time course of persistent lesions. The most important component of management is eliminating all inflammation from affected areas by using a treatment tailored to the underlying condition. Hydroquinone, topical retinoids, azelaic acid, kojic acid, glycolic acid peels, and combination cream with hydroquinone, tretinoin, and fluocinolone have been successfully used. The treatment course is often prolonged and may result in no benefit. Sun avoidance and use of broad-spectrum sunscreens are essential, especially in individuals with higher skin phototypes who may not be aware of the darkening effects of UV radiation. Evidence for the various available treatment modalities for PIH is not strong, and is underpowered by small population size, poor study design, and lack of validated outcome measures. Few studies focus on dark-skinned patients.

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 Laser treatment in patients of darker skin types A.C. Lim Department of Dermatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia Patients of darker skin types (DST) – Fitzpatrick skin types 4–6 – are not exempt from common skin conditions such as acne, acne scarring, facial telangiectases and pigmentary conditions such as dematosis papulosa nigra and melasma. DST patients are more likely to experience PIH following common benign inflammatory conditions such as acne and also experience a higher incidence of post-laser PIH. The algorithm for treating DST patients involves a graduated approach where first line topical therapy is recommended before undergoing treatment with energy devices. Topical therapy and peels are generally safer than energy devices in minimising PIH. When topical therapy is suboptimal, energy devices can be considered, based on the balance between likely procedural benefit versus likelihood of PIH, taking into account disease severity and patient temperament and preference. The role of non-ablative devices such as IPL and lasers will be discussed for common skin conditions in DST patients. DST-safer fractional lasers for textural therapy such as acne scarring will also be discussed. Non-laser modalities such as fractional radiofrequency – useful for all skin types – is particularly beneficial for DST patients. Treating DST patients require a peri-procedural protocol to minimize PIH. Treatment parameters need to be modified with peri-procedural bleaching. For textural conditions requiring ablation, counseling about likely PIH, its natural history and subsequent management plan needs to be discussed as part of the informed consent. Practitioners dealing with DST patients should develop an awareness of a patient’s attitude towards potential PIH, which is a key factor in directing therapeutic options.

Plenary Session 2 Management of melasma A.G. Pandya Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA Although there are many treatments for melasma, this disorder is often recalcitrant to treatment. The chronic and relapsing nature of melasma makes treatment especially difficult. Darker skin types (Fitzpatrick types IV to VI) are more difficult to treat because of the increased risk of postinflammatory hyperpigmentation with various treatments and the increased amount of melanin and melanophages associated with melasma lesions. There is no single universally efficacious treatment, thus, combination treatment is the best approach for challenging cases. Avoidance of exacerbating factors and photoprotection are essential in the treatment of melasma. Topical depigmenting agents combined with retinoids and mild corticosteroids are particularly effective. While peels and laser therapy can help patients with lighter skin, these treatment methods are

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often unsuccessful in darker-skinned patients and can even exacerbate melasma-associated pigmentation. Tranexamic acid is an oral agent which has recently found success in melasma treatment, likely due to its effect on blood vessels associated with melasma lesions.

Genital Dermatology Symposium Long-term management of adult vulval lichen sclerosus: a prospective cohort study of 507 women A. Lee1, J. Bradford2, G. Fischer1,2 1 Department of Dermatology Royal North Shore Hospital, St Leonards, New South Wales, Australia 2 The Centre for Vulvovaginal Health, Northern Paediatric Dermatology, Royal North Shore Private Hospital, St Leonards, New South Wales, Australia Introduction: Adult vulval lichen sclerosis is frequently complicated by loss of normal vulval structure and has an approximate risk of vulval carcinoma of 5%. The ideal method to maintain long-term remission and prevent complications lacks evidence. Methods: A prospective, longitudinal single centre cohort study between 2008 and 2014 in Sydney, Australia using individualised topical corticosteroids (TCS) treatment regimens. The target outcome was skin with minimal or no observable sign of disease activity. TCS potency was adjusted to disease severity to maintain this outcome. All patients were assessed at least yearly. Results: Mean age of presentation was 55.4 years, and mean duration of follow up 4.7 years. After induction of remission, most patients were managed with a combination of weak to moderate TCS to achieve the target. 70.5% of patients were fully compliant and 29.5% partially compliant, defined as using treatment of less frequency and potency than advised. Squamous cell carcinoma occurred during follow up in 0/360 compliant patients versus 4/147(4.7%) partially compliant patients (P < 0.001). Symptom suppression occurred in 93% of compliant patients versus 57% of partially compliant patients (P < 0.001). Adhesions and scarring occurred during follow up in 3.4% of compliant patients versus 40.7% of partially compliant patients (P < 0.001). Reversible cutaneous atrophy occurred in 1% of compliant patients and 2% of partially compliant patients. Conclusion: This is the first study of adequate power to demonstrate that preventative TCS treatment used to a target outcome normal skin is able to modify the course of the disease and may prevent scarring and cancer.

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

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Pre-pubertal onset vulval lichen sclerosus: the importance of maintenance therapy in long-term outcomes A. Lee1, E. Ellis2, G. Fischer1 1 Department of Dermatology Royal North Shore Hospital, St Leonards, New South Wales, Australia 2 Department of Dermatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia Introduction: There is adequate data on short-term management of childhood vulval lichen sclerosus (VLS), but data on appropriate long-term management is limited. The disease extends beyond menarche and repercussions of suboptimal long-term disease control may be devastating and permanent. Methods: A retrospective, single centre study was conducted in Sydney, Australia in 2014. 46 female patients with pre-pubertal onset VLS were included. Outcomes of individualized topical corticosteroid maintenance regimens with regular follow up where the target outcome was to achieve complete objective normality in addition to symptom control were recorded. Photographic records were available for all patients. Results: 35 patients (76%) had received treatment prior to their first consultation but disease control had been achieved in only 3 patients who were using daily treatment with potent (TCS). 12 children (26%) had architectural change on presentation. All achieved initial objective disease suppression with induction treatment using potent TCS. Compliant and non-compliant patient groups were compared. 31/33 (94%) of compliant patients maintained complete disease remission with no scarring on maintenance treatment compared to 1/13 (8%) of non-compliant patients, defined as those applying intermittent or no longterm TCS (p < 0.001). 9/13 (69%) non-compliant patients experienced disease progression during treatment compare to none in the compliant group (p < 0.001). Scarring developed in 3/13 of non-compliant patients compared to none in the compliant group (p < 0.001). Conclusion: Maintenance treatment of childhood onset VLS with individualized regimens that achieve objective normality in addition to symptom control provide optimal outcomes with preservation of normal vulval architecture to puberty and beyond.

Plasma cell vulvitis: presentation of a case S. Strathie Page1, C. Tait1, J. McCloskey1, J. Parry1, C. Dykstra1 Royal Perth Hospital, Perth, Western Australia, Australia Introduction: Zoon first described plasma cell balanitis in 1950 and since then there have been many cases described.1 The equivalent condition in women is plasma cell vulvitis (PCV), which is less frequently reported in the literature.1,2 For this reason it continues to be a diagnosis that is challenging to make and leads to difficulties for clinicians and patient alike. We report here the treatment of two cases of plasma cell vulvitis at Royal Perth Hospital and explore the other treatment modalities reported for this condition.

Results: Standard therapy for plasma cell vulvitis which mainly includes topical steroids was not successful in either patient. The first patient had a symptomatic recurrence and the second patient was successfully treated with tacrolimus 0.1%. Conclusion: PCV should be considered in patients presenting with a violaceous vulvitis who fail initial topical steroid, have non-specific initial biopsy results or continue to have pruritus, pain or burning.3 It is a complicated condition and further research is warranted to further define this clinical entity.

References 1.

Zoon J. Chronic circumscribed balanitis with plasma cell infiltration. Nederlands Tijdschrift voor Geneeskunde 1950; 94: 1529– 30. 2. Fischer G. The commonest causes of symptomatic vulvar disease: A dermatologist’s perspective. Australasian Journal of Dermatology 1996; 37: 12–8. 3. Goldstein A, Christopher K, Burrows L. Plasma cell vulvitis: A rare cause of intractable vulvular puritis. Archives of Dermatology 2005; 141: 789–790.

Phenotypic variations in hidradenitis suppurativa imply heterogeneous pathogenic pathways with potential adjuvant therapeutic targets D.A. Vekic1, J.W. Frew1,2, J. Woods1, G.D. Cains1,2 1 Department of Dermatology, Liverpool Hospital, Sydney, New South Wales, Australia 2 Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia Hidradenitis Suppurativa (HS) is a chronic inflammatory condition characterised by recurrent, painful, deep-seated nodules and abscesses with variable phenotypic presentations. The physical disability caused by HS results in chronic psychological distress and a negative impact on a patients’ quality of life. A recent latent class analysis has identified commonalities in clinical presentations which have been grouped into “axillary-mammary,” “follicular” and “gluteal” HS subtypes with differing morphology, distribution of lesions and associated prevalence of co-morbidities. Advances in the understanding of HS as an autoinflammatory disease with dysregulation of the Gamma-secretase/Notch pathway, as well as variations in response to monoclonal antibody therapies have led to the suggestion that variable phenotypic presentations are suggestive of heterogeneous pathogenic dysregulation involving TNF-α, the IL-23/Th17 pathway and IL-22 deficiency. Application of this new understanding and classification system infer that specific phenotypic manifestations reflect aspects of disease pathogenesis which can be targeted using established therapies. Active co-morbidities including insulin resistance, glucose intolerance and dysregulated adipokine levels through visceral adipose tissue (indirectly measured via BMI), are possible active

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 modulators in the inflammatory activity of HS, with the presence/absence of these co-morbidities possibly contributing to variances in treatment response. The prevalence of these co-morbidities varies between phenotypic ‘subtypes’ of HS. Hence adjuvant metabolic therapies alongside current biologic regimens may increase therapeutic response.

Free Papers Session Dermatology teaching in Australian medical schools: preliminary survey results A.H. Chong1 and C. Scarff2 1 Skin and Cancer Foundation Inc. Melbourne, University of Melbourne, Melbourne, Victoria, Australia 2 Department of Medical Education, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia Introduction: Many dermatologists are involved in the teaching of dermatology to students in Australian medical schools, but there is little data available on the content taught, including methods of delivery and assessment. Method: In October 2013 an email survey was sent out to members of the Australasian College of Dermatologists inviting them to describe the teaching that they do for medical schools. Results: Sixteen dermatologists replied, covering the teaching in 10 Universities and 12 Medical schools. A lack of consistency and wide variation in the topics covered, amount and methods of teaching was noted. Some described very minimal dermatology core teaching and analysis showed respondents were often frustrated by the amount of dermatology teaching in their medical schools. However, there were some innovative programs which utilised online learning, ITunes University and hands-onworkshops. Discussion: This preliminary survey demonstrates that dermatology teaching in Australian medical schools vary greatly between Universities and clinical schools. Multicentric reticulohisticytosis: rituximab as an alternative to established therapy regimens F. Schauer1, L.L. Solari1, V. Schacht2, J.S. Kern1 1 Department of Dermatology, Medical Center – University of Freiburg, Freiburg, Germany 2 Department of Dermatology, Hannover Medical School, Hannover, Germany

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analysis of all reported cases since the year 2000 with respect to clinical and laboratory characteristics, treatment and outcome. Results: In total 99 cases were identified. The mean age was 50 years; the male to female ratio was one to three. 90% of patients had joint involvement, 7% other organ involvement. Association with cancer was frequent (22%, cancer mostly present at time of diagnosis), as well as association with other autoimmune disease (ANA positive in 18%).

A family in Wagga Wagga… D. Dyall-Smith1, R. Pramanik2, T. Takeichi2, J.A. McGrath2 1 Riverina Dermatology, Wagga Wagga, New South Wales, Australia 2 King’s College London (Guy’s Campus), London, United Kingdom Three family members across three generations presented with ‘crocodile skin’ in childhood, and palmoplantar keratoderma and red scaly plaques as adults. Blood was collected from seven family members across four generations, and skin biopsies were taken from affected and unaffected skin from two affected adults. Whole exome sequencing (WES) was performed on peripheral blood genomic DNA. The three affected individuals shared a novel non-synonymous heterozygous missense mutation in SLC38A10, which was confirmed by Sanger sequencing. Unaffected family members were shown to be wild type. SLC38A10 is a member of the solute carrier families (SLC) 38, with a role in the intracellular transport of neutral amino acids. Immunostaining of normal skin with an antibody to SLC38A10 showed pan-epidermal cytoplasmic and occasional nuclear labeling within keratinocytes. In nonlesional patient skin there was a moderate reduction in the intensity of the keratinocyte staining. Although the application of WES to map a single novel genetic variant to an atypical disease variant in a single family may generate false-positive data, our findings provide support for a potential novel role for SLC38A10 in skin biology and inherited disorders of keratinisation.

Background: Multicentric reticulohistiocytosis (MRH) is a very rare systemic inflammatory histiocytic disease that manifests with skin lesions, severe arthritis and possible other organ involvement. Only case reports and small case series exist to date and treatment can be very challenging. Methods: Detailed characterization of a current series of two MRH patients from our department. Comprehensive © 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

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EV.E.I.L.S Program: Raman-spectroscopic electron and genomic characterization of newborn and children skin physiology C. de Belilovsky1, J.W. Fluhr2, M. Haftek3, N. Lachmann4, C. Baudouin4 1 Department of Dermatology, Institut Alfred Fournier, Paris, France 2 Department of Dermatology, Charité University Clinic, Berlin, Germany 3 University Lyon 1, EA4169 “Fundamental, Clinical and Therapeutic Aspects of the Skin Barrier Function,” SFR Lyon-Est Santé INSERM US 7– CNRS UMS 3453, Lyon, France 4 Innovation R&D Direction, Laboratoires Expanscience, Epernon, France Postnatal cutaneous adaptation and maturation may now be investigated and visualized by new non-invasive skin evaluation technologies. Approach: In vivo Raman spectroscopy (RS) and Scanning Electron Microscopy (SEM) on D-squames were performed on 138 healthy volunteers of 6 age groups. Corneodesmosomes were labelled with antibody to corneodesmosin. Gene expression from age-specific reconstructed epidermis (Stelaskin®) was analyzed by “full transcriptome microarray” and confirmed by quantitative RT-PCR, with a focus on Inter-Follicular Stem Cell (IFSC) markers. Data were collected from birth and longitudinally followed till adulthood in order to determine their maturation age. Then, we have UV-irradiated Stelaskin® of 3 months and 11 years and analyzed SC parameters. Results: RS revealed high NMF levels at birth with a rapid decrease till 6 months. On SEM pictures, a semiquantitative maturation score demonstrated a correlation with increasing age (maturation point between 1 and 2 years old) and with a low central corneodesmosome labeling in neonates. Epidermal barrier genes (involucrin, claudin 1, keratin 1 ) had a low expression in younger infants and increased with age, which is the opposite to IFSC markers expression. IFSC markers like alpha 6 and beta 1 integrin, survivin and TP63 (at gene and protein levels), were decreased after UV irradiation, with a more pronounced decrease in the 3 months Stelaskin® than in the older ones. Conclusion: This research program introduced new fundamental knowledge on infant and children skin. It represents the basic background to provide the most adapted management of infants’ healthy skin. Registrars’ Teaching Session Genetic skin diseases: An approach to diagnosis A.C. Yan Section of Dermatology, Division of General Pediatrics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, USA The diagnosis of genetic skin diseases can be challenging. When evaluating a patient with a possible genetic skin dis-

order, it is important to catalog the relevant findings, discriminate between those that are likely to be specific and those that are coincidental, and utilize appropriate databases to narrow down the differential. Once candidate diagnoses are available, these can be cross-checked with the index patient to determine how best to approach genetic testing. References 1. 2. 3. 4.

http://www.pubmed.org http://www.omim.org http://www.genetests.org http://www.genereviews.org

Global Dermatology Symposium Skin cancer prevention and education: First Fijian Albinism Workshop M.J Whitfeld1, J. Hawker, G. Beale2, C. Brown2, H. Maguire3, L. Maude4 1 Department of Dermatology, St Vincents Hospital, Darlinghurst, New South Wales, Australia 2 University of Notre Dame, Darlinghurst, New South Wales, Australia 3 Loretto Sisters, Sydney, New South Wales, Australia 4 e-GPS Solutions, Sydney, New South Wales, Australia Introduction: Skin cancer is being increasingly recognised as an important cause of morbidity and mortality for people with Albinism living in the Pacific. The importance of sun protection of both the skin and the eyes has not been widely appreciated. There has been no education on albinism in Fiji thus far. Methods: In order to start to address this lack of information within the health and education community, a one-day workshop entitled “The First Fiji Albinism Workshop” was held on 26 November 2014 at the request of the Fiji Society for the Blind. Results: A one-day workshop was held in partnership between the Fiji society for the blind, Fiji school for the blind and St Vincent’s Hospital. In addition donations of hats, sunscreen, corrective vision glasses, sunglasses and long sleeved shirts were donated. In addition to these reading Aids for the school including CCTV reading equipment, lamps and magnifying lenses were donated. 40 participants included parents, community workers for low vision, teachers, and staff from the skin and eye institutes, The workshop consisted of educational sessions on the genetics of Albinism, the skin, and eye consequences of albinism, guidance on classroom teaching of persons with Albinism, and sun safe messages learnt from Australia. The afternoon session consisted of breakout sessions to make recommendations to the various Ministries regarding further education about albinism. The main recommendation is that further workshops and other education, including the medical, school and lay communities. The lack of knowledge and understanding of albinism in the community was highlighted.

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 Systematic review of the global prevalence of scabies and impetigo L. Romani1, A.C. Steer2, M.J. Whitfeld3, J.M. Kaldor1 1 Kirby Institute, University of New South Wales, Sydney, Australia 2 Centre for International Child Health, University of Melbourne, Australia 3 Department of Dermatology, St Vincent’s Hospital, Sydney, Australia Background: Scabies is a skin disease that, through secondary bacterial skin infection (impetigo), leads to serious complications such as septicaemia, renal disease and rheumatic heart disease. Scabies and its complications are regarded as being conditions of resource poor settings and particularly affect young children. The global impact of scabies has been a matter of uncertainty, so we undertook a systematic review of the community prevalence of scabies and impetigo with the goal of guiding public health strategies for the control of scabies in endemic populations. Methods: References for this review were identified through searches of Medline, EMBASE and LILACS for articles published from January 1985 to September 2014. A search of the grey literature was undertaken by seeking reports not published in peer-reviewed journals. Articles resulting from these searches and relevant references cited in those articles were reviewed. No language restrictions were applied in the search but we restricted the search to human studies only. Results: 2409 articles were identified, and 48 studies met the selection criteria. Data were available for all global regions except North America. The prevalence of scabies ranged from 0.2% to 71.4%. All regions except for Europe and the Middle East included populations with a prevalence greater than 10%. Overall the scabies prevalence was highest in the Pacific and Latin regions. The prevalence of scabies was considerably higher in children than in adolescents and adults. Impetigo was common, particularly in children, with the highest prevalence in Australian Aboriginal communities (49%). Conclusions: This review found that scabies and associated impetigo are common problems in many developing countries, affecting particularly children and communities in under-privileged areas and tropical countries, with a very high prevalence in the Pacific region. Comprehensive scabies control strategies are urgently needed, along with a much more systematic approach to the monitoring of disease burden.

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90,000 abstracts related directly to articles published on skin disorders in children. After several further refinements, approximately 2 dozen articles were then selected from the recent literature to be highlighted as among the most interesting, relevant, instructive, or entertaining contributions to pediatric dermatology.

References 1. Simpson et al. JACI. 2014 Oct;134(4):818–823. 2. Ahluwalia et al. Br J Dermatol. 2015; Epub ahead of print. 3. Dutkiewicz et al. JAAD. 2015; in press. doi:10.1016/ j.jaad.2014.11.009

Inpatient consultative pediatric dermatology: The Children’s Hospital of Philadelphia experience A.C. Yan, MD Section of Dermatology, Division of General Pediatrics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, USA Inpatient consultative pediatric dermatology is an important adjunct to the practice of academic pediatric dermatology. Formal consultations are generally preferred over curbside consultations, but curbsides (or what has been called remote informal advice) still remains an important aspect of interactions between hospital-based clinicians and consulting subspecialists. Consult indications vary depending on the requesting service, but concern for skin infections, medication-related reactions, flares of primary skin diseases (such as atopic dermatitis or psoriasis), bone marrow transplant-related complications, vascular anomalies, and evaluation for genetic skin conditions are among the most common consult requests made.

References 1. Perley et al J Med Libr Assoc. 2006;94(2):137–44. 2. McMahon et al. JAAD. 2013;68(6):926–31. 3. Bale et al. Australas J Dermatol. 2014;55(3):191–5. 4. Storan et al. Pediatr Dermatol. 2013;30(4):433–7.

Poster Presentations

The year in review: Pediatric dermatology A.C. Yan Section of Dermatology, Division of General Pediatrics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, USA

Use of adhesive retention tapes to anchor surface sutures in random pattern flaps: designs, plans and options L. Abdel-Malek1,2, P. Peters3,4, K Lun3 1 Gold Coast Hospital, Gold Coast, Queensland, Australia 2 Deakin University, Geelong, Victoria, Australia 3 Dermatology Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia 4 School of Medicine, University of Queensland, St Lucia, Queensland, Australia

In 2014, PubMed reported just over a million new publications in the medical literature. In this same year, nearly

Treatments of non-melanoma skin cancers increased by 86% between 1997 and 2010 (1). With an increasingly elderly

Plenary Session 3

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population and thereby increased cumulative sun damage to skin make the surgical repair of skin cancers more problematic. The use of random pattern cutaneous flap to repair large defects post-surgical excision of non-melanoma skin cancers is a common practice, thus avoiding split thickness and full-thickness skin grafts and associated morbidity. The use of adhesive retention tapes is a recently reported method to assist in wound closures which was reported by Foster and Chan (2) with the use of Fixomull adhesive tape to support atrophic skin with surface sutures placed through the tape. This was further adapted by Peters et al (3) with the use of Fixomull on the poles of a tripolar advancement flap to close a large surgical defect following the excision of a squamous cell carcinoma on a forearm with severe solar elastosis We display and illustrate the variety of random pattern flaps and the placement of adhesive support tape to counteract the atrophy of the skin and avoidance of suture related skin tears.

References Fransen M, Karahalios A, Sharma N, English DR, Giles GG, Sinclair RD. Non-melanoma skin cancer in Australia. Med. J. Aust. Nov 19; 197(10): 565–8. 2. Foster RS, Chan J. The Fixomull skin support method for wound closure in patients with fragile skin. Australas. J. Dermatol. Aug; 52(3): 209–11. 3. Peters P, Abdel-Malek L, Lun K. Adhesive retention tape supporting atrophic skin on a tripolar advancement flap: a novel wound closure option for atrophic skin in an aging population. J. Cutan. Med. Surg. Oct; 18(5): 1–2.

Our patient was commenced on Omalizumab for her co-morbid severe asthma, which resulted in dramatic clearance of her skin within 30 days, resulting in cessation of other active treatments including topical therapies. Her skin remains well managed on emollients alone with concurrent Omalizumab – a dramatic improvement in a patient with previously recalcitrant disease.

Reference 1.

K. S. Babu et al. Anti-IgE – emerging opportunities for Omalizumab. Expert. Opin. Biol. Ther. 2013; 13(5).

Tele-Derm national highlights: eruptive xanthomas heralding type V hyperlipidaemia S. Andrews1,2, C. Adikari3, I. Strungs4, J. Muir1,2 1 Dermatology Department, Mater Misericordiae Health Services, Brisbane, Queensland, Australia 2 School of Medicine, University of Queensland, Brisbane, Queensland, Australia 3 Monto Family Practice, Monto, Queensland, Australia 4 Queensland Medical Laboratories (QML) Pathology, Brisbane, Queensland, Australia

1.

Treatment refractory atopic dermatitis with ichthyosis vulgaris responding to Omalizumab M. Abikhair1,2, A.H. Chong1,2. 1 Department of Dermatology, St. Vincent’s Hospital Melbourne, Victoria, Australia 2 Skin and Cancer Foundation Inc., Melbourne, Victoria, Australia Omalizumab, an IgG1 monoclonal antibody that selectively binds to immunoglobulin E (IgE) antibodies, is presently only accessible on the pharmaceutical benefits scheme for severe uncontrolled asthma. It has been investigated in various dermatological conditions, including atopic dermatitis, chronic urticaria, and various other diagnoses.1 In atopic dermatitis, numerous small case series have showed mixed results.

We present a case of a 31-year-old man who presented to a rural Queensland primary care facility with a four-month history of a progressive non-pruritic rash consisting of multiple clustered papules distributed across both knees and elbows. An initial biopsy was considered to be suggestive of granuloma annulare. After further review by a teledermatologist, direction was provided for the pathologist to revisit the case as the clinical appearances did not correlate with this histological diagnosis. Eruptive xanthoma, however, was one of a number of differentials postulated and the patient was subsequently found to have a serum triglyceride level of 47.0 mmol/L [Target Range 12 month monitoring or those where patients did not undergo any nail biopsy or develop a diagnosis of melanoma on the pathology database. Results: 11 biopsies were performed due to change. 5 were found to be melanoma. 2/5 were detected at 6 weeks, and 3/5 were detected at 3 months. 1/3 and 2/5 lesions biopsied at 6 weeks and 3 months respectively were benign. Of the 100 lesions unchanged at 3 months, all were found to be benign. Significant and non-significant changes will be reviewed in detail and the usefulness of monitoring in the management of melanonychia will be discussed. Reference 1.

Sawada M, Yokota K, Matsumoto T, Shibata S, Yasue S, Sakakibara A et al. Proposed classification of longitudinal melanonychia based on clinical and dermoscopic criteria. International Journal of Dermatology. 2014; 53(5): 581–5.

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Optical coherence tomography in the presurgical margin delineation of Mohs surgery in infiltrative BCC H.M. Cheng1, P. Guitera1,2, R. Harvey3 1 Melanoma Institute Australia, North Sydney, New South Wales, Australia 2 Sydney Melanoma Diagnostic Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia 3 Skin and Cancer Foundation, Darlinghurst, Sydney, New South Wales, Australia Introduction: Non-melanoma skin cancers (NMSC) are the commonest cancer worldwide and incidence continues to rise in Australia.1 Mohs surgery is a technique where intraoperative histological analysis is carried out to achieve surgical margin clearance and complete removal of tumour. Infiltrative BCC is associated with requiring higher numbers of Mohs stages for margin clearance.2 OCT is an emerging noninvasive technology that allows in-vivo imaging of tumour margins.3 The aims of this study are to define the OCT features of infiltrative BCC and to evaluate the value of OCT in defining the excision margins of infiltrative BCC before Mohs surgery. Method: Patients with biopsy-proven infiltrative BCC were recruited in this prospective study. OCT was performed on the lesion and margin was determined. Clinical photography and measurement was taken of the surgical margins. Mohs surgery was performed by a blinded investigator and clinical photography and measurement was taken of the surgical margins. Number of stages of Mohs excision, final defect size measurement and clinical photography were recorded. OCT images were analysed with reference to the histopathology slides to correlate OCT features with histopathologic features. Results: OCT is a fast and new imaging technique that has the potential to reduce the number of Mohs stages of infiltrative BCC excision. References 1.

Olsen CM, Williams PF, Whiteman DC. Turning the tide? Changes in treatment rates for keratinocyte cancers in Australia 2000 through 2011. Journal of the American Academy of Dermatology 71(1): 21–6.e1. 2. Orengo IF, Salasche SJ, Fewkes J, Khan J, Thornby J, Rubin F. Correlation of histologic subtypes of primary basal cell carcinoma and number of Mohs stages required to achieve a tumorfree plane. Journal of the American Academy of Dermatology 1997; 37(3): 395–7. 3. Wang KX, Meekings A, Fluhr JW, McKenzie G, Lee DA, Fisher J et al. Optical coherence tomography-based optimization of Mohs micrographic surgery of basal cell carcinoma: A pilot study. Dermatologic Surgery 2013; 39(4): 627–33.

Safety of TNF-α inhibitors in HIV patients A.Chia1,2, M. Whitfeld1,2 1 Department of Dermatology, St Vincent’s Hospital, Darlinghurst, New South Wales, Australia 2 Skin & Cancer Foundation, Darlinghurst, New South Wales, Australia Introduction: TNF-α inhibitors are increasingly being used for dermatologic conditions, particularly psoriasis, but © 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

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their use increases the risks of new or reactivated infections, and demyelinating diseases. In HIV infected persons, these risks may be increased. Efalizumab (CD11 monoclonal) was withdrawn following three confirmed and one suspected case of progressive multifocal leukoencephalopathy. Since then, there has been increased concern regarding the use of these biologics agents, especially in the context of HIV. HIV can be associated with severe psoriasis, and may require systemic agents including TNF-α inhibitors. Methods: A literature search was performed using Medline for HIV, anti-TNF, TNF inhibitors, and biologics. Case reports, case series, and relevant trials of TNF-α inhibitors in HIV patients were included. HIV infection was an exclusion criteria for many trials. We included articles from other specialties including rheumatology and gastroenterology because of the paucity of relevant articles in dermatology Results: Nine articles including 17 cases were included. One case of recurrent polymicrobial infections resulting in death, in a patient with a CD4 below 50. Another patient with a CD4 count of 240 developed facial abscess, which responded to antibiotics. We do not recommend TNF-α inhibitors be used in those with CD4 below 200, because of the higher risk of infectious complications. We therefore conclude that TNF-α inhibitors could be considered for treatment-resistant psoriasis in HIV patients, provided that their CD4 count is above 200, and there are no other preexisting or latent infections. Larger studies are needed to firmly establish safety.

Biochip immunofluorescence microscopy as a new diagnostic tool for autoimmune blistering skin diseases in Australia Y.Z. Chiang1, C.Y. Zhao1,2, W. Melbourne1,3, A. Wijayanti1, K. Tran3, J. Kim1, K. Legaspi1, N. Ishii4, H. Koga4, E. Schmidt5, D. Zillikens5, T. Hashimoto4, D.F. Murrell1,2 1 Dermatology, St George Hospital, Sydney, New South Wales, Australia 2 University of New South Wales, Sydney, New South Wales, Australia 3 Anatomical Pathology, St George Hospital, Sydney, New South Wales, Australia 4 Kurume University, Kurume, Fukuoka, Japan 5 University of Luebeck, Luebeck, Germany Introduction: Autoimmune blistering skin diseases are a group of disorders characterised by autoantibodies targeting important structural proteins in the skin that mediate cell-cell or cell-matrix adhesion. Recently, the Biochip mosaic-based indirect immunofluorescence technique has been made available in Australia to allow polyvalent immunofluorescence tests and provide antibody profiles in a single incubation. Our aim is to determine the sensitivity and specificity of the Biochip technique, using the enzymelinked immunosorbent assay (ELISA) as the gold standard control.

immunofluorescence microscopy using the Biochip method and to Japan for ELISA. The Biochip mosaic contained 6 test substrates which included monkey oesophagus, human salt-split skin, bullous pemphigoid (BP) antigen 180, desmoglein (Dsg) 1, Dsg 3, and BP230. The results were compared with each other. Results: So far, 29 results from 24 patients were included: 9 had pemphigus vulgaris (PV), 2 had pemphigus foliaceus (PF) and 13 had BP. The Biochip has good diagnostic sensitivities for PV on cells transfected with Dsg 1 (100%) and Dsg 3 (90%). The specificities for Dsg 1 and Dsg 3 were 70% and 50% respectively. In patients with BP, the Biochip also has a good diagnostic sensitivity (100%) and specificity (64%) for BP 230. The sensitivity (67%) and specificity (57%) for BP 180 were lower than that for BP 230. Our preliminary results showed that the Biochip method has a high diagnostic accuracy for PV and BP.

Another chemotherapy reaction? Hyperpigmentation due to alkylating agents revisited S.D. Choi, J.A. Woods Department of Dermatology, Liverpool Hospital, Liverpool, New South Wales, Australia Cutaneous reactions due to chemotherapy agents are concerning to patients and oncologists alike, and tend to summon an urgent consult by a dermatologist. We report a case of a 17-year-old Caucasian boy with glioblastoma multiforme who has come under a rapid assessment by our dermatology centre with such a circumstance. He presented with 2 weeks history of worsening “bruising” in between finger-web spaces as well as in axillae and around the neck. He had been undergoing oral chemotherapy with Temozolomide, an alkylating agent, and brain radiation for the past three weeks. His skin was asymptomatic, and he felt well. His blood counts were unremarkable. On close inspection, brown furry hyperpigmentation resembling acanthosis nigricans was noted. This was easily rubbed off using 70% isopropyl glycol alcohol wipes, confirming the suspicion for diagnosis of terra firma forme dermatosis. Alkylating agents are commonly known for a range of cutaneous reactions, which include hyperpigmentation. To date, the range of reported hyperpigmentation reactions encompass cutaneous hyperpigmentation some in occluded areas, hyperpigmentation of nails, teeth and gingiva1, but do not include terra firma forme dermatosis. It is possible that hyperpigmentation in occluded and flexural areas may have been due to accumulation of excreted aklylating agent or its by-product. Adding this knowledge to the literature would aid in reassuring patients who develop this condition undergoing chemotherapy, and also further aid in research for the pathogenesis of this fascinating condition.

Reference 1.

Methods: Sera from patients with provisional diagnoses of autoimmune blistering skin diseases were collected prospectively and sent to the pathology laboratory for indirect

Reyes-Habito CM, Roh EK. Cutaneous reactions to chemotherapeutic drugs and targeted therapies for cancer. Part 1. Conventional chemotherapeutic drugs. J. Am. Acad. Dermatol. Aug 2014; 71(2): 203.e1–e12.

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 Radiotherapy-induced eruptive keratoacanthomas of the face – a case of Ferguson-Smith disease responsive to acitretin therapy M. Cicchiello, M. Goh Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia

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Sensitivity of our model to correctly classify people with melanoma as high risk was 81.6% with specificity of 70.9%.

References 1.

Ferguson–Smith disease is an autosomal dominant condition characterised by multiple keratoacanthomas (KAs) that clinically and histologically resemble welldifferentiated squamous cell carcinomas (SCCs). We report the case of an 82-year old woman with a known past history of up to 50 SCCs, who had post-operative radiotherapy to the cheek following excision of a welldifferentiated SCC or KA with perineural invasion. Whilst undergoing the course of radiation therapy, she erupted with multiple new SCCs or KAs on the cheek localised only within the radiotherapy field. These lesions regressed over 4 months with oral acitretin doses between 10–20 mg daily. There was no significant scarring after resolution of the tumours. She had recurrent new tumours when acitretin was ceased, and therefore, remains on maintenance low-dose acitretin 10 mg daily.

Reference 1.

Robertson SJ. Severe exacerbation of multiple self-healing squamous epithelioma (Ferguson Smith disease) with radiotherapy, which was successfully treated with acitretin. Clincal and Experimental Dermatology 2009; 35(4): e110–2.

Risk factors for melanoma in the Tasmanian population: can targeted screening be achieved? †I.H. Illingworth1, P. Clarke1,2, †K.Ogden1, I. Robertson1 1 University of Tasmania, Launceston, Tasmania, Australia 2 Department of Dermatology, Launceston General Hospital, Launceston, Tasmania, Australia Introduction: Whole of population-based screening is not currently recommended for melanoma due to lack of evidence for feasibility and effectiveness1,2 Targeted screening of high-risk individuals may be appropriate. Identifying major risk factors and producing a risk profile for patients could make this achievable. Method: 100 melanoma patients and 250 control patients were enrolled in the study. Screening involved a questionnaire and full skin examination with documentation of clinical features. A risk assessment model was developed to categorise people as high or low risk for melanoma through backwards stepwise logistic regression. Results: Characteristics included in the risk assessment model were: naevi (20–100, >100); severe freckling; past history of non-melanoma skin cancer; dark-brown eye colour; red-hair colour; Fitzpatrick skin type II; no exercise; age and moderate-severe solar keratosis. Protective associations were found with having ‘a few’ and ‘a lot of’ sunburns.

Cancer Council Australia. Screening and early detection of skin cancer [Internet]. Sydney, NSW: Cancer Council Australia, 2014 [cited 16 Oct 2014]. Available from URL: http://wiki.cancer .org.au/policy/Position_statement_-_Screening_and_early _detection_of_skin_cancer. 2. Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice 8th edition [Internet]. East Melbourne, Melbourne: The Royal Australian College of General Practitioners, 2012 [cited 2014 Mar 21]. Available from URL: http://www.racgp.org.au/download/Documents/ Guidelines/Redbook8/redbook8.pdf. †Correction added on 10 December 2015, after initial online publication. Presenting author was changed from P. Clarke to I.H. Illingworth and K.Ogden has been added to the list of authors.

Secukinumab 300 mg demonstrates highest probability of efficacy than other biologics in psoriasis: indirect comparison A. Collins1 on behalf of E. Hawe2, A. Vickers2, UG. Mallya3, D. McBride2, G. Capkun-Niggli4, M. Olson4, K. Thorlund5 1 Novartis Pharmaceuticals Australia, North Ryde, New South Wales, Australia 2 RTI Health Solutions, Ann Arbor, Michigan, USA 3 Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA 4 Novartis Pharma AG, Basel, Switzerland 5 McMaster University, Ontario, Canada Introduction: A mixed-treatment comparison (MTC) assessed the relative efficacy of secukinumab versus other biologics in patients with moderate-to-severe psoriasis. Methods: A systematic literature review was performed (MEDLINE, EMBASE, Cochrane Library) from inception to June 2013, including randomized control trials of Secukinumab (5), etanercept (7), adalimumab (6), infliximab (6) and Ustekinumab (7). Binomial MTCs were used to model PASI75 and PASI90. Bayesian random effects models are presented, fixed effects gave similar results. All analyses were conducted in R Development Core Team (2013). For placebo patients with no data at 16 weeks, 12-week data were carried forward. Results of PASI75 and PASI90 analyses at 12 and 16 weeks are presented. Results: Secukinumab 300 mg was the highest in the treatment hierarchy among all biologics. At 12 weeks, secukinumab was statistically superior to etanercept 50 mg and ustekinumab 45/90 mg and similar to adalimumab 80/40 mg and infliximab for PASI75. For PASI90, secukinumab was superior to etanercept 50 mg, ustekinumab 45 mg and adalimumab 80/40 mg and similar to ustekinumab 90 mg and infliximab. At 16 weeks, secukinumab was superior to etanercept 25/50 mg and ustekinumab 45/90 mg for PASI75. For PASI90, secukinumab was superior to adalimumab 80/40 mg, etanercept, and ustekinumab 45 mg.

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Conclusions: Among psoriasis biologics in the network for PASI75 and PASI90, secukinumab 300 mg was the highest in the treatment hierarchy at 16 weeks. As measured by PASI response, secukinumab efficacy is superior at 12 and 16 weeks, relative to most other biologics, in treating moderate to severe psoriasis. Review of the proposed pathogenic mechanisms underlying rosacea and possible clinical implications of vascular and inflammatory involvement V.R.V. Cox1, J.W. Frew 2,3 1 Department of Dermatology, Flinders Medical Centre, Adelaide, South Australia, Australia 2 Department of Dermatology, Liverpool Hospital, Sydney, New South Wales, Australia 3 Conjoint Associate Lecturer, University of New South Wales, Sydney, New South Wales, Australia Rosacea is a common, chronic inflammatory dermatosis with heterogenous clinical presentations. It is commonly characterised by central facial erythema, oedema, telangiectasia, the presence of pustules, papules and occasionally burning or stinging, although not all of these manifestations may be present in a single individual. Clinical subtypes of rosacea include erythematotelangiectatic rosacea, papulopustular rosacea, phymatous rosacea and ocular rosacea. It is still unclear whether the clinical subtypes represent a linear progression of disease activity, or are distinct disease processes collectively described as a clinical syndrome. Current understanding of rosacea pathogenesis is incomplete; however it has been proposed that four major areas of dysregulation contribute to the clinical manifestations of the disease. All of these areas experience complex interactions and feedback mechanisms which contribute to the development of rosacea. These dysregulated systems include increased vascular permeability and dilatation, increased neurogenic vascular stimulation, dysregulation of the cutaneous microbiome, (with a role for increased density of demodex mites), and localised abnormalities of the innate immune system. The clinical presentations of rosacea can be explained through application of this current pathogenic model and further understanding of the complex interplay of these systems are essential in identifying and developing improved therapeutic options for the management of this common condition. Lipohypertrophy after autologous fat transplantation for lip enhancement G. Daley1, P. Peters1,2, F. Hossain1, T. Nguyen2, K. Lun1 1 Dermatology Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia 2 School of Medicine, University of Queensland, Brisbane, Queensland, Australia Lipohypertrophy is recognised to occur at the site of insulin injection among patients with Diabetes Mellitus. It

has also been described in patients with HIV receiving anti-retroviral therapy and associated with increased urine cortisol levels in patients with Cushing’s Syndrome.1 Lipohypertrophy following autologous fat transplantation is a rare complication of this procedure. Although described by a number of case reports, there is no clear documented pathophysiology among patients without these mentioned endocrine and medical conditions.2 We report a case of localised lipohypertrophy in a 58-year-old female who had undergone cosmetic lip augmentation by autologous fat transplantation. Prednisolone was commenced due to lung pathology and at this time fat hypertrophy was noted in her upper lip. The patient subsequently required bilateral lung transplant and was placed onto an antirejection regime consisting of long standing prednisolone. The patient reported an increase in the size of her lips in the years following her transplantation. Lipohypertrophy is a recognised side affect of the use of glucocorticosteroids, however this is the first recorded case of lipohypertrophy after autologous fat transplantation for lip enhancement. This particular adverse reaction to an autologous fat transfer needs to be discussed with patients either undergoing or potentially requiring solid organ transplantation.

References 1.

Leung VL, Glesby MJ. (2011) Pathogenesis and treatment of HIV lipohypertrophy. Curr Opin Infect Dis. 24(1): 43–9. 2. Miller JJ, Popp JC. (2002) Fat hypertrophy after autologous fat transfer. Ophthal PLast Reconstr Surg. 18(3): 228–31.

Glutathione S-transferase P1 Ile105Val polymorphism: phenotypic characteristics and melanoma risk G.M. Daley1, K.J. Lee1, K. Jagirdar1, B.M. Smithers2, D.L. Duffy3, R.A. Sturm1, H.P. Soyer1 1 Dermatology Research Centre, The University of Queensland, School of Medicine, Translational Research Institute, Brisbane, Queensland, Australia 2 Queensland Melanoma Project, The University of Queensland, School of Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia 3 Queensland Institute of Medical Research, Brisbane, Queensland, Australia Introduction: The role of glutathione S-transferase P1 (GSTP1) genotype (rs1695*A/G, pIle105Val polymorphism) in malignant melanoma (MM) susceptibility is not yet well defined. A recent study found GSTP1 polymorphism was associated with light coloured hair, an increase in melanoma risk, and greater penetrance of melanoma risk when combined with melanocortin-1 receptor (MC1R) RHC-variant allleles.1 Method: Individuals presenting to dermatology or melanoma surgical clinics and individuals from the Brisbane Twin Naevus Study cohort were invited to join a casecontrol study of melanoma and nevus morphology. Two hundred and thirty-four participants with MM and three hundred and seventeen controls with no history of MM were

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included in this analysis. Genotyping was conducted on saliva samples using TaqMan probes and PCR. Statistical analysis was performed using univariate and multivariate logistic regression.

Protecting the delicate skin of infants D.P. Daniels, K.A. Greive Ego Pharmaceuticals Pty Ltd, Melbourne, Victoria, Australia

Results: In this study there was no statistically significant association between GSTP1 Ile105Val and melanoma: AG alleles (OR 1.07 95% (CI) 0.75–1.53, p = 0.72) and GG alleles (OR 1.30 95% (CI) 0.74–2.28, p = 0.36). An association was found between MC1R RHC-variant alleles and the development of melanoma (OR 2.08 95% (CI) 1.09–3.95, p = 0.025). Expected associations between age and red hair colour were also observed. There was no statistically significant association between GSTP1 Ile105Val and hair colour. Furthermore, there was no interaction between MC1R RHC-variant alleles and GSTP1 and melanoma risk.

Infants are born with relatively dry skin as indicated by significantly lower stratum corneum (SC) hydration at birth compared to older infants, children and adults.1

Reference 1.

Ibarrola-Villava M, Martin-Gonzalez M, Lozaro P, Pizarro A, Lluch A, Ribas G. Role of glutathione S-transferases in melanoma susceptibility: association with GSTP1 rs1695 polymorphism. B J Dermatol. 2012; 166(6): 1176–83.

An Australian perspective on skin of colour: results of a national survey B.S. Daniel1,2, M.A. Rodrigues1,3 1 Skin and Cancer Foundation Inc., Melbourne, Victoria, Australia 2 Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia 3 The Royal Children’s Hospital, Victoria, Australia; St Vincent’s Hospital, Melbourne, Victoria, Australia Australia’s demographic is continuously changing with a constant increase in immigrants with skin of colour (SOC) being documented around the country. This dramatic demographic shift demands a higher level of education, training and expertise in the diagnosis and management of dermatological conditions in patients with SOC. We present the findings of a national survey of dermatologists who attended the 2014 Australasian College of dermatologists’ Annual Scientific Meeting. The survey aimed to obtain demographic data and to assess the dermatologists’ perspectives on skin of colour including adequacy of training and interest in further learning on the topic. The findings of the survey demonstrate a need for more formal teaching during dermatology training and ongoing medical educational activities in this area.

In infants, both the SC and epidermal thickness are considerably different from adults: the SC is on average 30% thinner and the supra-papillary epidermis is 20% thinner in infants 6–24 months of age.1 Studies have shown that lower amounts of NMF were documented in infants in comparison to adults.2 In addition, water absorption and desorption properties were disturbed in infants.2 These discrepancies could partly explain the vulnerability of infant skin to the development of dehydration and dermatitis.2 Also, babies are born with neutral skin pH which becomes progressively more acidic.1 However, the occlusive and humid environment of diapered skin has been found to have high pH.1 Neutral pH of infant skin in diapered areas correlates with a susceptibility to develop skin irritation.1 Once skin barrier disruption has occurred, infant skin is less able to promote skin repair.1 Several studies have shown that emollient use can improve skin barrier function or improve fluid and electrolyte balance in preterm infants.3,4 Also, the use of mild surfactant systems in cleansers can enable maintenance of skin barrier integrity.5 The QV Baby range of products are pH-balanced to cater to the delicate nature of infant skin. In addition to providing short-term benefits such as maintaining and improving skin barrier function, long-term use of the QV Baby range can produce lasting benefits to skin barrier function and overall infant skin conditions.

References 1.

2.

3.

4.

5.

Stamatas GN, Nikolovski MC, Mack MC, Kollias N. Infant skin physiology and development during the first years of life: a review of recent findings based on in vivo studies. Int J Cos Sci. 2011; 33: 17–24. Fluhr JW, Darlenski R, Lachmann N, Baudouin V, Msika P, De Belilovsky C, Hachem JP. Infant epidermal skin physiology: adaptation after birth. Brit J Derm. 2012; 166: 483–90. Lane AT, Drost SS. Effects of repeated application of emollient cream to premature neonates’ skin. Pediatrics 1993; 92(3): 415– 419. Nopper AJ, Horii KA, Sookdeo-Drost S, Wang TH, Mancini AJ and Lane AT. Topical ointment therapy benefits premature infants. J Pediatr. 1996; 128(5): 660–69. Lorena S, Telofski A, Morello P, Mack MC, Stamatas GN. The infant skin barrier: Can we preserve, protect, and enhance the barrier. Dermatology Research and Practice 2012; Article ID 198789, 18 pages, 2012. doi:10.1155/2012/198789.

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Sunflower oleodistillate: a topical PPAR-α agonist developed for atopic dermatitis C. de Belilovsky1, S. Bredif2, B. Chadoutaud3, C. Baudouin2 1 Dermatology Department, Institut Alfred Fournier, Paris, France 2 Innovation R&D Direction, Laboratoires Expanscience, Epernon, France 3 ClinReal Online, Toulouse, France

quality. It is important to use specific skin care products which have been formulated but also assessed under specific conditions. That’s why we have developed specific guidelines on formulation and safety evaluation of products dedicated to children under the age of 3 years.

Sunflower oleodistillate (SO) activates PPARs-α (Peroxisome Proliferator-Activated Receptors) in cell model and has a triple action on epidermal lipid barrier, cutaneous inflammation and immunological Th2 response:

Modified stinging test: Cosmetics’ sensory irritation potentials are independent of objective irritation. We developed a modified stinging test (increased ambient temperature and relative humidity and earlier measures) to screen different pre-formulations of the same baby product which obtained similar objective irritation scores. Clinical relevance of Global Score 10% of pts were exacerbation of HS (13.2% PBO, 9.2% ADA) and nasopharyngitis (10.5% PBO, 5.9% ADA). Cellulitis was reported by 2 pts for each PBO and ADA. Serious AEs included pyelonephritis (n = 1 ADA) and breast cancer (n = 1 PBO). No deaths occurred.

CC Zouboulis has received honoraria from AbbVie and Stiefel/GSK for participation on advisory boards, as an investigator and speaker, from Dermira and Galderma for participation on advisory boards, from Leo for participation as a consultant, and from Almirall, Bayer Health Care, Bioderma, Biogen-Idec, General Topics, and Glenmark for his participation as a speaker; his department received grants from AbbVie, Biogen-Idec, BMS, Immundiagnostik AG, LVMH, Merz, Pierre Fabre, and UCB for his participation as an investigator, and from Intendis for his participation on an advisory board. AW Armstrong serves as investigator and/or consultant to AbbVie, Amgen, Janssen, Merck, Lilly, Celgene, UCB, and Pfizer. NJ Korman has acted as a prinicipal investigator for Abbvie, Amgen, Celgene, Eli Lilly, Janssen, Merck, and Pfizer, as an advisor for Abbvie, Apopharma, Baxter, Celgene, Eli Lilly, Jannsen, Leo, Novartis and Pfizer, as a speaker for Abbvie and Janssen, and has received fellowship funding from Janssen. J Crowley has received honoraria and grants from AbbVie, Amgen, and Maruho for participation on ad boards and as a speaker and investigator, and grants from Astra-Zeneca, Celgene, Janssen, Lilly, Pfizer, Merck, and Regeneron for participation as an investigator. C Lynde has acted as a Principal Investigator/Speaker/ Consultant for Abbott/AbbVie, Merck Frosst, Actelion, Merz Aestheticas, Amgen/Pfizer, Cipher Pharmaceuticals, Stiefel /GSK, Galderma, Valeant Pharma, Janssen/Johnson & Johnson. K Belknap, Y Gu and D Williams receive a salary as employees of AbbVie and may also receive AbbVie stock, stock options and/or stock grants. The authors would like to acknowledge Jody Bennett, employed by AbbVie, for medical writing support in the production of this abstract.

Disclosures: AbbVie Inc. participated in the study design; study research; collection, analysis and interpretation of data; and writing, reviewing and approving of this publication. All authors had access to the data, and participated in the development, review, and approval, and in the decision to submit this publication. AbbVie funded the research for this study and provided writing support for this abstract.

Efficacy and safety of Adalimumab in patients with moderate to severe hidradenitis suppurativa: results from PIONEER II, a phase 3 randomised placebo-controlled trial L. Escudero Herra1 on behalf of G.B.E. Jemec2, A. Gottlieb3, S. Forman4, E.J. Giamarellos-Bourboulis5, Z. Reguiai6, Y. Gu7, M.M. Okun7 1 Abbvie Pty Ltd, Mascot, New South Wales, Australia 2 University of Copenhagen, Roskilde, Denmark 3 Tufts Medical Center, Boston, Massachusetts, USA 4 Forward Clinical Trials, Tampa, Florida, USA 5 4th Department of Internal Medicine, University of Athens, Medical School, Athens, Greece 6 CHU de Reims, Hôpital Robert Debré, Service de Dermatologie, Reims Cedex, France 7 AbbVie Inc., North Chicago, Illinois, USA

A Kimball is a consultant and investigator for Janssen, AbbVie, Amgen and has received fellowship funding from Janssen.

Introduction and objectives: PIONEER II evaluated the safety and efficacy of adalimumab (ADA) vs placebo (PBO)

In PIONEER I, a Phase 3 randomized PBO-controlled study of ADA in HS, significantly more pts randomized to ADA achieved HiSCR vs pts randomized to PBO. AEs were comparable to PBO and consistent with the ADA safety profile; no new risks were identified.

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 in patients (pts) with moderate to severe hidradenitis suppurativa (HS). Methods and results from the first 12 weeks (wks) are reported. Materials and methods: This multicenter study included a 12-wk double-blind PBO-controlled period (Per A). Pts were randomized 1:1 to blinded ADA 40 mg weekly starting at Wk4 (following 160 mg at Wk0; 80 mg at Wk2) or matching PBO. At baseline, pts had a diagnosis of HS for at least 1 year, a total abscess and inflammatory nodule (AN) count of ≥3, HS lesions in ≥2 body areas (1 at Hurley Stage II or III) and had no prior TNF-α–inhibitor treatment, including ADA. Efficacy in Per A was analyzed for all randomized pts (intent-to-treat [ITT_A Population]); safety was analyzed for pts in the ITT_A Population who received at least 1 dose of study drug. The primary endpoint was HiSCR (HS Clinical Response; ≥50% reduction from baseline in AN count and no increase in abscess or in draining fistula counts) at Wk12. Missing assessments were handled by nonresponder imputation (categorical variables) and lastobservation-carried-forward (continuous variables). Results: Of the 326 in the ITT_A Population, 67.8% were women; 83.7% were white; mean age was 35.5 (SD 11.13) years; mean HS duration was 11.5 (SD 9.03) years. Baseline characteristics were similar between groups. 93.9% completed Per A. HiSCR rate at Wk12 was significantly higher for pts randomized to ADA (96/163, 58.9%) vs PBO (45/163, 27.6%; p < 0.001). Statistically significant treatment differences were observed for all 3 ranked secondary endpoints (Wk12, ITT_A Population) as follows: 1) among pts with Hurley Stage II, a significantly higher proportion of ADA pts achieved AN count of 0, 1 or 2 (ADA [44/85, 51.8%] vs PBO [28/87, 32.2%; p = 0.010]); 2) a significantly higher proportion of ADA pts achieved at least a 30% reduction and at least 1 unit reduction from baseline in Patients’ Global Assessment of Skin Pain numerical rating scale(NRS) based on 24-hour recall of worst pain (ADA [48/105, 45.7%] vs PBO [23/111, 20.7%; p < 0.001]), among pts with baseline NRS ≥ 3; 3) ADA pts achieved a significantly greater mean reduction from baseline in modified Sartorius Score (ADA [n = 163, −28.9] vs PBO [n = 162, −9.5; p < 0.001]). 57.7% (ADA) and 66.9% (PBO) reported at least 1 treatmentemergent adverse event (TEAE). TEAEs in ≥10% of pts in any treatment arm were headache (12.9% ADA; 12.9% PBO) and exacerbation of HS (4.3% ADA; 12.9% PBO). 1.8% (ADA) and 3.7% (PBO) had serious TEAEs. There were no deaths. Conclusions: Significantly more HS pts treated with adalimumab achieved clinically relevant reduction in objective disease activity and pain compared to placebo. The safety profile for pts in both treatment groups was comparable. Disclosures: AbbVie Inc. funded this study and participated in the study design; study research; collection, analysis and interpretation of data; and writing, reviewing and approving of this publication. All authors had access to the data, and participated in the development, review, and approval, and in the decision to submit this publication. G Jemec: Received honoraria from AbbVie, Pfizer and MSD for participating on ad boards. Received grants from Leo Pharma, Actelion, Janssen-Cilag for participation as an investigator.

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A Gottlieb: Has received compensation from AbbVie, Actelion, Akros, Amgen, Astellas, Beiersdorf, Bristol Myers Squibb, Canfite, Catabasis, Celgene, Centocor (Janssen), Coronado, CSL Behring Biotherapies for Life, Dermipsor, DUSA, Glaxo Smith Kline, Incyte, Karyopharm, Lilly, Novartis, Novo Nordisk, Pfizer, Sanofi Aventis, TEVA, UCB, Vertex, and XenoPort for consulting and/or advisory board agreements. Research/educational grants (paid to Tufts Medical Center) with AbbVie, Amgen, Celgene, Coronado, Centocor (Janssen), Levia, Lilly, Novartis, Merck, and Pfizer. S Forman: Received compensation from Abbvie, AstraZeneca, Janssen, Novartis, Promius, and Regeneron for research; from AbbVie for speaker services; and from Galderma for consultation services. E Giamarellos-Bourboulis: Received honoraria from AbbVie and The Medicine Company; serves as consultant for Astellas Greece; received independent educational grants (paid to the University of Athens) from AbbVie and Sanofi. He is funded by the FrameWork 7 program HemoSpec. Z Reguiai: Received honoraria from Abbvie, Pfizer, JanssenCilag, Novartis for participating on advisory boards. Has been an investigator for AbbVie, Actelion, Amgen, Glaxo Smith Kline, Janssen-Cilag, Pfizer, Novartis. Received speaker honoraria from Abbvie, Glaxo Smith Kline, Janssen-Cilag, Leo Pharma, Pfizer. Y Gu and M Okun receive a salary as employees of AbbVie and may also receive AbbVie stock, stock options and/or stock grants. The authors would like to acknowledge Jody Bennett, employed by AbbVie, for medical writing support in the production of this abstract.

Perforating paraneoplastic granuloma annulare of the hands and feet – two cases reported B. Fergie, D. Davies, M. McRae Orange Dermatology, Orange, New South Wales, Australia Granuloma annulare as a paraneoplastic process is rare and has been described in just 20 cases of English literature since 1966.1,2,4 To date over half the cases were associated with a haematological malignancy. Most cases presented as atypical Granuloma annulare with typical histopathology. Some cases improved with treatment of the underlying malignancy. Here we describe two cases of perforating paraneoplastic granuloma annulare of the hands and feet. Both cases were associated with haematological malignancy and improved or resolved with treatment of the malignancy.

References 1.

Abunasra H, Morgan E. Granuloma annulare and malignant neoplasms. American Journal of Dermatopathology 2003 Dec; 25(6): 502–3.

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3. 4.

5.

6.

Australasian Journal of Dermatology (2015) 56 Li A, Hogan DJ, Sanusi ID, Granuloma annulare and malignant neoplasms. American Journal of Dermatopathology 2003 Apr; 25(2): 113–6. Review. Cohen PR. Granuloma annulare associated with malignancy. Southern Medical Journal 1997 Oct; 90(10): 1056–9 Hinckley MR, Walsh SN. Generalized granuloma annulare as an initial manifestation of chronic myelomonocytic leukemia: a report of 2 cases. American Journal of Dermatopathology 2088 Jun; 30(3): 274–7. Ono H, Yokozeki H et al. Granuloma annulare in a patient with malignant lymphoma. Journal of Dermatology 1997; 195(1): 46–7. Chiu ML, Tang MB. Generalised granuloma annulare associated with gastrointestinal stromal tumour: a case report and review of the clinical features and management. Journal of Clinical and Experimental Dermatology 2008 Jul; 33(4): 469–71.

Secukinumab shows efficacy in subjects with and without previous exposure to biologic psoriasis therapy: subanalysis from the phase 3 FIXTURE study P. Foley1, E. Rivas2, CEM. Griffiths3, P. Rich4, M. Notter5, C. Papavassilis5 1 The University of Melbourne, Skin and Cancer Foundation Inc, Carlton, Victoria, Australia 2 Dermos, Guatemala City, Guatemala 3 Dermatology Centre, Salford Royal Hospital, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK 4 Oregon Dermatology and Research Center, Portland, Oregon, USA 5 Novartis Pharma AG, Basel, Switzerland Introduction: Secukinumab, an anti-IL-17A antibody, demonstrated efficacy and acceptable safety to Weeks 12 (vs. placebo and etanercept) and 52 (vs. etanercept) in moderate-to-severe plaque psoriasis (FIXTURE study). This subanalysis evaluated the relationship between prior exposure to biologics and response to secukinumab. Methods: In this double-blind study, subjects aged ≥18 years were randomized 1:1:1:1 to secukinumab sc 300 or 150 mg (weekly for 4 weeks, then q4wk starting at Week 4), etanercept sc 50 mg (twice weekly for 12 weeks, then weekly), or placebo. The relationship between response to secukinumab and previous biologic exposure was assessed at Week 12 based on PASI75, PASI90, and modified 5-point investigator’s global assessment (IGA-mod 2011) 0/1 responses. Results: Of 1306 subjects randomized, 163 were previously exposed to biologics, including 59 who had failed biologics. Each secukinumab dose had higher PASI90 and IGA-mod 2011 0/1 (p < 0.05) responses than etanercept and placebo in both the subgroup previously exposed and those not exposed to biologics. The 300 mg dose had higher PASI75 responses than etanercept and placebo in both subgroups. Responses to secukinumab were generally higher in subjects not previously exposed to biologics vs those with previous exposure. Incidence of treatment-emergent adverse events (events/100 subject-years) for any secukinumab dose was similar in the overall study population (244.1) and the subgroup with no previous biologics (239.6), and slightly higher in the previously exposed subgroup (276.3).

Conclusions: Secukinumab 300 mg dose consistently exhibited greater benefit than placebo, etanercept, and 150 mg dose in moderate-to-severe plaque psoriasis in subjects with or without previous exposure to biologics.

Secukinumab treatment sustains patient-reported outcome benefits through 1 year P. Foley1, B. Sherif2, UG. Mallya3, T. Fox4, A. Gottlieb5 1 The University of Melbourne, Skin and Cancer Foundation Inc, Carlton, Victoria, Australia 2 RTI Health Solutions, Research Triangle Park, North Carolina, USA 3 Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA 4 Novartis Pharma AG, Basel, Switzerland 5 Tufts Medical Center, Boston, Massachusetts, USA Introduction and objectives: Secukinumab, an antiinterleukin-17A antibody was evaluated in two phase 3 clinical studies for efficacy and safety in subjects with moderate-to-severe plaque psoriasis. This analysis focuses on the sustainability of patient-reported outcomes (PRO) response with secukinumab treatment over time. Materials and methods: Patients aged ≥18 years were randomized 1:1:1 in ERASURE to subcutaneous treatment groups (secukinumab 150 mg, secukinumab 300 mg, and placebo) and 1:1:1:1 in FIXTURE (including an additional etanercept 50 mg twice-weekly group). Psoriasis clinical improvement was assessed by Psoriasis Area and Severity Index (PASI), and PROs were assessed with the Dermatology Life Quality Index (DLQI) and the visual analog scale (VAS) from the EuroQOL 5-Dimension Health Status Questionnaire (EQ-5D). Sustained response was defined as ≥PASI90 at week 24 and no psoriasis impairment (DLQI score of 0 or 1) maintained through week 52. Results: Of the 572 subjects randomized to secukinumab 300 mg, 70% (398/572) achieved PASI90 at week 24. Of those achieving PASI90 at week 24, 81% (324/398) reported no psoriasis impairment (DLQI 0 or1). Of these subjects, 86% (278/324) sustained PASI90 and no psoriasis impairment at week 52. Similar findings were observed for sustained health status as measured by the EQ-5D VAS response – 91% of subjects who achieved clear or almost clear skin (PASI90) by week 24 and meaningful health status (an increase of 7 points or more on the EQ5D VAS) maintained both through 1 year. Conclusions: Treatment with secukinumab 300 mg resulted in higher response rates for plaque clearance and provides sustained health-related QoL and health status benefit.

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 Tofacitinib withdrawal and retreatment in moderate-to-severe chronic plaque psoriasis: A phase 3 randomized trial R. Bissonnette1, L. Iversen2, H. Sofen3, C.E.M. Griffiths4, P. Foley5, R. Romiti6, M. Bachinsky7, S.T. Rottinghaus7, H. Tan7, J. Proulx7, H. Valdez8, P. Gupta7, L. Mallbris9, R. Wolk7 1 Innovaderm Research, Montreal, Canada 2 Aarhus University Hospital, Aarhus, Denmark 3 UCLA School of Medicine, Department of Medicine/ Dermatology, Los Angeles, California, USA 4 The Dermatology Centre, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK 5 The University of Melbourne, Skin and Cancer Foundation Inc, Carlton, Australia 6 Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil 7 Pfizer Inc, Groton, Connecticut, USA 8 Pfizer Inc, New York, New York, USA 9 Pfizer Inc, Collegeville, Pennsylvania, USA Introduction: Tofacitinib is a novel oral Janus kinase inhibitor being investigated for moderate-to-severe plaque psoriasis treatment. Method: Patients received (blinded) tofacitinib 5 mg (n = 331) or 10 mg (n = 335) twice daily (BID) for 24 weeks (initial treatment). Patients achieving both ≥75% reduction in PASI score (PASI75 response) and PGA of ‘clear’ or ‘almost clear’ (PGA response) were randomised to receive placebo (treatment withdrawal) or initial tofacitinib dose. At relapse (>50% loss of Week-24 PASI response) or at Week 40, patients received initial tofacitinib dose for 16 weeks. Primary endpoints: proportion maintaining PASI75 or PGA responses during withdrawal; proportion of relapsers regaining PASI75 and proportion regaining PGA responses upon retreatment (NCT01186744). Results: Initial treatment: 33.5% and 55.2% of patients achieved both PASI75 and PGA responses with tofacitinib 5 and 10 mg BID, respectively. Withdrawal: 56.2%, 62.3%, 23.3%, and 26.1% maintained PASI75 with tofacitinib 5 mg, 10 mg, placebo (5 mg), and placebo (10 mg); 49.9%, 63.9%, 22.9%, and 18.0% maintained PGA responses. Retreatment: 31.6% and 50.9% of relapsers achieved PASI75 with tofacitinib 5 mg or 10 mg, respectively, after 16 weeks; 41.4% and 49.0% regained PGA responses. No patients experienced psoriasis rebound during withdrawal. Conclusions: Results indicate that both doses of tofacitinib improved psoriasis. Patients on continued therapy maintained better efficacy compared with patients undergoing treatment withdrawal. Safety profiles were comparable among continuous and retreatment groups. Among relapsers, ∼half recaptured initial response within 16 weeks.

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Long-term safety and tolerability of Apremilast in patients with psoriasis: pooled safety analysis of the ESTEEM 1 and 2 trials P. Foley1, K. Reich2, K. Papp3, K.B. Gordon4, C.E.M. Griffiths5, S. Chimenti6, J.L. Lopez-Estebaranz7, A.B. Gottlieb8, Kamal Shah9, ChiaChi Hu9, Robert M. Day9, Carle Paul10 1 Skin & Cancer Foundation Inc., St. Vincent’s Hospital, Melbourne, Victoria, Australia 2 SCIderm Research Institute and Dermatologikum Hamburg, Hamburg, Germany 3 Probity Medical Research, Waterloo, Ontario, Canada 4 Northwestern University, Chicago, Illinois, USA 5 Dermatology Centre, University of Manchester, Manchester, UK 6 University of Rome Tor Vergata, Rome, Italy 7 Hospital Universitario Fundacion Alcorcon, Madrid, Spain 8 Tufts Medical Center, Boston, Massachusetts, USA 9 Celgene Corporation, Warren, New Jersey, USA 10 Toulouse University, Hôpital Larrey, Toulouse, France Patients with moderate to severe plaque psoriasis (PASI ≥ 12, BSA ≥ 10%, sPGA ≥ 3) were randomized (2:1) to apremilast 30 mg BID (APR30) or placebo through Week 16. All patients received APR30 through Week 32, followed by a randomized treatment withdrawal phase through Week 52. 1,250 patients received placebo (n = 418) or APR30 (n = 832) at Week 0. 1,184 patients received APR30 (n = 968 for ≥24 weeks and n = 564 for ≥52 weeks). In all treatment periods, most AEs were mild to moderate in severity, with diarrhea, nausea, URTI, nasopharyngitis, headache, and tension headache reported most frequently. During Weeks 0 to 16, AEs ≥ 5% in the placebo or APR30 groups were diarrhea (6.7%, 17.8%), nausea (6.7%, 16.6%), URTI (6.5%, 8.4%), nasopharyngitis (6.9%, 7.3%), tension headache (3.3%, 7.3%), and headache (3.3%, 5.8%). Serious AE incidence was similar between placebo (2.6%) and APR30 (2.0%). There were no increases in AEs (including serious AEs) with longer exposure based on exposure-adjusted incidence rates (EAIR)/100 patient-years. Discontinuations due to AEs were low for Weeks 0 to 16 and, based on EAIR/100 patient-years, there was no increase in discontinuations with longer APR30 exposure. Comparable results were observed between placebo and APR30 in adjudicated events of major adverse cardiac events, malignancies, and serious and opportunistic infections. There were no clinically meaningful effects on laboratory measurements. Incidence of weight decrease reported as an AE was low and was reported in (1.5%) patients treated with APR30 (Weeks 0 to ≥52). APR30 demonstrated an acceptable safety profile and was generally well tolerated for ≥52 weeks. Statins reduce the risk of melanoma: truth or myth? S. Gabizon1, M. Freeman2 1 Department of Cardiothoracic Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia 2 Department of Dermatology, Gold Coast University Hospital, Gold Coast, Queensland, Australia Introduction: During the last decade, research on the effects of statins reducing risk of melanoma showed

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promising results, particularly through in vitro studies and animal models. Perhaps the most significant findings of these early studies were the discovery that statins induced melanoma cell apoptosis and cell cycle arrest.1 Translation to human studies did not yield such significant results, thus finding minimal or no relationship between statins and reduction in risk or mortality. There have been a number of studies attempting to find an association between the antitumour effects of statins on humans which has been extended to other types of cancer including melanoma. Method: A search of the terms ‘Statin(s)’ AND ‘Melanoma’ were performed on MEDLINE only from 1995 to 2014, with a total of 50 from 67 publications relevant to hypothesis that statins reduce the risk of melanoma. These included metaanalyses, cohort, prospective, case control, in vitro, in vivo and review articles which were examined and data extracted in an attempt to objectively and quantitatively determine whether statins reduce the risk of melanoma. Results: All 26 in vitro and in vivo studies agreed that statins have anti-tumour effects on human melanoma cells. All 6 Meta-analyses agreed that there is no short-term relationship between statin use and reduction in risk for melanoma in human trials. However, a recent cohort study did find a significant association between statin use which improved the relative survival rates over 3 years only following gender stratification for males.2 Associations between long-term statin use warrants further research.

References 1.

Saito A, Saito N, Mol W, Furukawa H, Tsutsumida A, Oyama A, Sekido M, Sasaki S, Yamamoto Y. Simvastatin inhibits growth via apoptosis and the induction of cell cycle arrest in human melanoma cells. Melanoma Res. 2008; 18(2): 85–94. 2. Livingstone E, Hollestein LM, van Herk-Sukel MP, van de Poll-Franse L, Joosse A, Schilling B, Nijsten T, Schadendorf D, de Vries E. Statin use and its effect on all-cause mortality of melanoma patients: a population-based Dutch cohort study. Cancer Medicine 2014; 3(5): 1284–93.

Clear cell renal carcinoma presenting as a skin papule on the nose: a rare presentation with variable prognosis D.C. Gaffney1,2, N. Anjum1 and B. Hughes1 1 Department of Dermatology, Portsmouth Hospitals NHS Trust, Portsmouth, UK 2 The University of Queensland, School of Medicine, Brisbane, Queensland, Australia Renal cell carcinoma (RCC) is a common cancer with a propensity for metastasis. Cutaneous metastases are among the least common of sites for RCC spread.1 The majority of skin metastases develop months or years after treatment of the primary tumour usually by partial or total nephrectomy.2 We present an exceptionally rare case of primary RCC diagnosed following presentation with a solitary facial cutaneous lesion. These lesions are erythematous or vascular-

looking and exophytic. An alternative diagnosis is usually suspected and the diagnosis discovered following histopathological analysis. The clinician should be aware that cutaneous metastases often signify a bleak prognosis however there are exceptions, particularly in the case of a solitary metastasis of RCC.1,2,3 The treatment of cutaneous metastases of RCC is not standardised and recent reports of surgical and radiological approaches are briefly discussed.

Reference 1.

Kouroupakis D, Patsea E, Sofras F, Apostolikas N. Renal cell carcinoma metastases to the skin: a not so rare case? Br. J. Urol. 1995; 75: 583–85. 2. Lim C, Chan R, Regan W. Renal cell carcinoma with cutaneous metastases. Australas. J. Dermatol. 2005; 46: 158–160. 3. Porter NA, Anderson HL, Al-Dujaily S. Renal cell carcinoma presenting as a solitary cutaneous facial metastasis: case report and review of the literature. Int. Semin. Surg. Oncol. 2006; 3: 27.

Trichodysplasia spinulosa A. Gin1, D. MacGregor2, D. Orchard1 1 Department of Dermatology, The Royal Children’s Hospital, Melbourne, Victoria, Australia 2 Department of Anatomical Pathology, The Royal Children’s Hospital, Melbourne, Victoria, Australia Trichodysplasia spinulosa (TS) is a rare skin disease characterised by a folliculocentric process. To date at least 20 cases of TS have been published. TS has distinctive appearances both clinically and histologically. TS is thought to be caused by the trichodysplasia spinulosa-associated polyomavirus, and is most commonly seen in the context of immunosuppression following allograft solid organ transplantation or chemotherapy for haematological malignancy. We present a case of a 3-year-old girl with trichodysplasia spinulosa after chemotherapy treatment for an embryological rhabdomyosarcoma of the cervix. Characteristic clinical photography and histology will be presented.

ReCell – an automated kit for the treatment of hypopigmentation G. Goodman Melbourne, Victoria, Australia Since 2005, a commercially available single-use, standalone, autologous cell harvesting device has been available to treat hypopigmented disorders. Since that time this system has been used by the author to treat stable, segmental and non-segmental vitiligo and hypopigmented scarring. This abstract highlights its use in these conditions and its successful treatment utilizing a fractional ablative CO2 laser and the ReCell system. ReCell is a simple-to-use device, which allows processing of a thin, split-thickness skin sample into a suspension

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 comprised of a viable cell population of skin cells for immediate application to wounds. The use of the ReCell kit enables skin processing at the site of treatment without the use of a specialized laboratory or staff. Incubation of a split-skin sample in a proprietary enzyme formulation initiated the disaggregation of the skin cells. Harvested cells are suspended in a buffer solution and the suspension is drizzled or sprayed onto a previously resurfaced recipient bed. ReCell enables the delivery of keratinocytes, melanocytes, fibroblasts, and Langerhans cells, harvested from the epidermis, dermis and epidermal–dermal junction, to a wound surface. Keratinocyte repopulation enables faster wound coverage with a better quality of epidermis. Melanocyte reintroduction along with healthy keratinocytes and fibroblasts may also result in the reintroduction of pigmentation into hypopigmented regions.

Topical products to relieve and restore sun-exposed skin I.R. Heinicke, K.A. Greive Ego Pharmaceuticals Pty. Ltd., Melbourne, Victoria, Australia The damaging effects of the sun are often seen particularly in summer on beaches around the world. The skin protects us from the external environment, but when skin is damaged this defense system is compromised. Ultraviolet light causes both long-term and immediate damage to unprotected skin. This damage can be minimized with the use of sunscreens, protective clothing and decreasing the time spent outdoors during peak periods. However, when these protective measures are ignored or are inadequate skin damage will result. The most obvious sign of UV damage is sunburn. Symptoms of sunburn include erythema, skin which is warm or hot to touch, with pain or itching. Skin peeling is a natural defense mechanism of the body once exposed to UV, however this leaves the new skin underneath vulnerable to damage also. Immediate concern of sunburn can be remedied with a refreshing, non-occlusive, cooling moisturiser. Further moisturising with an antioxidant moisturiser after sun exposure will help to protect the skin during the healing process. Topical products to relieve the symptoms of sunburn should help to rehydrate the skin, soothe and reduce redness, restore damaged skin as well as lessening the signs of skin ageing.

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Multiple cutaneous reticulohistiocytomas successfully treated with topical PUVA combined with intralesional injections of triamcinolone acetonide A.G. Harris1,2, A. Wijayanti1,2, M. Llewellyn3, J. Muhaidat4, S. Kossard4, D.F. Murrell1,2 1 Department of Dermatology, St George Hospital, Sydney, New South Wales, Australia 2 University of New South Wales, Sydney, New South Wales, Australia 3 Campsie, New South Wales, Australia 4 Skin & Cancer Foundation, Sydney, New South Wales, Australia Introduction: Cutaneous reticulohistiocytosis is a rare form of non-Langerhans cell histiocytosis. Reticulohistiocytomas tend to be solitary and there is a paucity of documented cases presenting multiple lesions, limited to the skin and a very limited number presenting high quality clinical photographs and potential therapeutic strategies to treat the condition.1 Method: A 61-year-old Hungarian lady with multiple cutaneous reticulohistiocytomas was treated with of a series of three intralesional injections, three months apart each containing 10 milligrams of triamcinolone acetonide. This was combined with the topical application of 0.01% oxsoralen, followed by the treatment with UVA three times a week, for a total of four months. Results: At the end of the treatment there was a marked reduction in the amount, size and height of the lesions. Discussion: We present a case of the rare entity of multiple reticulohistiocytomas, localised to the skin, successfully treated with topical PUVA combined with intralesional injections of triamcinolone acetonide. Reticulohistiocytomas are generally treated with surgical excision1,2 and this case represents a possible minimally invasive technique, without the morbidity associated with surgery, as a management strategy for this rare condition. References 1.

Toporcer MB, Kantor GR, Benedetto AV. Multiple cutaneous reticulohistiocytomas (reticulohistiocytic granulomas). J Am Acad Dermatol. 1991 Nov; 25(5 Pt 2): 948–51. 2. Miettenen M, Fetsch JF. Reticulohistiocytoma (solitary epithelioid histiocytoma): a clinicopathologic and immunohistochemical study of 44 cases. Am J Surg Pathol. 2006; 30: 521–8.

The epidermolysis bullosa disease activity and scarring index (EBDASI) mobile phone application A.G. Harris1,2, S. Jain1,2, T. Murrell3, D.F. Murrell1,2 1 Department of Dermatology, St George Hospital, Sydney, New South Wales, Australia 2 University of New South Wales, Sydney, New South Wales, Australia 3 University of Adelaide, Adelaide, South Australia, Australia The Epidermolysis Bullosa Disease Activity and Scarring Index (EBDASI) mobile phone application is a disease © 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

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Australasian Journal of Dermatology (2015) 56

severity scoring system specifically designed for the evaluation of Epidermolysis Bullosa (EB). The EBDASI mobile phone application was adapted from the paper version, published in 2014, which was shown to be reliable, valid and feasible.1 The EBDASI was designed as an objective tool for clinicians to aid in disease monitoring, to guide and evaluate response to treatment and to communicate severity between health care professionals. By porting the paper version of the EBDASI to the mobile phone platform, we aimed to increase its accessibility and ease of use for clinicians and to additionally make it more available to patients. For patients with EB, it is a way to monitor their own health and to objectively quantify and remotely communicate the severity of their condition with their treating team. Having a touch-based user interface improves the EBDASI’s utility as many patients with EB have hand deformities. Four updates to the EBDASI mobile phone application have so far been released. Additions have included a graphical representation of severity scores over time and the ability to email scores to a designated email address once the EDBASI has been completed. It is an exciting future in dermatology with availability of more and more digital and electronic aids. We hope the EBDASI mobile phone application will be a valuable tool to be utilized by patients with EB and health care professionals around the world. Reference 1.

Loh CC. Kim J. Su JC. Daniel BS. Venugopal SS. Rhodes LM. Intong LR. Law MG. Murrell DF. Development, reliability, and validity of a novel Epidermolysis Bullosa Disease Activity and Scarring Index (EBDASI). J Am Acad Dermatol. 2014; 70(1): 89–97.e1–13

An analysis of the rurality of patients with epidermolysis bullosa in Australia A.G. Harris1,2, N. Todes-Taylor1, D.F. Murrell1,2 1 Department of Dermatology, St George Hospital, Sydney, New South Wales, Australia 2 University of New South Wales, Sydney, New South Wales, Australia Introduction: Patients with epidermolysis bullosa (EB) frequently require multidisciplinary specialist care in large tertiary institutions. Although one third of the Australian population outside of the major cities and tend to have worse health outcomes than those in the major centres.1 Method: 365 Australian patients with EB, drawn from the Australian and New Zealand EB patient database were included in a cross-sectional analysis to determine their rurality. Postal codes were used to calculate the Australian Standard Geographic Classification (ASGC) and the Rural, Remote and Metropolitan Areas (RRMA) classification. Results: The ASGC revealed 242 patients with EB lived in major cities, 73 in inner regional, 32 outer regional, 5 in

remote and 2 in very remote areas, giving a total of 46% of the patients analysed living outside of the major cities. The RRMA classification showed 258 patients lived in metropolitan zones, 90 in rural areas and 6 in remote areas giving a total of 37% of the patients analysed living in rural or remote areas. The different subtypes of EB were evenly represented in each rurality classification and 3 patients with generally regarded severe subtypes, were found to live in remote and very remote areas. Discussion: A significant amount of patients with EB live in rural areas and a small number in remote areas. Patients with EB in rural areas may benefit from targeted healthcare strategies such as teledermatology, video Skype, mobile phone applications and outreach clinics to overcome geographical barriers and better optimize health care delivery.

Reference 1.

Rural, regional and remote health: a study on mortality (2nd edition). 2007. AIHW website. Available from URL: http:// www.aihw.gov.au/publication-detail/?id=6442468054. (Accessed Nov 2014.)

Combining microneedling and triamcinolone – a novel way to increase the tolerability of intralesional corticosteroid delivery in children with alopecia areata A.G. Harris1,2, D.F. Murrell1,2 1 Department of Dermatology, St George Hospital, Sydney, New South Wales, Australia 2 University of New South Wales, Sydney, New South Wales, Australia Introduction: Alopecia areata is common, idiopathic, autoimmune condition that causes hair loss in adults and children. One therapeutic strategy is the intralesional injection of corticosteroid. Unfortunately this method is often restricted, especially in children, because of its intolerability due to pain. Microneedling is a relatively new, welltolerated, cosmetic procedure, which can increase the penetration of topically applied preparations. Method: We used the technique of microneedling to deliver intralesional triamcinolone acetonide to areas affected by alopecia areata on the scalp of two paediatric patients who failed treatment with intralesional injections because of intolerability due to pain. Each patient had four treatments, one to five months apart with a hand held electronic microneedling device with the addition of the topical application of 10 milligrams of triamcinolone acetonide in a 5 mg/ml solution to the area during the procedure. Results: Both patients tolerated the procedure well and completed all the planned visits. Pain was significantly reduced when compared to the intralesional injection of the same medication and efficacy was maintained with both patients showing improvements in hair growth. No adverse events were reported.

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 Conclusion: Microneedling may be an effective way to improve the tolerability of the intralesional delivery of corticosteroid in children with alopecia areata while preserving its efficacy.

Skin needling as a treatment for acne scarring: an up-to-date review of the literature A.G. Harris1,2, S. Naidoo, D.F. Murrell1,2 1 Department of Dermatology, St George Hospital, Sydney, New South Wales, Australia 2 University of New South Wales, Sydney, New South Wales, Australia Introduction: Skin needling, microneedling or percutaneous collagen induction are all terms used to describe a cosmetic procedure which uses fine needles to puncture the skin, resulting in increased dermal elastin and collagen and thickening of the dermis.1 This technique is becoming increasing popular as is a simple and low cost way to treat acne scarring, yet, to our knowledge, no detailed review of this treatment has been performed. Method: A literature search was performed using the different terms used to describe skin needling combined with its use as a treatment for acne scarring. Results: A total of 18 published articles presenting patients with acne scarring treated with skin needling, were included in the analysis. The median number of treatments was three, the median duration between treatments was four weeks and the median needle length was 1.5 mm. Five prospective observational uncontrolled studies and one placebo-controlled trial2 showed a positive benefit of skin needling treatment when objective scar severity scores were compared pre- and post-treatment. Skin needling was found to be comparable to the focal application of 100% trichloroacetic acid and was shown to be effective when combined with glycolic acid peels, platelet rich plasma, subcision, fractional thermolysis and trichloroacetic acid treatments. Reported adverse events included postinflammatory hyperpigmentation, ‘tram track’ scarring, bruising, haematoma formation, development of active acne, milia, development of pustules and the recurrence of herpes simplex virus infection.

References 1.

Schwarz M, Laaff H. A prospective controlled assessment of microneedling with the dermaroller device. Plast Reconstr Surg. 2011; 127(6): 146e–148e. 2. Alam M, Han S, Pongprutthipan M, Disphanurat M, Kakar R, Nodzenski M, Pace N, Kim N, Yoo S, Veledar E Poon E, West DP. Efficacy of a Needling Device for the Treatment of Acne Scars. A Randomized Clinical Trial. JAMA Dermatology. Published online June 11, 2014.

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Psoriasis severity is influenced by nutritional intake: results of a dietary and lifestyle questionnaire in Victorian psoriasis patients C. Higgins1, A. Braue1, A. Phemister1, M. Hatz2, A. Jackson2, M. Hughes2, M. Tacey3, G. Varigos1 1 Department of Dermatology, Royal Melbourne Hospital, Parkville, Victoria, Australia 2 Clinical Nutrition Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia 3 Melbourne EpiCentre, Royal Melbourne Hospital, Parkville, Victoria, Australia and Department of Medicine, University of Melbourne, Carlton, Victoria, Australia Introduction: Psoriasis is a chronic systemic inflammatory disease mediated by multiple genetic and environmental factors. Psoriasis patients have increased metabolic co-morbidities including obesity, dyslipidaemia, hypertension and insulin resistance.1 Evidence suggests a hypocaloric diet and weight loss may decrease psoriasis severity.2 Further studies suggest consumption of certain food groups or nutritional supplements may influence disease.3 This project sought to evaluate correlations between psoriasis patients’ dietary intake and their disease severity. Method: The project group developed and administered a dietary questionnaire to psoriasis patients attending Royal Melbourne Hospital Dermatology outpatient clinic between 1 July and 31 October 2014. Descriptive analyses and linear regression identified associations between baseline Psoriasis Area Severity Index (PASI) and question responses. Results: 110 patients were surveyed with average age 48.3 years; 49% were female (n = 52); 89% (n = 87) were obese/ overweight; 85% (n = 93) were on biologics. The baseline PASI was 9.9 points higher on average for patients consuming more than one take-away meal per week compared with those never having more than one take-away meal per week (p = 0.04). Baseline PASI scores were approximately 6.6 points lower on average for patients indicating they ‘always’ had fruit and vegetables each day compared with those who did so only ‘sometimes’ (p < 0.01). Conclusion: To our knowledge, this is the first formal nutritional assessment conducted in Victorian psoriasis patients. Future work could include expanding the questionnaire to enable collection of detailed quantitative and qualitative dietary history at baseline PASI. These results suggest trialling early clinical nutrition and lifestyle interventions may benefit disease progression.

References 1.

Toussirot E, Aubin F, Dumoulin G. Relationships between adipose tissue and psoriasis, with or without arthritis. Front Immunol. 2014; Aug 12; 5: 368. 2. Jensen P, Zachariae C, Christensen R, Geiker NRW, Schaadt BK, Stender S, Hansen PR, Astrup A, Skov L. Effect of Weight Loss on the Severity of Psoriasis. A Randomized Clinical Study. JAMA Dermatol. 2013; 149(7): 795–801.

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

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Australasian Journal of Dermatology (2015) 56 Millsop JW, Bhatia BK, Debbaneh M, Koo J, Liao W. Diet and psoriasis, part III: role of nutritional supplements. J Am Acad Dermatol. 2014; 71(3): 561–9.

The proportion of the Australian population that develops skin cancer P. Clarke1,2, I.H. Illingworth2, I. Robertson2 1 Department of Dermatology, Launceston General Hospital, Launceston, Tasmania, Australia 2 University of Tasmania, Launceston, Tasmania, Australia A systematic approach to calculating the true prevalence of skin cancer is lacking in the literature due to the great number of skin cancers diagnosed yearly, and the large number of people with multiple skin cancers. The figure of 70% prevalence has been calculated by dividing the incidence of skin cancer over several years by the total population, but this does not take into account the multiple skin cancers occurring in individual patients1. In Australia skin cancer is the most costly cancer to treat2. All skin cancers from across Northern Tasmania, Australia from 2011 were identified by examination of records from the two pathology services in Tasmania. Our provisional conclusion is that a very small proportion of the population produces the vast bulk of skin cancers.

References 1. Staples MP, Elwood M, Burton RC, Williams JL, Marks R, Giles GG. Non-melanoma skin cancer in Australia: the 2002 national survey and trends since 1985. Med J Aust. 2006;184(1):6–10. 2. Australian Institute of Health and Welfare. Health system expenditure on cancer and other neoplasms in Australia, 2008–09 [Internet] Canberra, ACT; Australian Institute of Health and Welfare; 2013 [cited 2014 7th May]

Nasal bridge skin necrosis following regular use of CPAP ventilation pressure mask A. Ingham1,2, L. Gordon1 1 Department of Dermatology, Flinders Medical Centre, Adelaide, South Australia, Australia 2 Department of Dermatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia Increasing rates of obstructive sleep apnoea (OSA) are being observed in Australia, due to the obesity epidemic and the aging population.(1) Continuous positive airway pressure (CPAP) delivered by a face mask is recognised as an effective management tool for moderate to severe patients. We report a case of nasal bridge skin necrosis following regular wearing of a non-invasive ventilation pressure mask. A 73-year-old man was referred for management of a non-healing wound over the nasal bridge. He wore a CPAP mask for eight to ten hours a night and reported a pustule arising along the point of contact between the CPAP mask and his skin, which then proceeded to ulcerate over the next

month. Following investigation and specialised wound management in a hospital setting, it was concluded that the ulceration was caused by the pressure exerted by the CPAP mask. The ulcer improved with dressings and modification of the CPAP mask to a full face mask. Our case demonstrates that ulceration secondary to a CPAP mask may occur with long-term overnight use unlike the previously reported cases from an acute care setting with masks worn for 72 hours or more.

Reference 1.

Adams RJ, Piantadosi C, Appleton SL et al. Investigating obstructive sleep apnoea: will the health system have the capacity to cope? A population study. Aust Health Rev. 2012; 36: 424–9.

Characterising severity and responsiveness of a new outcome measure for epidermolysis bullosa – the Epidermolysis Bullosa Disease Activity and Scarring Index S.V. Jain1,2, A.G. Harris1,2, C.C.H. Loh1,2, J. Kim1, J.S. Su3, D. Orchard3, L. J. Warren4, H. McManus5, D.F. Murrell1,2 1 Department of Dermatology, St George Hospital, Sydney, New South Wales, Australia 2 Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia 3 Department of Dermatology, The Royal Children’s Hospital, Melbourne, Victoria, Australia 4 Department of Dermatology, Women’s and Children’s Hospital, Adelaide, South Australia, Australia 5 Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia Introduction: The development of novel therapies for epidermolysis bullosa (EB) necessitates validated outcome measures that can capture disease severity. The Epidermolysis Bullosa Disease Activity and Scarring Index (EBDASI) was developed to measure disease activity and damage in clinical trials.1 The aim of this study was to assess the responsiveness of the EBDASI by characterising disease severity and the clinical response of epidermolysis bullosa over time. Methods: 48 patients with EB attending routine outpatient clinics at three institutions were prospectively evaluated. Patients at each visit were evaluated by the principal investigator at each site using the EBDASI, a physician assessment of disease severity (mild, moderate, severe), a physician assessment of change compared to the previous visit (improved, deteriorated, stable) and a 15-point Likert scale of the magnitude of change. Site-specific analysis determined EBDASI score ranges for patients in each severity category. The minimal clinically important difference of the EBDASI activity subscale was calculated in the responsiveness analysis. Receiver operating characteristic (ROC) curves were used to determine score cut-offs. Results: An EBDASI score cut-off of 42 differentiated mild from moderate disease and a cut-off of 107 differentiated

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 severe from moderate disease. Reduction in EBDASI activity scores of greater than 7 and increase in scores of greater than 3 corresponded with clinical improvement and deterioration, respectively. All cut-offs correctly classified approximately 80% of patients. Conclusions: The EBDASI can be used to categorise patients according to severity and clinical response and is promising as an outcome measure for future clinical trials.

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in the treatment of NMSC and skin dysplasia. Low irradiance PDT is well tolerated with less pain and more convenience while remaining a cheaper option for treatment of NMSC and skin dysplasia in patients with few lesions. Despite Ambulight only being able to treat a maximum of 3 lesions per session, it has a target population, especially those with few lesions, those living in remote rural towns or in patients with chronic disease like Parkinson’s disease and dementia where they could otherwise not remain still for standard PDT.

Reference 1.

Loh CCH, Kim J, Su JC, Daniel BS, Venugopal SS, Rhodes LM et al. Development, reliability, and validity of a novel Epidermolysis Bullosa Disease Activity and Scarring Index (EBDASI). Journal of the American Academy of Dermatology 2014; 70(1): 89–97.

Ambulatory photodynamic therapy J. Johnston1,2, K. Lun1, A. Bond1, L. Spelman1,2 1 Queensland Institute of Dermatology, Greenslopes Private Hospital, Brisbane, Queensland, Australia 2 Veracity Clinical Research, Brisbane, Queensland, Australia Background/Purpose: Traditional photodynamic therapy (PDT) can be initially costly to the dermatologist to establish, inconvenient and may also result in patient discomfort and pain. Ambulight is an ambulatory form of PDT utilizing a low irradiance inorganic light-emitting diode in the treatment of non-melanoma skin cancer (NMSC) and skin dysplasia. We compare the validity, practicality, cost effectiveness and application of Ambulight PDT to the traditional form namely with the Aktilite PDT unit. Methods: Patients with NMSC, including superficial basal cell carcinoma (sBCC), Intraepidermal squamous cell carcinoma (IEC) and skin dysplasia namely actinic keratosis (AK) utilized the Ambulight PDT. Ambulight PDT was contrasted to traditional PDT in convenience, skin pain/ irritation, possible cost reduction and overall effectiveness for patients requiring such treatment. Four patients with individual lesions, either NMSC or AK’s used Ambulight PDT with follow up after a 3-month period. Photographic evidence of the lesion site pre and post-Ambulight PDT were taken to assess longer term lesion healing and outcomes. Results: Ambulight PDT demonstrates effectiveness similar to conventional PDT in the treatment of NMSC and skin dysplasia. Exposure to a lower irradiance over a longer time period reduces pain of the procedure whilst maintaining adequate treatment response seen at the 3-month period. Ambulight PDT is more convenient and cost effective with better treatment toleration, reduced staff time, and the ability to use cheaper photosensitizing medications, namely 5-ALA. Photographic evidence demonstrates good cosmetic outcomes with little scarring at the 3-month mark post-Ambulight PDT. Conclusions: Ambulatory PDT, utilizing the Ambulight device, demonstrates effectiveness similar to standard PDT

Validation of the physician global assessment and body surface area composite tool as an alternative to the psoriasis area and severity index for psoriasis assessments J. Walsh1, H. Jones2, L. Mallbris2, K. Callis Duffin1, G. Krueger1, D. Clegg1, A. Szumski2 1 University of Utah School of Medicine, Salt Lake City, Utah, USA 2 Global Medical Affairs, Pfizer Inc, Collegeville, Pennsylvania, USA Introduction: The Psoriasis Area and Severity Index (PASI) is commonly used but complicated to calculate and relatively insensitive in mild PsO.1 The product of the Physician Global Assessment and Body Surface Area (PGAxBSA) has been evaluated as an alternative.1 This post-hoc analysis aimed to validate use of PGAxBSA as a simpler alternative to PASI for measuring response to PsO therapy. Method: Data were pooled from 2 randomized, controlled trials in moderate-severe PsO, the PRISTINE and PRESTA trials. This analysis was conducted on the pooled ETN 50 mg QW dose groups. The relationship between PGAxBSA and PASI was assessed at baseline (BL), 12 and 24 wks using Spearman Correlation and intra-class correlation coefficients (ICC) as measures of agreement, and effect sizes for benchmarks to determine magnitude of change. Results: Mean age in group (N = 510) was 46 + 12 yrs; 65% male. Mean duration of PsO was 18.0 + 11.2 yrs, median PASI score 16.7, and median BSA involvement 22.0%. PASI and PGAxBSA scores were ordered from lowest to highest, grouped into quintiles and summarized according to whether they fell into the same category.2 At wk 24, 73% of patients were in the same quintile, 14% underrated and 14% overrated. When comparing PASI 75 to 75% improvement in PGAxBSA, there was 86% concordance at wk 24.2 The analysis indicates a strong correlation between PASI and PGAxBSA in measuring PsO severity.2 Conclusions: PGAxBSA correlates with PASI in moderatesevere PsO, and may be an alternative tool for assessing PsO severity and response to therapy.

References 1. Walsh J et al. J Am Acad Dermatol. 2013: 69: 931–7. 2. 23rd EADV Congress, Amsterdam.

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

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Cross-reactivity in multiple classes of topical corticosteroids C. Kalai, M. Tam Skin & Cancer Foundation, Carlton, Victoria, Australia Allergic contact dermatitis to topical corticosteroids is more common than previously thought with a reported incidence of 0.5–5%. Cross-reactivity between certain classes is welldocumented but is more commonly found between Class A and D2 or Budesonide and D2. A 63-year-old gentleman with a seven-year history of intractable pruritic groin dermatitis presented for patch testing. He was found to react to multiple classes of corticosteroids including Class B (Triamcinolone, Budesonide), Class D1 (Betamethasone valerate, Betamethasone dipropionate, Clobetasol), Class D2 (Methylprednisolone aceptonate) and Mometasone. Due to its anti-inflammatory nature, the diagnosis of allergy to corticosteroids is more difficult but should be considered in treatment-resistant dermatitis.

Reference 1.

Jacob SE, Steele T. Corticosteroid classes: A quick reference guide including patch test substances and cross-reactivity. J Am Acad Dermatol. 2006; 54: 723–7.

Comparison of P53, COX-2, PTCH1 and Ki67 gene expression patterns between basal cell carcinomas at different anatomical sites and of different subtypes M. Khalesi1,2,4, D.C. Whiteman2,4, C. Rosendahl5,6, R. Johns5, A. Cameron5,6, T. Hackett5,6, T. Pollak7, E. Hacker1,3, M. Waterhouse2, M.G. Kimlin1, R.E. Neale2,4 1 AusSun Research Lab, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia 2 Department of Population Health, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia 3 Department of Genetics & Computational Biology, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia 4 NHMRC Centre for Research Excellence in Sun and Health, Queensland University of Technology, Brisbane, Queensland, Australia 5 Skin Cancer College Australasia, Brisbane, Queensland, Australia 6 School of Medicine, The University of Queensland, Brisbane, Queensland, Australia 7 The University of Queensland, Brisbane, Queensland, Australia Introduction: Basal cell carcinoma (BCC) is the most commonly diagnosed cancer in white populations. There are suggestions that the pathophysiology of BCCs arising on different body sites and developing to different histological subtypes differs, but this is not well understood. A number of genes and their expression have been shown to be altered in BCC tumours. The major genetic changes affect tumour suppressor genes including PTCH1 and p53. Expression of other genes such as COX-2 and Ki-67 has also shown to be

altered in BCC. Over-expression of Ki-67, COX-2, PTCH1, and mutant p53 in BCC compared to normal non-malignant skin has been observed, but little is known about whether their expression differs between BCCs at different body sites or of different histological subtypes. Method: We conducted a case-case study in Brisbane to compare the expression of these genes between BCCs on the head (n = 55) and trunk (n = 53), and also between the most two common BCC subtypes, nodular (n = 52) and superficial (n = 43). Results: Expression of COX-2, Ki-67 and p53 was higher in tumour tissue than in normal appearing epidermal tissue adjacent to the tumour, while for PTCH1 the opposite was found. With the exception of Ki-67, no difference was observed in expression of these genes between normal appearing epidermal tissue adjacent to the tumour of the head and trunk. Expression of PTCH1 and COX-2 was significantly higher in truncal tumours than those arising on the head. Compared to nodular BCCs, expression of PTCH1 and Ki-67 was higher in superficial BCCs.

How SunSmart are Australian women? B. Kim1,2, J. Norman1,2, P. Fernandez-Penas1,2 1 Skin and Cancer Foundation Australia, Westmead, New South Wales, Australia 2 University of Sydney, Camperdown, New South Wales, Australia Objective: Our study aims to investigate current levels of ‘sunsmart’ behaviours, attitudes and knowledge amongst Australian women. Methods: A total of 505 women were recruited from an online panel. Questionnaire items included demographic data, patterns of sun exposure, patterns of sunscreen use, factors governing product choice and factors limiting sunscreen use, attitudes towards tanning, and level of knowledge relating to UV and skin cancer. Results: Only 9.7% of participants applied sunscreen every morning. Younger participants were more likely to report a recent sunburn (p < 0.001). A total of 45.5% participants didn’t like the way that sunscreen felt on their skin, 24.2% were bothered by the smell, 21.6% felt that it was too thick to wear under makeup and 28.9% claimed that sunscreen clogged their pores and causes pimples. The dominating factors governing purchase were price (60.6%), proven results (51.1%), fragrance free and low irritant (38.0%), recommended by a dermatologist (27.9%) and soap-free (22.8%). According to 42.2% participants, tanned skin looked more beautiful than pale skin. A small proportion (7.7%) reported knowing what the UV index is and checking it daily. Whilst 90.5% knew that melanoma was one of several types of skin cancer, a significant proportion (60.2%) also thought that melanoma was the most frequent type of skin cancer.

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 A total of 51.7% of participants knew what to look for when examining moles for skin cancer, with older age groups were more likely to know what to look for when examining moles for signs compared to younger age groups (p < 0.05).

Cyclical inguinal keratoderma: a new clinical entity? S.P. Kumarasinghe1, J. Kim2, L. Yu3 1 Department of Dermatology, Royal Perth Hospital and St John of God Hospital Subiaco, Perth, Western Australia 2 Sir Charles Gairdner Hospital, Perth, Western Australia, Australia 3 Dermatopathology WA, Perth, Western Australia, Australia A 56-year-old male presented with scaly, inflamed skin lesions on the groins and scrotum of 6 months duration with cyclical exacerbations approximately every 4–6 weeks. He was on Esomeprazole and Ranitidine for gastrooesophageal reflux, and otherwise well. Skin scrapings from groins were negative for fungus. Previous treatments with anti-fungals and topical steroids had been ineffective. Differential diagnoses were endogenous eczema, seborrhoeic dermatitis, flexural psoriasis, tinea cruris, necrolytic migratory erythema, erythrasma, contact dermatitis, intertrigo, granular parakeratosis and Hailey-Hailey disease. Clinical presentation, course, investigations and non-response to multiple trials of treatment excluded above entities. Initial biopsies were inconclusive; subsequent biopsies during an exacerbation showed irregular acanthosis, elongated rete ridges, mild spongiosis, focal follicular plugging with perifollicular accentuation of parakeratosis, and confluent parakeratosis alternating with compact hyperkeratosis. Histopathology findings were consistent with pityriasis rubra pilaris (PRP). Clinically, however, the condition was inconsistent with established types of PRP. Considering the abnormality in keratinization, Acitretin 25 mg daily was commenced. This resulted in remission, which was maintained over one year. Cessation of the Acitretin resulted in a relapse, which responded once treatment was re-commenced. Currently he is maintained on Acitretin 25 mg twice a week. Adult-onset PRP is not cyclical, and eruptions localised to the inguinal regions and scrotum in adults has never been reported. If this is a case of PRP this is a new variant of PRP. This could however be a new entity. We believe that this is a new clinical entity and propose the name “cyclical inguinal keratoderma”. We discuss the differential diagnoses.

Dystrophic calcinosis cutis in the setting of a myositis/ scleroderma overlap syndrome J. Kim1, D. Singh2, G. Masel2 1 Sir Charles Gairdner Hospital, Perth, Western Australia, Australia 2 Department of Dermatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia Calcinosis cutis is a disorder of cutaneous and subcutaneous calcium deposition. It is rare and debilitating, especially if it involves extensive areas of skin. Complications include recurrent ulceration, pain, extrusion of calcium and infec-

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tion. Management of calcinosis cutis can be challenging due to the lack of data from controlled clinical trials, and the absence of a definitively efficacious treatment. We report an unusual case of a 69-year old female with extensive right forearm and bilateral thigh calcinosis cutis in the setting of an overlap autoimmune connective tissue disease (ACTD) syndrome. Dystrophic calcinosis cutis is a subtype occurring with aberrant tissue architecture as a result of chronic tissue damage or defective collagen synthesis in the setting of normal serum calcium and phosphate levels.1 Associated diseases include connective tissues diseases, cutaneous neoplasms including pilomatricoma and trichilemmal cysts, and collagen/elastin disorders. Small areas of calcinosis cutis affect approximately 25% of patients with systemic sclerosis with limited scleroderma, and 20% of patients with adult dermatomyositis.1 In contrast, 44–70% of juvenile dermatomyositis patients are affected.1 Due to the relative rarity of the condition, there is a lack of controlled clinical trials on treatment. Various therapies have been reported in case reports and small series; however there remains no gold standard of treatment to date.1,2 These therapies are presented.

References 1.

Guitierrez Jr A, Wetter D. Calcinosis cutis in autoimmune connective tissue diseases. Dermatologic Therapy 2012; 25: 195– 206. 2. Reiter N, El-Shabrawi L, Leinweber B et al. Calcinosis cutis: Part II Treatment options. J Am Acad Dermatol. 2011; 65: 15–22.

Cutaneous alternaria infection of the hand in an immunocompromised patient J. Kim1, D. Singh2, E. Tan2 1 Sir Charles Gairdner Hospital, Perth, Western Australia, Australia 2 Department of Dermatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia Alternaria is a genus of melanised/dematiaceous hyphomycetes that are commonly found in the environment and uncommonly pathogenic in immune-competent humans.1,2 Immunocompromised patients, however, can be affected by cutaneous and subcutaneous infections, oculomycosis, rhinosinusitis, onychomycosis, granulomatous pulmonary disease, soft palate perforation and even disseminated disease.2 Such cases have been reported most commonly in transplant recipients, those with Cushing’s syndrome, and those on immunosuppressants.2 A range of clinical manifestations of cutaneous and subcutaneous alternariosis has been described; therefore clinical diagnosis may be difficult2. We report a 63-year-old female with a chronic and progressive, centrally necrotic ulcer on the dorsum of her right second metacarpophalangeal joint in the setting of a secondary immunodeficiency syndrome and progressive multifocal leukoencephalopathy. Incisional biopsy was performed and alternaria was cultured from the tissue. Treatment with voriconazole 200 mg twice daily showed

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

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improvement, however conversion to posaconazole was required after two months due to the development of deranged liver function tests. Immunoglobulin infusions were also given and surgical debridement was considered but not undertaken. We discuss diagnosis and treatment of this atypical infection.

Squamous cell carcinoma in recessive dystrophic epidermolysis bullosa has high metastasis potential due to a permissive tumour microenvironment M. Kim1,2, D.F. Murrell1,2 1 Department of Dermatology, St George Hospital, Sydney, New South Wales, Australia 2 University of NSW, Sydney, New South Wales, Australia

References

Recessive dystrophic epidermolysis bullosa (RDEB) is a recessively inherited blistering disorder due to a mutation in the collagen VII gene, named COL7A1. Patients with RDEB have up to 50 fold increased incidence of cutaneous squamous cell carcinoma (cSCC) that is independent of UV exposure. The pathogenesis of cSCC development and its aggressive nature in RDEB remain unclear.

1.

Hu W, Ran Y, Zhuang et al. Alternaria arborescens infection in a healthy individual and literature review of cutaneous alternariosis. Mycopathologica 2015 Feb; 179(1–2): 147–52. 2. Pastor F, Guarro J. Alternaria infections: laboratory diagnosis and relevant clinical features. Clin Microbiol Infect. 2008; 14: 734–6.

Facial follicular porokeratosis: two cases from Western Australia J. Kim1, N. Harvey2, B. Wood2 1 Sir Charles Gairdner Hospital, Perth, Western Australia, Australia 2 Department of Dermatopathology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia Porokeratosis is a disorder of keratinisation with a potential for malignant degeneration in 7.5–11%.1 Typical lesions are annular with an atrophic centre, surrounded by a hyperkeratotic ridge-like border which histologically correlates to the cornoid lamellae.1,2 Since classic porokeratosis of Mibelli (PM) was first described in 1893, several clinical subtypes have been defined. These include disseminated superficial actinic porokeratosis (DSAP), linear porokeratosis, porokeratosis plantaris palmaris et disseminata and punctate porokeratosis.1 Follicular porokeratosis, a rare histological variant characterised by cornoid lamellae localised to follicular infundibulum, has been reported in association with DSAP and PM. In the last few years, a unique variant of follicular porokeratosis occurring exclusively on the face of young patients aged 19–34 years of age has been reported four times, once on the cheek and thrice on the nose. We report two more cases of follicular porokeratosis occurring exclusively on the nose of patients aged 26 and 35 years of age. Clinical and histological diagnosis of such lesions may be difficult due to the rarity of cases; however it is an important differential to be considered in order to prevent misdiagnoses. Recognising the features of cornoid lamellae on histological examination is important, as architecture within a follicle is more likely to be distorted.

We demonstrated that RDEB patients secrete higher levels of the angiogenic factor and basic FGF, compared to other forms of EB.1 Our collaborative studies on genetic profiling of RDEB-SCC keratinocytes and UV induced SCC keratinocytes found that these are genetically similar.2 Furthermore, they have similar contents of HPV as UV-SCCs and they show increased expression of an organic ionic transporter, OATP1B3, implicated in tumor therapeutics. RDEB-SCC fibroblasts extracellular matrix on the other hand has been shown to be permissive for tumour invasion and growth and behaves differently to UV induced SCC fibroblasts.2 The genetic profiling of the fibroblasts surrounding RDEB cSCC has been shown to be distinct from that of normal skin and UV induced cSCC with 674 differentially expressed genes. This differential gene expression appears to enrich the extracellular matrix to promote cSCC invasion and growth. In particular, COL7A1 gene re-expression in RDEB SCC fibroblasts showed increased collagen VII expression and reduced expression of type XII collagen, TSP1 and Wnt5A resulting in an extracellular matrix environment that impaired cSCC invasion and growth. Hence, supplementing collagen VII by protein therapy in RDEB may not only heal wounds but reduce the incidence of RDEB-SCC.

References 1.

Arbiser JL, Fine JD, Murrell DF, Paller A, Connors S, Keough K, Marsh E, Folkman. Basic fibroblast growth factor: a missing link between collagen VII, increased collagenase, and squamous cell carcinoma in recessive dystrophic epidermolysis bullosa. Mol Med. 1998; 4: 191–5. 2. Ng YZ, Pourreyron C, Salas-Alanis JC, Dayal JHS, Cepeda-Valdes R, Yan W, Wright S, Chen M, Fine JD, Hogg FJ, McGrath JA, Murrell DF, Leigh IM, Lane EB, South AP. Fibroblast-derived dermal matrix drives development of aggressive cutaneous squamous cell carcinoma in patients with recessive dystrophic epidermolysis bullsa. Cancer Res. 2012; 72(14): 3522–34.

References 1.

Sertznig P, von Felber V, Megahed M. Porokeratosis: present concepts. Review article. JEADV 2012; 26:404–412. 2. Rocha-Sousa VL, Costa JB, de Aquino Paulo-Filho T, et al. Follicular porokeratosis on the face. Am J Dermatopathol 2011;33(6):636–8.

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 Diabetes mellitus and necrobiosis lipodica A. Lalji1,2,3,4, M. Lalji4, N. Khiroya4 1 St Vincent’s Hospital, Melbourne, Victoria, Australia 2 Gold Coast University Hospital, Gold Coast, Queensland, Australia 3 Department of Medicine, Griffith University, Gold Coast, Queensland, Australia 4 Department of Medicine, Bond University, Gold Coast, Queensland, Australia Diabetes mellitus is a chronic illness exhibiting both microscopic and macroscopic pathology. Necrobiosis lipodica, a granulomatous inflammatory dermopathy, has been described in less than 1% of patients with diabetes mellitus.1 A 54-year-old male with a 26-year-old history of poorly controlled insulin dependent diabetes mellitus presented with new bilateral lesions on his anterior shins, which appeared over a 5-year period. Dermatological examination revealed two tender, yellow–brown, welldemarcated, indurated, irregularly shaped, waxy plaques, measuring 6 cm × 3 cm on the right shin and 7 cm × 3 cm on the left shin, with areas of both ulceration and telangiectasia in the centre of the plaques. The patient’s chronic diabetes mellitus and poor diabetic control together with poor compliance were thought to have contributed to the development of necrobiosis lipodica, a disorder characterised by collagenolysis, thickening of blood vessel walls, fat deposition and a granulomatous response. Studies suggest diabetic microangiopathy, deposition of immunoglobulins, antibody-mediated vasculitis, collagen degeneration, elevated lysyl oxidase levels and tumour necrosis factor, impaired neutrophil migration, fat deposition and thickening of the walls of blood vessels all to be possible causes of necrobiosis lipodica.2 Treatment is often unsatisfactory and ulceration causes significant morbidity. Tight glycaemic control in diabetic patients may be necessary in both the prevention and management of this disease. References 1.

Heidenheim M, Jemec GB. Successful treatment of necrobiosis lipoidica diabeticorum with photodynamic therapy. Arch Dermatol. 2006; 142: 1548–50. 2. Kota S, Jammula S, Kota S, Meher L, Modi K. Necrobiosis lipoidica diabeticorum: A case-based review of literature. Indian J Endocrinol Metab. 2012; Jul–Aug: 16(4): 614–20.

A single-institution experience of pediatric melanoma in Victoria, Australia Q. Le1, D. Norris1, C. McLean2, R. Meani1, J. Kelly1, Y. Pan1. 1 Victorian Melanoma Service, Alfred Hospital, Melbourne, Victoria, Australia 2 Department of Anatomical Pathology, Alfred Hospital, Melbourne, Victoria, Australia

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Methods: A search of the VMS database was performed to identify all patients who were diagnosed with melanoma at less than 20 years of age from 1994 to 2013. Histological, demographic and phenotypic information of all patients were collected. Patients were matched against the Victorian Death Registry to identify those who had died. Fisher’s exact tests were used to examine associations and melanomaspecific survival was estimated using Kaplan-Meier method. Results: 65 patients with pediatric melanoma were identified. 72% were diagnosed between 16 and 19 years of age. 75% of patients had blue to hazel eye color and 93.8% had Fitzpatrick skin phototype I to III. Superficial spreading melanoma was the most common melanoma subtype (69%). 33.9% of the patients had melanomas located on their trunk. The mean Breslow thickness was 1.4 millimeters (mm) (range: 0.1–9.0 mm). Median Breslow thickness was greatest in the youngest age group (3.4 mm). Majority of patients had AJCC stage I disease on presentation. Ten patients developed nodal metastatic disease with eight patients progressing to visceral metastatic disease. The 5-year melanoma-specific survival rate was 96.8%. Conclusion: This is the first study of descriptive epidemiological data of pediatric melanoma experience in Victoria. Further large population, multi-institutional studies of pediatric melanoma are warranted to provide a clearer understanding of this unique group of melanoma patients.

Fractional carbon dioxide laser in recalcitrant vulval lichen sclerosus A. Lee, A. Lim, G. Fischer Department of Dermatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia Vulval lichen sclerosus is an uncommon skin condition that can usually be managed with topical corticosteroids to maintain remission. However there is a subset of patients with hyperkeratotic disease which is resistant to superpotent topical corticosteroids. We report a case series of four patients undergoing fractional carbon dioxide laser resurfacing and one with ablative carbon dioxide laser for severe, hyperkeratotic biopsy-confirmed vulval lichen sclerosus not responding to super-potent topical corticosteroid. Patients were given prophylactic antibiotic and antiviral therapy in addition to pain relief to minimise side effects. In these patients, carbon dioxide laser was successful in achieving remission. Their vulval lichen sclerosus was able to be maintained with topical super-potent corticosteroid treatment post-laser.

Background: Pediatric melanoma is an uncommon presentation of melanoma that accounts for 3% of all cases of pediatric cancers. Objective: To describe a series of pediatric melanoma patients presenting to the Victorian Melanoma Service (VMS) over the past 19 years. © 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

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Cardiac medications in dermatology – a review of the literature P.A. Lee1,2, F. Pathan3, B.S. Daniel4,5 1 Faculty of Medicine, Imperial College London, London, UK 2 Whittington Hospital, London, UK 3 Department of Cardiology, Prince of Wales Hospital, Sydney, New South Wales, Australia 4 Skin and Cancer Foundation, Carlton, Melbourne, Victoria, Australia 5 Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia There is a strong interaction between cardiac medications and dermatology. Cardiac medications are often used to treat dermatological conditions including vasculitis, Raynaud’s phenomenon, haemangiomas and hyperhidrosis. Cardiac medications are known to worsen and trigger some dermatological conditions such as beta-blockers in psoriasis. More recently, novel antiplatelet and antithrombotic agents pose bleeding risks, given their characteristics of limited reversal and monitoring. This presentation reviews the use and evidence behind cardiac medications in dermatologic conditions. It also reviews the literature about newer antiplatelet and antithrombotic medications which have an impact on dermatological surgery and outlines the guidelines for stopping and reversal of these agents.

Case of atypical Sweet’s syndrome N. Linklater, D. Copson and N. Sharma Department of Plastic and Reconstructive Surgery, Royal Hobart Hospital, Hobart, Tasmania, Australia We present a case of a 48-year-old male with a known history of metastatic renal cell carcinoma who was admitted following a four day history of fever and diarrhoea with multiple bullous lesions, which commenced postbushwalking. Following admission he failed to respond to antibiotic therapy and require an ICU admission. Initial consideration was of an infective precipitant for the lesions, which were painful and not associated with any rash. Lesion initially commenced on volar surface of left forearm, with further lesion to left calf and thigh. Lesions were variable in size from 2–8 cm in diameter, each bullous with necrotic core, giving an initial differential as bullous pemphigoid or possible drug reaction. Subsequent biopsies revealed Sweet’s syndrome, which was treated successfully on corticosteroids with the lesions settling and healing well with dressings.

severe Staphylococcal Scalded Skin Syndrome (SSSS) involving 95% TBSA. The Burns unit was consulted to assist with the management as it is very similar to that of a large dermal burn. Percutaneous IV access was impossible necessitating CVC insertion through a small IV cut-down through involved skin. The CVC site was dressed with a chlorhexidine impregnated CVC dressing (Biopatch) as prophylaxis against line sepsis. After a two week period of dressings with Acticoat and SSD all affected areas were healed with the exception of the area under the chlorhexidine impregnated CVC dressing which was in place for 8 days and showed the appearance of a full-thickness burn in the exact outline of the chlorhexidine impregnated CVC dressing. This area required excision, the tissue was sent for histopathology which showed the appearance of coagulative necrosis consistent with a chemical burn. Case of toxic epidermal necrolysis following a dog bite N. Linklater, D. Copson, N. Sharma Department of Plastic and Reconstructive Surgery, Royal Hobart Hospital, Hobart, Tasmania, Australia We present a case of an 86-year-old female who developed a fatal case of toxic epidermal necrolyis (TENS) following a minor injury to left forearm. She developed an initial rash post-injury and was treated with oral Augmentin Duo forte by her GP resulting in a presentation to hospital two days later with blistering and bullous lesions to ∼30% TBSA of her body and within oral cavity. All lesions were painful, however her eyes were spared. She was initially dressed with silver dressings (acticoat). She rapidly progressed to 81% TBSA of skin desquamation and required ICU admission. After some initial improvement in ICU with inotropic support she ultimately deteriorated and was palliated. Melanoma – the Royal Hobart Hospital experience N. Linklater, D. Copson, N. Sharma Department of Plastic and Reconstructive Surgery, Royal Hobart Hospital, Hobart, Tasmania, Australia Melanoma is the least common type of skin cancer but the most life threatening. Australia has the highest incidence of skin cancer in the world with both non-melanoma and melanoma skin cancers presenting a significant health issue for Tasmania and Australia at large. We looked at the presentation, characteristics and management of melanoma treated at the Royal Hobart Hospital over a 3-year period. The study involved a retrospective audit of skin cancer presentations to Royal Hobart Hospital from June 2010–January 2013. The aims were:

Case report of a full-thickness burn following the use of a chlorhexidine patch N. Linklater, D. Copson, F. Kimble Department of Plastic and Reconstructive Surgery, Royal Hobart Hospital, Hobart, Tasmania, Australia

1. Review presentations of Melanoma skin cancers and source of referral 2. To assess whether current management and follow-up complies with national management protocols and current evidence-based healthcare and guidelines 3. To evaluate how patients were managed to improve understanding of clinical and epidemiological profile of melanoma in a Tasmanian hospital.

We present a case report of a 17 month old girl who was admitted under the Paediatric unit for the management of

Data were collected from electronic-based medical records and included demographics, lesion type, Breslow thickness,

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 location of lesion, follow-up, surgical intervention, SLNB and imaging data.

Pigmented purpuric eruption following the lines of Blaschko in a child H. Lolatgis1, J. Su1,2 1 Eastern Health (Box Hill Hospital), Melbourne, Victoria, Australia 2 Department of Dermatology, Royal Children’s Hospital, Melbourne, Victoria, Australia We present a case of pigmented purpuric eruption (PPE) along the lines of Blaschko in a thirteen-year-old boy with no prior medical history. The diagnosis of PPE was confirmed clinically and histologically. Blaschkoid skin patterns are an example of genetic mosaicism, following the lines of skin cell migration during embryogenesis. The cells of abnormal skin represent daughter cells of a mutated epidermal progenitor cell.1 In the case of PPE, the exact aetiology remains unknown, however it has been hypothesised that cells responsible for PPE are those involved in determining the structure of blood microvessels.2 We propose that a mutation has affected these microvessel progenitor cells during development and predisposed them to later development of PPE. Like lichen striatus, another acquired Blaschkoid skin pattern, this would suggest a combination of genetic and environmental factors, such as a virus, playing a part in the disease manifestation.3 To support the theory of a viral trigger, we note that varicella infections are a wellrecognised trigger for both lichen striatus and blaschkitis.4 Localized cell-mediated immune response represents another possible theory. The environmental trigger could bring about cell-mediated immunity against the mutant cells and therefore explain this distribution of PPE along the path of Blaschko’s lines.

References 1.

Paller AS. Piecing together the puzzle of cutaneous mosaicism. The Journal of Clinical Investigation. 2004. 114: 1407–1409 2. Torchia D. Segmental manifestation: a clue to explain the nature of pigmented purpuric dermatosis. Australasian Journal of Dermatology. 2011; 52: 235 3. Tilly JJ et al. Lichenoid eruptions in children. Journal of the American Academy of Dermatology. 2004; 51: 606–618 4. Hafner C, Landthaler M, Vogt T. Lichen striatus following varicella infection. Journal of the European Academy of Dermatology and Venereology. 2006; 20: 1345–57.

Tiger, tiger: a dermatomal distribution of AGEP C. Maiolo, J. Ma, L. Monet, G. Marshman Department of Dermatology, Flinders Medical Centre, Adelaide, South Australia, Australia We report a unique case of acute generalised exanthematous pustulosis in a 71-year-old Caucasian man,

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which presented in a symmetrical and almost dermatomal distribution. As it resolved, areas that were involved became clear, while the previously clear areas became erythematous, in an inverse pattern. The literature has described atypical presentations of AGEP including toxic epidermal necrolysis-like AGEP, AGEP/drug-induced hypersensitivity overlap syndrome and localised AGEP. We can now add dermatomally distributed AGEP to this list. Disseminated Mycobacterium chelonae infection N.G. Maher1,2, D.F. Murrell1,2 1 Department of Dermatology, St George Hospital, Sydney, New South Wales, Australia 2 Faculty of Medicine, University of NSW, Sydney, New South Wales Australia Mycobacterium chelonae is a nontuberculous mycobacterium that is widely found in soil and water supplies.1,2 It may also be found on medical instruments.1 It rarely causes infection in humans, but if so, can affect both immunocompetent and immunocompromised patients.2 Infection may be introduced by trauma or medical procedures/injections, although in other cases, no antecedent can be clearly attributed.1,2 Cutaneous clinical presentations can be nodules, plaques, ulcers, cellulitis, or abscesses,2,3 which may be localized or disseminated. Multiple lesions may be distributed in a sporotrichoid pattern.4,5 Treatment is with a prolonged course of antibiotics. Clarithromycin has been recommended as a first line agent in cutaneous infections depending on sensitivities,6 and combination therapy is often suggested to prevent resistance.3 We present two cases of disseminated Mycobacterium chelonae infections manifesting with lower leg red nodules in immunocompromised patients. No definite causative antecedent event could be identified. The first patient was on immunosuppressant medications for a kidney transplant, and had lower leg oedema on the same side affected by the nodules. The second patient was on long-term prednisolone for silicosis, and was having fevers of unknown origin at the time of diagnosis. Diagnoses were confirmed with skin biopsies of the red nodules. In both cases histopathology showed acid-fast bacilli, whilst skin culture confirmed the organism. Treatment was complicated by intolerance of antibiotics. References 1.

Hay R. (2009) Mycobacterium chelonae – a growing problem in soft tissue infection. Curr Opin Infect Dis. 22(2):99–101. 2. Chung W, Klim M, Kim C, Lee M, Choi J, Moon K, Koh J. (2009) Cutaneous Mycobacterium chelonae infection presenting as symmetrical plaques on both shins in an immunocompetent patient. Acta Derm Venereol. 89(6):663–664. 3. Hoetzenecker W, Ulmer A, Klingel K, Kempf V, Schanz S, Metzler G, Fierlbeck G. (2007) Dissemination of a localized cutaneous infection with Mycobacterium chelonae under immunosuppressive treatment. Arch Dermatol. 143(7):951–952. 4. Demitsu T, Nagato H, Inoue T, Yoneda K, Fujiwara Y, Miura M, Manabe M. (2001) Cutaneous Mycobacterium chelonae infection with bilateral sporotrichoid involvement. Int J Dermatol. 40(9):597–599.

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5.

Zahid M, Klotz S, Goldstein E, Bartholomew W. (1994) Mycobacterium chelonae (M. chelonae subspecies chelonae): report of a patient with a sporotrichoid presentation who was successfully treated with clarithromycin and ciprofloxacin. Clin Infect Dis. 18(6):999–1001. 6. Wallace RJ, Tanner D, Brennan P, Brown B. (1993) Clinical trial of clarithromycin for cutaneous (disseminated) infection due to Mycobacterium chelonae. Ann Intern Med. 119(6):482–486.

Complications of hydroxyurea therapy: dermatology, the key to diagnosis C. Maiolo, G. Marshman Department of Dermatology, Flinders Medical Centre, Adelaide, South Australia, Australia We present the case of an elderly man with a 6-year history of essential thrombocytosis treated with hydroxyurea but lost to follow up by the haematology team due to his remote location. Dermatology was consulted during an inpatient admission for non-healing diabetic ulcers. The patient was noted to have extremely painful, bilateral ulcers over the malleolar areas with surrounding liveoid reticularis. He also had dermatomyositis-like changes on his hands, diffuse hyperpigmentation and dyspnoea at rest. Hydroxyurea was ceased and after one week with good wound care, the patient demonstrated measurable improvement in the healing of his ulcers. Investigations demonstrated interstitial lung disease consistent with hydroxyurea toxicity. This case highlights the importance of dermatology in the holistic approach to diagnosis of systemic disease in a complicated patient.

Improvement in nail psoriasis in the open-label extension of a phase-2 trial of ixekizumab in patients with moderate-to-severe plaque psoriasis N. McKevitt1 on behalf of P. Rich2, R.G. Langley4, A. Menter5, G. Krueger6, B. Zhu3, H. Wei3, G.S. Cameron3, M.P. Heffernan3 1 Rx Communications, Mold, Flintshire, United Kingdom 2 Oregon Health & Science University School of Medicine, Portland, Oregon, USA 3 Lilly, Indianapolis, Indiana, USA 4 Dalhousie University, Halifax, Nova Scotia, Canada 5 Baylor University Medical Center, Dallas, Texas, USA 6 University of Utah School of Medicine, Salt Lake City, Utah, USA Introduction: Ixekizumab, an anti-interleukin (IL)-17A monoclonal antibody, was effective in treating moderate-tosevere psoriasis in a 20-week phase-2 study. We evaluated nail psoriasis response to ixekizumab during the 48-week open-label extension (OLE). Method: In the phase-2 study, 142 patients (pts) were randomized to receive subcutaneous ixekizumab 10, 25, 75, or 150 mg or placebo at weeks (wks) 0, 2, 4, 8, 12, and 16. After 0–12 wks in a treatment-free period, eligible patients could enter an OLE during which they received ixekizumab 120 mg every 4 weeks. Fingernail and toenail psoriasis was evaluated using the Nail Psoriasis Severity Index (NAPSI).

Results: Mean baseline NAPSI for all pts with nail psoriasis (N = 60) was 40.6. Fifty-nine patients had ≥1 post-baseline visit; 52 entered the OLE. At wk 20, pts receiving ixekizumab 75 and 150 mg, had a mean decrease in NAPSI from baseline of 63.8% (26.3 absolute change) and 52.6% (23.1 absolute change) vs. a 5.1% increase (1.9 absolute change; p < 0.01 between treatments) for pts receiving placebo. After 48 weeks of OLE, NAPSI significantly improved by 81.7% (−34.3 absolute change; p < 0.001) in the 44 patients remaining in the study, and by 91.7% (n = 12, −30.8 absolute change; p < 0.001 vs baseline) in patients initially assigned to placebo (n = 16), who had no nail improvement at Week 20. Conclusions: Improvements in nail psoriasis were observed by wk 20 with ixekizumab 75 and 150 mg. Significant and sustained improvements in nail psoriasis continued in the 48-wk OLE period. This abstract was presented at the 23rd EADV congress in Amsterdam 2014.

Effects of ixekizumab treatment on quality of life during 48 weeks of open-label treatment in a phase-2 trial in psoriasis N. McKevitt1 on behalf of A. Armstrong2, M. Lebwohl3, B. Zhu4, D. Shrom4, E. Nikaï5, M. Heffernan4 1 Rx Communications, Mold, Flintshire, United Kingdom 2 University of Colorado, Denver, Colorado, USA 3 Mount Sinai School of Medicine, New York, New York, USA 4 Lilly, Indianapolis, Indiana, USA 5 Lilly, Brussels, Belgium Introduction: After 20 weeks, ixekizumab, an anti-IL-17A monoclonal antibody, effectively controlled moderate-tosevere chronic plaque psoriasis and significantly improved health-related quality of life (HRQoL). This analysis assessed the effects of ixekizumab on HRQoL and treatment response after 48 weeks in an open-label extension (OLE) of the initial phase-2 trial. Method: In total, 120 patients entered the OLE and received ixekizumab 120 mg subcutaneously every 4 weeks. HRQoL was assessed with the Dermatology Life Quality Index (DLQI). Endpoints were the proportion of patients achieving: DLQI ≥5-point improvement, DLQI 0 or 1, DLQI 0, European Consensus Panel (ECP)-defined treatment response of PASI ≥75% improvement, at weeks 24 and 48 of the OLE. Results: The mean baseline DLQI score for patients entering the OLE was 10.9 ± 6.1. The mean DLQI score significantly decreased from baseline by 9.6 ± 5.8 (89% improvement, p < 0.001) to 1.2 ± 2.7 at week 24, and by 9.5 ± 5.6 (88% improvement, p < 0.001) to 1.3 ± 2.9 at week 48. At Week 24, 77% of patients achieved DLQI ≥5-point improvement, 83% achieved DLQI 0 or 1 and 61% achieved DLQI 0. At week 48, respective percentages were 80%, 79% and 64%. According to ECP treatment goals, continued therapy would be recommended for 98% of patients at week 24 and 93% at week 48.

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 Conclusions: Significant improvements from baseline were observed in HRQoL after 24 weeks of ixekizumab and those improvements were maintained after 48 weeks. At both 24 and 48 weeks, most patients achieved the ECP treatment goal. This abstract was presented at the 23rd EADV congress in Amsterdam 2014.

Impact of ixekizumab on blood neutrophil levels and the incidence of infections caused by Candida albicans or Staphylococcus aureus N. McKevitt1 on behalf of A. Blauvelt2, D.K. Braun3, G.S. Cameron3, D. Shrom3, M.P. Heffernan3 1 Rx Communications, Mold, Flintshire, United Kingdom 2 Oregon Medical Research Center, Portland, Oregon, USA 3 Lilly, Indianapolis, Indiana, USA Introduction: IL-17A plays an important role in neutrophil recruitment and protection against extracellular pathogens such as C. albicans and S. aureus. Ixekizumab, a monoclonal antibody directed against IL-17A, is in development for treating plaque psoriasis. Method: Data from an open-label extension of a phase-2 study were used to assess the impact of ixekizumab 120 mg subcutaneously every 4 weeks on blood neutrophil levels (neutropenia graded using CTCAE criteria) and the incidence of candidal and staphylococcal infections (investigator-reported without requirement for microbiologic confirmation) in 120 patients with moderateto-severe chronic plaque psoriasis. Results: Safety data were available to Week 52 for all patients and for some patients to Week 100. Overall, 4 patients experienced transient grade 1 neutropenia that was not clinically significant; no grade 2 or 3 neutropenia occurred. Overall, 49 patients experienced a treatmentemergent infection of any kind: 5 reported candida (4 oral and 1 vulvovaginal), 1 a vulvovaginal infection due to an unspecified yeast and 2 a staphylococcal infection (ear infection and impetigo), all of which resolved with proper treatment and did not interfere with ixekizumab dosing. None of these patients had concurrent neutropenia. Conclusions: Ixekizumab treatment for 1 year was associated with a low incidence of neutropenia, which was transient and not severe and a low frequency of candidal or staphylococcal infections in patients with psoriasis. Further study is needed to fully understand the impact of ixekizumab treatment on circulating neutrophil levels and host defences. This abstract was presented at the 73rd SID conference in Albuquerque 2014.

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Three IL-17 ligands contribute to psoriasis: blockade of IL-17RA signalling with brodalumab C.B. Russell1, Y. Zhang1, K. Kerkof1, M. Timour1, P. Klekotka2, D.A. Martin1, D.H. Salinger1, J. Bigler1 Presented by: R. McQualter3 1 Amgen Inc., Seattle, Washington, USA 2 Amgen Inc., Thousand Oaks, California, USA 3 Amgen Pty Ltd., Melbourne, Victoria, Australia The IL-17 family of cytokines are implicated in autoimmune inflammatory diseases, including psoriasis and spondyloarthropathies. IL-17A, IL-17C and IL-17F are highly overexpressed in lesional psoriasis skin and act through IL-17 receptor complexes that require the IL-17RA subunit. We examined a mouse skin inflammation model using blocking antibodies directed against the IL-17 ligands or the IL-17RA subunit and monitored effects by mRNA profiling and histology. Blockade of IL-17RA was more effective than blockade of individual ligands, suggesting inflammatory contributions from multiple ligands. Brodalumab antagonises signalling by competing with the IL-17 ligands for binding to the IL-17RA subunit. In humans, single 700 mg i.v. doses of brodalumab resulted in nearcomplete transcriptional normalisation to non-lesional levels within two weeks, including substantial suppression of IL-17C mRNA within one week, and IL-17A and IL-17F mRNA over six weeks. With lower s.c. doses, some individuals with low brodalumab exposure demonstrated only modest molecular responses, although others with similar exposure demonstrated near-complete responses. Less responsive individuals all had high levels of IL17 ligand mRNAs maintained over the first two weeks. These data are consistent with high levels of overexpressed IL-17 ligands competing with low levels of blocking antibody to maintain IL-17 signalling. No single IL-17 ligand was dominant in the effect. These data suggest that IL-17A, IL-17C, and IL-17F may all contribute the inflammatory processes of psoriasis. Blockade of signalling by multiple IL-17 ligands at IL-17 receptor A and subsequent decreases in ligand expression may both contribute to rapid improvements in psoriasis following treatment with brodalumab.

Improvement of psoriasis in subjects with and without psoriatic arthritis: subanalysis of a brodalumab (AMG 827) phase 2 study for moderate to severe plaque psoriasis (PsO) K. Papp1, A. Menter2, B. Strober3, C.E. Milmont4, P. Klekotka4 Presented by: R. McQualter5 1 Probity Medical Research, Waterloo, Ontario, Canada 2 Baylor University Medical Center, Dallas, Texas, USA 3 University of Connecticut School of Medicine, Farmington, Connecticut, USA 4 Amgen Inc., Thousand Oaks, California, USA 5 Amgen Pty Ltd., Melbourne, Victoria, Australia Introduction: Psoriasis patients with associated psoriatic arthritis (PsA) present an additional challenge to the treat-

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

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Australasian Journal of Dermatology (2015) 56

ing practitioner. The efficacy and safety of brodalumab were assessed in patients with psoriasis with and without a self-reported history of PsA. Method: This subanalysis from a phase 2, randomised, double-blind, placebo-controlled study of subjects with moderate-to-severe PsO receiving brodalumab 70, 140, or 210 mg every 2 weeks (with a loading dose at week 1) or 280 mg every 4 weeks, or placebo. Subjects were stratified by self-reported history of PsA (yes/no). Outcome measures included static Physician Global Assessment (sPGA) and adverse events. Results: Of 198 subjects enrolled, 46 (23.2%) had selfreported PsA. At baseline, subjects with PsA had similar or

Table 1

somewhat more severe psoriasis and lower quality of life than those without PsA; mean PASI score 19.7 vs 18.9; mean affected body surface area 27% vs 23%; mean Dermatology Life Quality Index score 12.6 vs 11.5. Complete clearance (sPGA 0) and clear/almost clear (sPGA 0 or 1) rates at week 12 are listed in Table 1. In subjects with and without PsA, adverse events were reported by 57% and 63%, respectively, of subjects receiving placebo, and 72% and 74% of subjects receiving brodalumab. Conclusion: Treatment with brodalumab was associated with significant clinical improvement in subjects with moderate-to-severe plaque psoriasis with or without a selfreported history of PsA.

Week 12 complete (sPGA 0) and clear/almost clear (sPGA 0 or 1) response rates (non-responder imputation)

Rate (95% CI)

PsA

70 mg Q2W

140 mg Q2W

210 mg Q2W

280 mg Q4W

Placebo

N

With PsA Without PsA With PsA Without PsA With PsA Without PsA

8 31 0% (0, 37) 13% (4, 30) 13% (0, 53) 29% (14, 48)

11 28 64% 32% 82% 86%

12 28 58% 64% 92% 75%

8 34 13% 32% 50% 74%

7 31 0% 0% 0% 3%

sPGA 0 sPGA 0 or 1

Maintenance of clinical response with long-term brodalumab (AMG 827) therapy for psoriasis: week 144 results from an open-label extension study K. Papp,1 C. Leonardi,2 A. Menter,3 E.H.Z. Thompson,5 C.E. Milmont,4 G. Kricorian,4 A. Nirula,4 P. Klekotka4 Presented by: R. McQualter6 1 Probity Medical Research, Waterloo, Ontario, Canada 2 St. Louis University, St. Louis, Missouri, USA 3 Baylor University Medical Center, Dallas, Texas, USA 4 Amgen Inc., Thousand Oaks, California, USA 5 Formerly at Amgen Inc., Thousand Oaks, California, USA 6 Amgen Pty Ltd., Melbourne, Victoria, Australia

(31, (16, (48, (67,

89) 52) 98) 96)

(28, (44, (62, (55,

85) 81) 100) 89)

(0, 53) (17, 51) (16, 84) (56, 87)

(0,41) (0,11) (0, 41) (0, 17)

enrolled in this open-label extension (OLE) study, and initially received brodalumab 210 mg Q2WK. A protocol amendment after 1 year, reduced the dose to 140 mg for subjects ≤ 100 kg (N = 119). A subsequent protocol amendment allowed subjects with an inadequate response during treatment with 140 mg to increase to 210 mg (n = 19). Outcome measures included 75% improvement in Psoriasis Area and Severity Index (PASI-75), PASI-90, and PASI-100 (as observed) and adverse events (AEs).

To determine the long-term efficacy and safety of brodalumab, a monoclonal antibody against the IL-17 receptor, for the treatment of moderate to severe plaque psoriasis.

Of 181 subjects enrolled at OLE baseline, 144 (80%) subjects remained on study at week 144 (88 on 140 mg; 56 on 210 mg). PASI response rates are listed in Table 1. Through week 144, 94.5% of subjects had a treatment-emergent AE. The most frequently reported AEs (≥10%) were nasopharyngitis (26.5%), upper respiratory tract infection (19.9%), arthralgia (17.1%), back pain (11.0%), and influenza (10.5%), which were predominantly grade 2 or less.

Subjects who had previously received placebo or brodalumab 70, 140, or 210 mg every 2 weeks [Q2WK] or 280 mg every 4 weeks in a parent phase 2 study were

At all measured time points from week 8 to week 144, the majority of subjects achieved a PASI100 response. Brodalumab was well tolerated.

Table 1.

PASI response rates (as observed)

Response (95% CI)

PASI-75

PASI-90

PASI-100

OLE week 12 OLE week 48 OLE week 144

95.4% (91.2, 98.0) 93.3% (88.4, 96.6) 85.4% (78.6, 90.7)

85.1% (79.0, 90.1) 83.0% (76.4, 88.4) 73.6% (65.6, 80.6)

62.9% (55.2, 70.0) 61.8% (53.9, 69.3) 51.4% (42.9, 59.8)

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 Emergence of chemoresistance in a metastatic basal cell carcinoma patient after complete response to hedgehog pathway inhibitor Vismodegib (GDC-0449) R.E Meani1, S.W. Lim1, A.S. Chang2, J.W. Kelly1 1 The Victorian Melanoma Service, Melbourne, Victoria, Australia 2 Stanford University Medical Center, Stanford, California, USA Vismodegib (GDC-0449, Genentech, USA), a small molecule inhibitor of the Hedgehog (Hh) signaling pathway, has potent anti-tumour activity in advanced basal cell carcinoma (BCC).1–3 Vismodegib was approved by the United States Food and Drug Administration (U.S. FDA), for use in locally advanced or metastatic BCC in 2012. We report a case of a 67-year-old Australian male with a 20-year history of multiple primary cutaneous BCCs, who subsequently developed metastatic BCC including pulmonary disease with malignant effusion, and who showed dramatic complete response to Vismodegib. After 10 months of continuous treatment, a computed tomography (CT) scan revealed recurrence of pulmonary disease, indicative of chemoresistance to Vismodegib. This case is the first that has been reported of chemoresistance in a patient with metastatic BCC, and demonstrates the need for close monitoring of metastatic BCC patients even after apparent complete response.

References 1.

Lorusso PM, Jimeno A, Dy G et al. Pharmacokinetic dosescheduling study of hedgehog pathway inhibitor vismodegib (GDC-0449) in patients with locally advanced or metastatic solid tumors. Clin Cancer Res. 2011; 17: 5774–82. 2. LoRusso PM, Rudin CM, Reddy JC et al. Phase I trial of hedgehog pathway inhibitor vismodegib (GDC-0449) in patients with refractory, locally advanced or metastatic solid tumors. Clin Cancer Res. 2011; 17: 2502–11. 3. Von Hoff DD, LoRusso PM, Rudin CM et al. Inhibition of the hedgehog pathway in advanced basal-cell carcinoma. N Engl J Med. 2009; 361: 1164–72.

Review of the Victorian Melanoma Service – a statewide multidisciplinary melanoma referral centre R.E. Meani1, Y. Pan1, C. McLean2, J.W. Kelly1 1 Victorian Melanoma Service, The Alfred Hospital, Melbourne, Victoria, Australia 2 Department of Anatomical Pathology, The Alfred Hospital, Melbourne, Victoria, Australia Introduction: The Victorian Melanoma Service (VMS) is a dermatologist driven, fully multi-disciplinary consultative clinic for the management of melanoma. Established in 1994, the service provides comprehensive assessment and management of patients diagnosed with primary cutaneous or metastatic melanoma by various health care professionals involved in the treatment of melanoma. Methods: Retrospective review of the clinic database of all patients who attended the VMS from 1st October 1994 to 30th September 2013 was performed.

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Results: A total of 6,721 new patients attended the VMS during the review period. The number of new patients seen each year has steadily increased from less than 200 to over 500 patients per year. Approximately 73% of patients seen live in metropolitan Victoria and 27% of patients were from regional Victoria. Overall, 20% of all melanomas seen were in situ melanomas and 70% were invasive melanomas. The median invasive melanoma Breslow thickness has increased from 0.85 mm to 1.2 mm. Pathology reviews performed by VMS histopathologists resulted in a change to diagnosis in approximately 20% of cases. Full skin examination revealed a second primary melanoma in 12% of patients and non-melanoma skin cancers in 30%. The dermatological drive places more emphasis on the care of primary melanoma and uses the guidance of dermatologists to ensure that other disciplines have the best opportunity to contribute. Conclusion: The review conducted demonstrated the current trends in melanoma within a state-wide multidisciplinary referral service. The results reflect a stronger role for dermatologists leading to emphasis on histological review and the detection of synchronous skin cancer.

A retrospective study of psoriasis patients treated with long contact dithranol in a dermatology day unit F. Menz1, S. Sidhu2 1 Intern, Royal Adelaide Hospital, Adelaide, South Australia, Australia 2 Head of Dermatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia Introduction: Dermatology day units offer intensive, time consuming or specialized treatments for severe skin disease. Long contact dithranol is a psoriasis treatment that has been used in day units since 1916.1 High level evidence is limited into the clinical efficacy of long contact dithranol however small studies show rapid improvement in psoriasis plaques and sustained periods of remission.2 Given the cost and time required in long contact dithranol treatment we conducted an audit of 50 patients who received treatment of their psoriasis with long contact dithranol in the day unit setting. Method: The case notes were reviewed of 50 randomly selected patients who were treated for psoriasis at the Royal Adelaide Hospital Dermatology Day Unit in 2013 and 2014. Patient demographics, past medical and dermatological history, day unit treatment regimen and outcomes were recorded. A phone interview was then conducted to follow up the patients’ psoriasis control since discharge and the patients’ impressions of the feasibility of day unit treatment. Results: The majority of patients had chronic plaque psoriasis. All 50 patients had long contact dithranol as part of their day unit treatment regimen, generally as part as Ingram’s regimen. All patients had improvement in their psoriasis by the end of their day unit admission. Aspects of treatments such as duration, remission times and patient satisfaction including Dermatology Life Quality Index (DLQI) scores will be discussed.

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Australasian Journal of Dermatology (2015) 56

References 1.

van de Kerkhof P. Dithranol treatment for psoriasis: after 75 years, still going strong! Eur J Dermatol 1991;1:77–80. 2. Koo J, Lebwohl M. Duration of remission of psoriasis therapies. J Am Acad Dermatol 1999;41:51–9.

Systemic and erythrodermic reaction following repeated exposure to bites from the common bed bug, Cimex lectularius R. Minocha1, S. Doggett2, K. Dang2, C. Wang2, C. Webb2, P. Fernandez-Penas1 1 Department of Dermatology, Westmead Hospital, Westmead, New South Wales, Australia 2 Department of Medical Entomology, Westmead Hospital Pathology West, ICPMR, Westmead, New South Wales, Australia The resurgence of infestations by bed bugs (Cimex spp.) has manifested in a multitude of social, economic and health concerns, particularly for first world nations. Diffuse cutaneous and systemic manifestations associated with bed bug bites have been sparsely documented. We report two cases of an acute systemic and erythrodermic reaction following bed bug bites in a 28-year-old and 42-year-old Chinese man, with history of previous exposure.

Interstitial granulomatous dermatitis presenting with scleroderma-like changes associated with dystrophic calcification and a review of the literature R. Minocha1, I. Hamann1, B. Dutta2 1 Department of Dermatology, Westmead Hospital, Westmead, New South Wales, Australia 2 Histopathology, Laverty Pathology, Ryde, New South Wales, Australia Interstitial granulomatous dermatitis (IGD) is a rare dermatosis, with variable cutaneous expression. The originally described clinically as ‘Ackerman syndrome’ in 1993 consisting of cutaneous cords, or bands, associated with arthritis. Since then, various other clinical presentations of IGD have been described. We report a 59-year-old patient who presented with clinical findings suggestive of limited sclerosis, but with histopathology in keeping with IGD of unknown cause. Her condition was further complicated by dystrophic calcification. Review of the literature suggests that this clinical presentation of IGD is unique. Methods: A systematic review of the literature was performed, of all IGD cases, excluding those with the clinical and histological features of classical Ackerman syndrome, Palisaded neutrophilic granulomatous dermatitis and Interstitial granulomatous drug reaction. Demographic, clinical and histopathological data were collated. Results: 39 cases of IGD were identified in the literature, as per the selection criteria. The median age of 62 with a predilection for females was in keeping with our case. Various autoimmune diseases, infections and malignancies

were found in conjunction with IGD. 72% of patients had a symmetrically distributed eruption and the majority of cases described an eruption of asymptomatic annular plaques, erythematous to violaceous in nature. 17 patients were recorded to have a complete response to treatment with a median time of 2.0 months. Ten patients were treated with systemic corticosteroids. Other immunosuppressants used with good effect were Methotrexate, Adalimumab and Etanercept. Discussion: IGD is becoming a more distinctive clinical and cutaneous entity than ever before. This case and literature review illustrates the unique spectrum of cutaneous presentations of this disorder and the importance of the histological findings to confirm a diagnosis of IGD. IGD without inflammatory arthritis are ill defined in the literature and may have a unique pathophysiological mechanism.

Necrobiotic xanthogranuloma: a report of two unique cases R. Minocha1, D. Sebaratnam1, J. Choi1, S. Lee2 1 Department of Dermatology, Westmead Hospital, Westmead, New South Wales, Australia 2 Department of Dermatology, Concord Hospital, Concord, New South Wales, Australia Necrobiotic Xanthogranuloma (NXG) is a rare, granulomatous disorder of the skin, first described by Kossard and Winkleman in 1980.1 It is characterised by indurated nodules and erythematous, yellow plaques mostly affecting the periorbital region. In recent years, NXG has been increasingly associated with paraproteineamia and haematological disorders, such as multiple myeloma. We report two cases with histological and clinical findings of NXG. We describe the first case reported of NXG on a background of Hepatitis C in a 54-year-old male. We also describe the first case of unilateral NXG, presenting as infiltrative plaques with a central yellow appearance, affecting the left neck, shoulder, arm, left submammary and left thigh in a 63-year-old female.

Reference 1.

Kossard S, Winkelmann RK. Necrobiotic xanthogranuloma with paraproteinemia. Journal of the American Academy of Dermatology.3(3):257–270.

The progressive clinical course of Cimicosis: the dermatological affects from the common bed bug, Cimex lectularius R. Minocha1, S. Doggett2, G. Carlos1, P. Fernandez-Penas1 1 Department of Dermatology, Westmead Hospital, Westmead, New South Wales, Australia 2 Department of Medical Entomology, Westmead Hospital Pathology West, ICPMR, Westmead, New South Wales, Australia Introduction and objectives: The Common Bed bug (Cimex lectularius) is a haematophagus parasite that

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 readily bites humans. There has been an unexpected worldwide resurgence in recent years, especially in low socioeconomic dwellings in first world nations. Cutaneous reactions to bed bugs have been widely reported in the literature, however to date, have all been based one-off clinical presentations and the progression of the disease has not been elucidated. This creates a diagnostic dilemma for clinicians. We conducted a pilot study with five volunteers to document the dermatological effects over time, from the initial bite of C. lectularius to the clinical resolution of the condition, using all stages of the bed bug to compare the respective development of the subsequent bite reactions. Three volunteers had known previous exposures to C. lectularius bites. Materials and methods: Seven C. lectularius (all five juvenile stages from the first to fifth instar, plus one male and one female each) were placed on the anterior forearm of each volunteer and the bed bugs allowed to feed until repletion. A photographic record through the course of the clinical development of the bite reactions was made for each volunteer. Each volunteer was photographed for two weeks. Objective reactions were assessed in regards to the development of erythema, oedema, papules, vesicles, crust. Each dermatological assessment was scored from 0–3. Length of time till reaction and time taken for dissipation of reaction was also recorded. Similarly, subjective reactions by the volunteers (itch, pain, scratch, insomnia, systemic symptoms, etc) were documented and scored within the twoweek interval. Only one volunteer took medications to control symptoms as they became unbearable. The other volunteers did not to prevent hindrance to the reaction type and pattern. Results: Three of the five volunteers that had previously known C. lectularius exposure produced immediate reactions (define the time i.e. less than 30 secs, 1 min or whichever) to the bites. Two with no known prior exposure developed delayed reactions. All volunteers developed surrounding erythema at the bite site. Two volunteers developed immediate papules and one of them also developed oedema at each bite site. Two volunteers developed immediate oedema at each bite site and one of them also developed vesicles. One volunteer developed cluster of papules over the bite site, two weeks after the original bites. All volunteers developed crusting over the punctate at each bite site, likely due to scratching. Volunteers experienced pain over the lesions, mild to severe itch that kept them awake at night. No one experienced systemic symptoms in this study. Conclusions: This pilot study was designed to elucidate the type and pattern of cutaneous reactions to the common bed bug to enable greater clinician and community understanding of this pest that has become a grave concern for many communities in the modern world.

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Chromonychia: a brief review E. Mooney1, C. Kronborg2, A. Howard3 1 Department of Dermatology, Austin Health, Melbourne, Victoria, Australia 2 Department of Medicine, Alfred Health, Melbourne, Victoria, Australia 3 Department of Dermatology, Western Health, Melbourne, Victoria, Australia Chromonychia is a common presentation to dermatologists and refers to an alteration in the colour of the nail – either involving the nail plate or subungual tissue. The causes of chromonychia are diverse, ranging from exogenous conditions to infection, malignancy and congenital disease. Chromonychia may be the result of overproduction of melanin, deposition on or alteration in the surface of the nail and may represent a wide range of colours, including melanonychia, leukonychia, erythronychia, or even blue, yellow or green discolouration. We review the different ways a discoloured nail may present to the dermatologist and a brief overview of clinical assessment, differential diagnosis, biopsy technique and management options in melanonychia, leukonychia, green nails, yellow nails and erythronychia. Kaposi’s sarcoma E. Mooney1, M. Goh1, J. Horton1, A. Ryan2, A. Darling2 1 Department of Dermatology, Austin Health, Melbourne, Victoria, Australia 2 Department of Anatomical Pathology, Austin Health, Melbourne, Victoria, Australia We present the case of a 76-year-old male referred for assessment of multiple, annular, violaceous plaques affecting both the dorsal and ventral aspects of his feet bilaterally. The patient had a background of metastatic melanoma for which he was receiving dabrafanib and trametinib however the evolution of the plaques preceded the initiation of this treatment. He had been treated for myasthenia gravis over many years with high-dose prednisolone, the lowered dosing of which seemed to correlate with improvement in the violaceous plaques. The initial differential diagnosis included Sweet’s syndrome or pseudo-Kaposi’s. The initial histology was consistent with venous stasis dermatitis, which was not in keeping with the clinical picture. However, following liaison with our pathology colleagues, deeper levels revealed one small focal spindle cell dermal proliferation with mitotic activity, which was not appreciated in the initial sections. Human herpes virus 8 (HHV8) immunohistochemistry was undertaken and confirmed the presence of HHV-8 latency-associated nuclear antigen within the spindle cells, confirming the diagnosis of Kaposi’s sarcoma. We propose that prolonged steroid therapy was the likely immunosuppressive trigger for this patient’s presentation

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

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Australasian Journal of Dermatology (2015) 56

with Kaposi’s sarcoma and note the clinical improvement when his oral steroid dose was reduced. We also highlight the need for clinic-pathological correlation and close liaison with our pathology colleagues at all times to ensure accurate diagnosis.

References 1.

R Hoshaw, R.A Schwartz, Kaposi’s Sarcoma After Immunosuppressive Therapy With Prednisone Arch Dermatol. 1980;116(11): 1280–1282. 2. R.W. Gange E. Wilson-Jones. Kaposi’s sarcoma and immunosuppressive therapy: an appraisal. Clinical and Experimental Dermatology. 1978;3(2):135–146. 3. Guo WX, Antakly T. AIDS-related Kaposi’s sarcoma: evidence for direct stimulatory effect of glucocorticoid on cell proliferation. Am J Pathol 1995;146:727–34. 4. Hudnall SD, Rady PL, Tyring SK, Fish JC. Hydrocortisone activation of human herpesvirus 8 viral DNA replication and gene expression in vitro. Transplantation. 1999; 15;67(5):648–52

Treatment of granuloma faciale with intralesional Kenacort-A 10 and 5-Fluorouracil combination therapy D. Norris1, M. Apikian2, G. Goodman2 1 Royal Melbourne Hospital, Parkville, Victoria, Australia 2 Dermatology Institute of Victoria, South Yarra, Victoria, Australia This report describes a sixty-year-old male with biopsy proven Granuloma Faciale (GF). GF is an uncommon benign inflammatory condition of the skin with characteristic clinical and histological features. The patient had been unsuccessfully treated with multiple therapies in the past. In 1999, Fitzpatrick described using a mixture 0.8 ml 5-Fluorouracil (5FU) and 0.2 ml Kenacort-A for the treatment of hypertrophic scarring.1 The same combination was used to treat this patient for GF, with various quantities used. These were given at intervals ranging from two weeks to two months. The patient received a total of twenty injections over a period of more than three years. An excellent response was noted and the patient is now able to tolerate long treatment free periods of between nine and twelve months. It is largely unknown why 5FU has been so useful in this case. As a pyrimidine analogue, 5FU is transformed inside the cell to form cytotoxic metabolites that are incorporated into DNA and RNA, inducing cell cycle arrest and apoptosis. It may be that 5FU is having such an effect on the inflammatory cells making up the infiltrate. 5FU is a simple injection material and can be considered by clinicians as an option for treatment of GF.

Reference 1.

Fitzpatrick RE. Treatment of inflamed hypertrophic scars using intralesional 5-FU. Dermatol Surg. 1999;25:224–232

Reduced levels of self-reported psychological distress associated with multidisciplinary melanoma clinic attendance D. Norris, Q. Le, Y. Pan, J. Kelly Victorian Melanoma Service, Melbourne, Victoria, Australia Introduction: Psychological distress is a well known factor affecting patients following a diagnosis of cancer. Guidelines regarding the most effective use of tools to assess distress and subsequent interventions as a result of these assessment tools are not well established. The National Comprehensive Cancer Network Clinical Practice Guidelines for distress management recommend that management for a patient with a diagnosis of cancer should include an initial assessment of distress, using validated tools such as the distress thermometer (DT) and problem list (PL). The aim of this study is to explore if the multidisciplinary team approach to management in melanoma patients is beneficial in decreasing distress perceived by patients. Methods: The self reported distress level of patients attending a multidisciplinary outpatient melanoma skin clinic in Melbourne, Australia was measured using the DT and PL. The patients completed a questionnaire inclusive of these two tools at the beginning of their first interaction with the service, and then again upon discharge following all management and interventions. Statistical analysis between these scores and variables such as tumour thickness, staging and gender was conducted. Results: There is a statistically significant improvement in distress levels of patients at the initial visit (median DT score of 4.38) compared with the discharge visit (median DT score of 2.05; p-value < 0.05). There is no significant difference in DT scores by gender, staging or tumour thickness (p-value > 0.05). The most common issues identified in patients with newly diagnosed melanoma were in the emotional domain.

Dermatology life quality index in the Australian Psoriasis Population D.Norris, C.Dolianitis Royal Melbourne Hospital Department of Dermatology, Melbourne, Victoria, Australia Introduction: Psoriasis is known to cause significant effects on quality of life yet despite this most published research focuses on the evaluation of treatment regimes in terms of their objective efficacy based on clinician assessments, rather than patient reported quality of life. The aims of this study are to evaluate the effect of commencement of a biologic medication in patients with psoriasis on healthrelated quality of life (HRQoL), explore the difference in HRQoL between the various classes of biologics prescribed to patients with psoriasis, investigate the relationship between HRQoL and change in PASI score for a patient with psoriasis commenced on a biologic, investigate the predictors and associations to change in HRQoL, and investigate the change in HRQoL for a patient on non-biologic systemic therapies or phototherapy. Methods: A retrospective cross-sectional study of data collected in the Australasian Psoriasis Registry from initiation

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 in 2008 to present was performed. Relevant data from all patients on the registry was extracted and analysis performed with all statistical tests being two-tailed, and a p-value of less than 0.05 considered to indicate statistical significance. Results: Initiation of a biologic medication improves the HRQoL. A significant reduction in DLQI score is seen when comparing baseline score and score at 24 weeks. Patients with higher PASI scores showed a significant change in DLQI score between baseline and 24 weeks. Associations between DLQI and certain demographic and medical comorbidities were also significant such as age >60 and alcohol intake. Acknowledgement: Data were made available for assessment by the Australasian Psoriasis Registry

Stewart-Bluefarb syndrome secondary to arteriovenous malformations and acquired non-traumatic arteriovenous fistula: report of five cases and a review of literature K. Parsi1,3,4, A.A. O’Connor1, L. Bester2,3,4 1 Department of Dermatology, St. Vincent’s Hospital, Sydney, New South Wales, Australia 2 Department of Medical Imaging, St. Vincent’s Hospital, Sydney, New South Wales, Australia 3 Sydney Skin and Vein Clinic, Sydney, New South Wales, Australia 4 University of New South Wales, Sydney, New South Wales, Australia Stewart-Bluefarb syndrome (SBS) is a rare angioproliferative disorder characterised by acroangiodermatitis (AAD) associated with an underlying arteriovenous shunt. This condition should be differentiated from AAD of Mali classically described in association with chronic venous insufficiency (CVI). Recognition of SBS may be difficult or delayed as the cutaneous manifestations may resemble a variety of other dermatological conditions. Most commonly, AAD may be confused with Kaposi’s sarcoma (KS) and the condition is often referred to as ‘Pseudo-KS’. AAD may also resemble or coexist with pigmentation of CVI and be clinically confused with the ‘cavernous’ form of a capillary malformation. We describe five patients with SBS. In one female and two male patients the diagnosis was delayed as the AAD closely resembled other conditions. All underlying AV communications were initially diagnosed on duplex ultrasound and confirmed with magnetic resonance angiography (MRA). Four patients were found to have a congenital AV malformation while one patient was diagnosed with a postthrombotic AV fistula. Management included observation and intervention using a variety of techniques including percutaneous or trans-catheter embolization, endovenous laser, radiofrequency ablation and foam ultrasound guided sclerotherapy. This case series highlights the challenges involved in the diagnosis and management of SBS. Given the local and systemic sequelae of high flow shunts, correct diagnosis and early detection of the underlying AV abnormality is crucial in the long-term management of these patients and in preventing the associated complications.

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Reference 1.

Parsi K, O’Connor AA, Bester L. Stewart-Bluefarb Syndrome Secondary to Arteriovenous Malformations and Acquired NonTraumatic Arteriovenous Fistula: Report of Five Cases and a Review of Literature. Phlebology. 2014 August 13 [Epub ahead of print].

My patient has loss of MSH2 and 6 in their sebaceous adenoma: do they have Muir Torre syndrome? N. Ong, E. McMeniman Department of Dermatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia A diagnosis of a cutaneous malignancy at times has serious implications for a patient, particularly in the setting of a sebaceous neoplasm. Muir-Torre syndrome (MTS) is an autosomal-dominant familial cancer syndrome, which is defined as the association of an internal malignancy with cutaneous sebaceous tumours, multiple keratoacanthomas or both diagnostic entities.1 Currently, sebaceous tumours remain a confusing topic in terms of nomenclature, diagnosis and management. Internal malignancies in MTS include colorectal cancers and other cancers seen in Lynch syndrome, such as ovarian, urinary tract and brain cancers.2 The majority of genetic mutations in MTS occur in the MSH2 gene.3 Thus, ancillary testing including microsatellite testing, immunohistochemistry (IHC) and genetic testing is usually undertaken. In a retrospective chart review undertaken at the Princess Alexandra Hospital Dermatology Department, 31 patients with at least one sebaceous neoplasm were identified from January 2010 to November 2013. Sebaceous neoplasms included adenomas, carcinomas and intraepidermal carcinomas with sebaceous differentiation. Of the 31 patients, 14 received IHC testing with 4 (29%) exhibiting abnormal IHC with loss of one or more mismatch repair (MMR) proteins. MMR IHC, however, is less reliable when undertaken on sebaceous neoplasms than on colon or endometrial tumours for accurately diagnosing MTS.2 Thus, it has been suggested that screening by guided by personal and family history even when a normal IHC is found2. Overall, it is essential to work-up a patient presenting with a sebaceous neoplasm for any detectable internal malignancies. This can best be achieved by attaining a thorough personal and family history of any colorectal cancers, and appropriate referral to a genetic counsellor.

References 1.

Ko, C (2010). Muir-Torre syndrome: Facts and controversies. Clinics in Dermatology 28:324–329. 2. Roberts, M.E., Riegert-Johnson, D.L., Thomas, B.C. et al. (2013). Screening for Muir-Torre syndrome using mismatch repair protein immunohistochemistry of sebaceous neoplasms. J Genet Counsel 22:393–405.

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3.

Pancholi, A., Collins, D., Lindley, R., Gandhi, P. (2008). Ann R Coll Surg Engl online publication 90: 1–2. 4. Eisen, D.B., Michael, D.J. (2009). Sebaceous lesions and their associated syndromes: Part I. JAMA Derm, 61 (4): 549–560.

Molecular profiles of reticular and globular naevus patterns: a pilot study N. Ong1,2, D. Duffy3, A. Leikvold1, K. Lee1, K. Jagirdar1, Lynlee L Lin1, M. Yamada1, R.A. Sturm1, T.W Prow1, H. Schaider,1 H.P. Soyer1,2 1 Dermatology Research Centre, The University of Queensland, School of Medicine, Translational Research Institute, Brisbane, Queensland, Australia 2 Department of Dermatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia 3 QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia Melanocytic naevi are well-known risk markers and precursors of cutaneous melanoma.1 Understanding naevogenesis is therefore imperative in assessing melanoma risk in a given individual. Oncogenic BRAF and NRAS mutations have been identified as crucial initial events in the development of melanoma, according to the multistep model of melanoma development.2 There are scarce studies employing genetic analyses correlating to dermoscopy based on the assumption that distinct dermoscopic naevus patterns represent particular molecular profiles. In contrast to reticular naevi, globular naevi are more frequently comprised of large melanocytic nests and show a dermal growth pattern.3 It has been previously described that globular naevi are at least three times more likely to express BRAF V600E, a mutation present in acquired naevi influenced by the environment, than reticular naevi.3 Another study demonstrated that 100% of globular naevi were BRAF V600E positive, whilst 75% of reticular naevi expressed this mutation.4 This study aims to investigate the molecular features of reticular versus globular naevus patterns in a small study group of individuals who had no family or personal history of melanoma. Three Caucasian males were recruited to contribute one reticular and one globular naevus from adjacent sites. Dermoscopic and clinical features of naevi were recorded followed by in vivo microbiopsies, excision and ex vivo microbiopsies. After DNA and RNA extraction molecular profiles are determined based on mutational analyses including whole exome sequencing and SNP arrays. The results of this pilot study will be instrumental in understanding the molecular make-up of globular and reticular naevus patterns with implications for early detection of melanoma. This will assist in assessing potential precursor lesions of melanoma, stratifying melanoma risk in a given individual.

2.

Tschandl, P., Berghoff, A.S., Presser, M. (2013). NRAS and BRAF mutations in melanoma-associated nevi and uninvolved nevi. PLoS one 8(7): e69639. 3. Marchetti, M.A., Kiuru, M.H., Busam, K.J. (2014). Melanocytic naevi with globular and reticular dermoscopic patterns display distinct BRAF V600E expression profiles and histopathological patterns. Br. J. Dermatol. 171(5): 1060–5. 4. Zalaudek, I., Guelly, C., Pellacani, G. et al. (2011). The dermoscopical and histopathological patterns of nevi correlate with the frequency of BRAF mutations. J. Invest. Dermatol. 131: 542–45. 5. McClenahan, P., Lin LL., Tan, J.M. et al. (2014). BRAFV500E Mutation Status of Involuting and Stable Naevi in Debrafenib Therapy With or Without Trametinib. JAMA Dermatol. 150(10): 1079–82.

A clinical audit of high-cost approved drugs in dermatology: 2003–2013 N. Ong1,2, E. McMeniman1,2, H.P. Soyer1,2 1 Dermatology Research Centre, The University of Queensland, School of Medicine, Translational Research Institute, Brisbane, Queensland, Australia 2 Department of Dermatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia Introduction: For challenging dermatological conditions, the use of high-cost drugs has become instrumental in the management of patients. High-cost drugs such as thalidomide and mycophenolate mofetil (MMF) have been approved in the treatment of patients with conditions such as prurigo nodularis and atopic dermatitis in a tertiary hospital Dermatology Outpatient clinic. Method: A retrospective clinical audit was undertaken for all high-cost drug applications for Dermatology patients at the Princess Alexandra Hospital, occurring between 2003 and 2013. As these medications are not subsidised by the Pharmaceutical Benefits Scheme, a High Cost Drugs Committee was responsible for the approval of the drugs. Data were collected from the High Cost Drugs Committee Meeting Minutes and individual patients’ medical records. Results: A total of 31 patients were presented to the Princess Alexandra Hospital High Cost Drugs Committee, with 29 of the applications approved. Approvals were granted in conditions with evidence in the literature for thalidomide in prurigo nodularis1 (3) and aphthous stomatitis2 (2); MMF in atopic dermatitis3 (9), psoriasis4 (3), pemphigus vulgaris4 (1) and pemphigus foliaceous4 (1); infliximab in hidradenitis suppurativa5 (2) and pyoderma gangrenosum6 (1); rituximab in pemphigus vulgaris7 (1); cyclosporin in chronic urticaria8 (1), lichen sclerosus (2) and lichen planopilaris (1); and adalimumab in hidradenitis suppurativa9 (1). Individual annual costs for these medications ranged from $2068.33 to $12, 327.84. Average duration of treatment and side effects were reported, as well as reasons for cessation of drug use. Efficacy was reviewed and cost-benefit analyses were undertaken.

References References 1.

Gandini, S., Sera, F., Cattaruzza, M.S. et al. (2005). Meta-analysis of risk factors for cutaneous melanoma: I. Common and atypical naevi. Eur. J. Cancer. 41: 28–44.

1.

Andersen, T.P. Fogh, K. (2011). Thalidomide in 42 patients with prurigo nodularis Hyde. Dermatology. 223(2):107–112.

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 2.

3.

4.

5.

6. 7.

8. 9.

Belenguer-Guallar, I., Jimenez-Soriano, Y., Claramunt-Lozano, A. (2014). Treatment of recurrent aphthous stomatitis: A literature review. J Clin Exp Dent. 6(2): e168–74. Plotz, S.G., Wiesender, M., Todorova, A., Rin, T. (2014). What’s new in atopic dermatitis/eczema? Expert Opin. Emerging Drugs. 19:3. George, L., Hamann, I., Chen, K., Choi, J., Fernandez-Peñas, P. (2013). An analysis of the dermatological uses of mycophenolate mofetil in a tertiary hospital. J Dermatolog Treat. [Epub ahead of print] Moriarty, B., Jiyad, Z., Creamer, D. (2014). Four-weekly infliximab in the treatment of severe hidradenitis suppurativa. Br J Derm. 170: 970–1001. Teagle, A., Hargest, R. (2014). Management of pyoderma gangrenosum. J R Soc Med. 107(6): 228–36. Ingen-Housz-Oro, S., Valeyrie-Allanore, L., Cosnes, A., Ortonne, N., Hue, S., Paul M., Wolkenstein, P., Chosidow, O. (2014). Firstline treatment of pemphigus vulgaris with a combination of rituximab and high-potency topical corticosteroids. JAMA Dermatol. doi: 10.1001/jamadermatol.2014.2421. [Epub ahead of print]. Amor, K.T., Ryan, C., Menter, A., (2010). The use of cyclosporine in dermatology: Part 1. JAMA Dermatol. 63(6): 925–46. Martin-Ezquerra, G., Masferrer, E., Masferrer-Niubo, M. et al. (2014). Use of biological treatments in patients with hidradenitis suppurativa. J Eur Acad Dermatol Venerol. doi: 10.1111/ jdv.12438. [Epub ahead of print].

Understanding longitudinal melanonychia G. Parham, J. von Nida Sir Charles Gairdner Hospital, Perth, Western Australia, Australia Longitudinal melanonychia is a brown or black pigment of the nail due to melanin in the nail plate. The concerning differential diagnosis is subungual melanoma, however other differentials include physiologic/systemic causes, inflammation, infections, drugs, benign melanocytic hyperplasia and trauma. We report a case of a 53 y/o woman who presents with insidious longitudinal melanonychia, and describe the causes and management of this condition which must be addressed with caution.

Linear erythematous cutaneous adverse reaction during intravenous Iloprost administration G. Parham, M. Reed Sir Charles Gairdner Hospital, Perth, Western Australia, Australia Iloprost is a synthetic prostacyclin analogue that may be used as treatment of a variety of conditions. This case describes a 65-year-old man with erythromelalgia who developed a linear erythematous cutaneous adverse reaction while receiving an Iloprost infusion. Uncertainty regarding this issue may result in delayed or cancelled administration, increased intervention and prolonged length of stay.

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Adult blaschkitis: an unusual unilateral presentation P. Peters1,2, H. Obermair3, J. Johnston1, V. Bhushan4, H.P. Soyer1,5 1 Dermatology Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia 2 School of Medicine, University of Queensland, St Lucia, Queensland, Australia 3 School of Medicine, University of Notre Dame Australia, Sydney, New South Wales, Australia 4 Rheumatology Department, The Canberra Hospital, Canberra, Australian Capital Territory, Australia 5 Dermatology Research Centre, The University of Queensland, School of Medicine, Translational Research Institute, Brisbane, Queensland, Australia A 31-year-old female presented to the dermatology outpatients department with a 10 day history of a unilateral erythematous rash extending from her right abdomen to her right heel. She reports it not being present when going to sleep but to have rapidly appeared overnight and being fully present the next morning. The lesion remained asymptomatic. The patient reported no significant medical history other than a recent viral upper respiratory tract infection. Examination revealed an extensive distribution, sharply demarcated in the midline and at the T4 level with extension to her ankle. Skin biopsy revealed a mild superficial perivascular lymphocytic infiltrate associated with occasional eosinophils. A diagnosis was made of adult blaschkitis. The patient was advised to apply emollients and following review at 4 weeks the lesion had begun to fade. This rare dermatosis is reported in some literature as an adult form of lichen striatus1,2 whilst others state it to be a separate entity3,4 with controversy existing regarding the actual definition. References 1.

Tejera-Vaquerizo A, Ruiz-Molina I, Solis-Garcia E, Moreno-Gimenez JC. [Adult blaschkitis (lichen striatus) successfully treated with topical tacrolimus]. Actas Dermosifiliogr. 2009 Sep; 100(7): 631–2. 2. Hofer T. Lichen striatus in adults or ‘adult blaschkitis’?. There is no need for a new naming. Dermatology. 2003; 207(1): 89–92. 3. Grosshans E, Marot L. [Blaschkitis in adults]. Ann Dermatol Venereol. 1990; 117(1): 9–15. 4. Brinkmeier T, Herbst RA, Schaller J, Kuegler K, Pirker C, Beiteke U et al. Drug-induced blaschkitis. Acta Derm Venereol. 2004; 84(4): 314–5.

Intermittent combined low-dose UVA1/narrow band UVB therapy for cutaneous T-Cell lymphoma/ Sezary syndrome: Report of a case and discussion of its implications L.K. Pitney1, M.J. Pitney2 1 Nambour General Hospital, Nambour, Queensland, Australia 2 Sherwood Road Dermatology, Toowong, Queensland, Australia A 74-year-old woman with long standing cutaneous T-Cell Lymphoma/Sezary Syndrome was referred to a private

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dermatology clinic for consideration of phototherapy after significant worsening of her condition. The patient lived a long distance from the clinic. The decision to treat her with intermittent courses of low-dose UVA1/Narrow Band UVB Therapy led to a dramatic improvement in her condition and quality of life. We reflect on how this may influence the treatment of similar patients into the future.

Scleredema of Buschke: A report of associated acute bowel obstruction and review of systemic complications L.K. Pitney1, M.J. Pitney2 1 Nambour General Hospital, Nambour, Queensland, Australia 2 Sherwood Road Dermatology, Toowong, Queensland, Australia Scleredema adultorum (Buschke) is a rare connective tissue disorder classically presenting in association with one of the following scenarios. Subtype 1: Post-Infective (often streptococcal) Subtype 2: Blood dyscrasias (commonly multiple myeloma) Subtype 3: Diabetic (usually type 2 and poorly controlled) Patients develop taut “unpinchable” thickened skin typically on the posterior neck, upper back and shoulders. Treatment options are limited but UVA1 Phototherapy has recently found favour. Systemic involvement and complications are infrequent. We present a 53-year-old diabetic male who while undergoing UVA1 Phototherapy for the condition, developed acute bowel obstruction necessitating laparotomy, as a result of retroperitoneal involvement of this scleredematous process. We further review the literature regarding reported significant complications, monitoring and management of this unusual condition.

Severe erosive lichen planus of the penis treated effectively with oral acitretin F. Poon1, R. De Cruz1,2, A. Hall2,3 1 Department of Dermatology, The Royal Melbourne Hospital, Parkville, Victoria, Australia 2 The Skin & Cancer Foundation Inc, Carlton, Victoria, Australia 3 Deakin University, Faculty of Medicine, Geelong, Victoria, Australia Lichen Planus (LP) is an incompletely understood T-cell mediated lichenoid dermatosis. When it affects the genitals, it can manifest as erythematous painful erosions – so called erosive LP. Vulval and penile LP can be exquistely painful, cause significant emotional distress, genitourinary and sexual dysfunction. They form common presentations to Sexual Health, Vulval and Men’s Health Dermatology Clinics across Australia. Management of this rare yet debilitating condition is often suboptimal. In 1991, oral acitretin was demonstrated to be effective in cutaneous and oral LP in a placebo-controlled randomised trial1 and small case series.2 Nevertheless, it features well below other immunsuppressive and immunomodulatory therapies such

as methotrexate and hydroxychloroquine. Herein, we present a case of severe penile erosive LP, successfully treated with oral acitretin, after systemic corticosteroids and ultrapotent topical corticosteroids failed to induce remission. We propose that acitretin should be considered earlier in the management of severe erosive LP. “Correction added on 6 May 2015, after first online publication. The word ‘acitreitin’ has been corrected to ‘acitretin’ in the abstract.”

References 1.

Laurberg G, Geiger JM, Hjorth N et al. Treatment of lichen planus with acitretin. A double blind, placebo-controlled study in 65 patients. J Am Acad Dermatol 1991; 24(3): 434. 2. A. Viglioglia, C.R. Villanueva, A.D. Martorano et al. Efficacy of acitretin in severe cutaneous lichen planus J Am Acad Dermatol 1990; 22(5): 852–3.

Return of the great masquerader: a review of the resurgence of Syphilis in Australia through clinical vignettes F. Poon1, J. Towns2, K. Berzins2, G. Varigos1, R. De Cruz1 1 Department of Dermatology, The Royal Melbourne Hospital, Parkville, Victoria, Australia 2 Melbourne Sexual Health Centre, Carlton, Victoria, Australia Syphilis is no longer considered a rare venereal disease harking back to the pre-antibiotic era. In 2013, Syphilis reached its highest rates in Australia ever, with 1765 new diagnoses –a 34 per cent increase since 2009.1 In fact national data suggests the rise in syphilis diagnoses has occurred steadily since 2002 with unprotected sex, including oral sex and skin-to-skin contact between males accounting for the majority of cases.1 Despite safer sexual practices that aim to prevent transmission of sexually transmitted infections, syphilis diagnoses continue to rise. Furthermore, with the increase in use of immunosuppressants in diseases and new biologics targeting the immune system, atypical presentations and masking of investigative tests are more reasons to have a heightened level clinical suspicion for syphilis. Recognition of the diverse clinical presentations of cutaneous syphilis remains vital for Sexual Health Physicians and Dermatologists alike. We present a review of up-to-date diagnosis, screening and management of syphillis in Australia, through a series of clinical vignettes.

References 1.

University of New South Wales Kirby Institute Annual Surveillance report of HIV, viral hepatitis and STIs. 2. Victorian Infectious Diseases Bulletin – Syphilis, 157–58.

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 The impact of an outpatients’ online handover tool: Timely follow-up and safe patient care in the Dermatology Department at the Royal Melbourne Hospital F. Poon1, R. Martyres1, A. Denahey2, G. Varigos1 1 Department of Dermatology, The Royal Melbourne Hospital, Parkville, Victoria, Australia 2 Department of Business Intelligence, The Royal Melbourne Hospital, Parkville, Victoria, Australia Introduction: Electronic medical record (EMR) systems have the potential to improve quality healthcare, patient safety and streamline workflow to potentially improve efficiency of a department.1,2 Drawbacks to using EMR systems could potentially impact on clinician-patient relationship, financial burden and training difficulties.1,2 Despite the current known benefits and difficulties of EMR systems, there is limited data on the impact and definable effectiveness it can have within a dermatology unit. We present an EMR system known as the ‘outpatients’ online handover tool’ (OHT) from its inception, delivery and audit of its use in evaluating the true impact of its use over a 6 month period. Method: An audit of the OHT was conducted during the period of 1st March–31st August 2014. Parameters assessed included quantitative data evaluating the amount of jobs entered and completed, including a breakdown of the type, number of overdue jobs and phone consults. Qualitative data were assessed via a short pilot survey assessing the users’ perspectives of the OHT evaluating communication, clinician-patient relationship and administrative tasks. Results: 754 jobs were entered for 411 dermatology outpatients using the OHT. Majority of entered jobs concerned follow up of bloods / swabs (38%) or biopsy results (36%). 51 jobs were not completed by the specified due dates and 188 phone consults were performed representing 20% of all entered jobs. User profiles encompassed residents, registrars, nurses and consultants with the residents completing 90% of all jobs. Comparison of clinic patients reviewed during this specified period compared with data for the same duration in 2013 revealed a 13% reduction where 3273 and 2878 patients were reviewed in clinic for the specified duration during 2013 and 2014 respectively. Survey results highlighted the majority of respondents felt this OHT improved communication within the department, did not affect clinician-patient relationship during review and felt more confident in their practice knowing there was a recordable system for patient follow up. Conclusion: The OHT at The Royal Melbourne Hospital dermatology department has provided a recordable timely system for follow-up of all patients reviewed by clinicians in clinic. It provides potential benefits from clinical, organisational and societal perspectives which has from our experience demonstrated improved patient follow-up, safety and care. Despite this, it must be acknowledged that during the initial implementation phase, the OHT may overawe some users at the beginning and may only improve workflow and safety if it is used correctly by all clinicians who work within the department.

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References 1.

Grosshandler JA, Tulbert MS, Kaufmann, MD et al. The electronic medical record in Dermatology. Arch. Dermatol. 2010; 146(9): 1031–36. 2. Walker JM. Electronic medical records and healthcare transformation. Health Aff (Millwood). 2005; 24: 1118–20.

Two cases of acute amoxycillin-induced follicular pustulosis H. Rajgopal Bala1, C. Jalilian1,2, M.S. Goh1,2, R. Williams3, A.H. Chong1,2 1 Skin and Cancer Foundation Inc, University of Melbourne, Melbourne, Victoria, Australia 2 Department of Dermatology, St Vincent’s Hospital, Melbourne, Victoria, Australia 3 Department of Anatomical Pathology, St Vincent’s Hospital and University of Melbourne, Melbourne, Victoria, Australia Localised pustular eruptions are rare and can occur as a result of drug exposure. Amoxycillin can cause a drug reaction manifesting as a sterile pustular eruption. We present two cases of Caucasian women who developed localised monomorphic pustulosis after exposure to amoxicillin. In both cases the rash resolved shortly after amoxicillin was ceased. A literature review revealed that most amoxicillin related pustular rashes were reported as an acute generalised exanthematous pustulosis (AGEP) or as an acute localised exanthematous pustulosis (ALEP). Histopathology for AGEP and ALEP commonly report non-follicular sterile pustules. Interestingly, the histopathology from both our cases showed a sterile suppurative folliculitis. Bacterial and viral swabs were negative. This case series illustrates an acute drug-induced pustulosis caused by amoxicillin. Given the lack of systemic symptoms and quick resolution of pustules post-cessation of amoxicillin, we concluded that these cases not only are related to amoxicillin exposure but present with novel histological features of suppurative folliculitis. Congenital Becker’s naevus – a case report and literature review S. Zagarella, J. Raymond Concord Repatriation General Hospital, Hospital Road, Concord, New South Wales, Australia We report a case of congenital Becker’s naevus in a 2-yearold girl. This is a rare presentation, with only 6 previously reported cases, and we discuss a literature review, and consider the main differentiating features from congenital smooth muscle hamartoma (CSMH). The associations, including the Becker’s naevus syndrome are also discussed. References 1.

Tymen R, Forestier JF, Boutet B, Colomb B. Nevus tardif de Becker. Ann Dermatol Venerol 1981; 108: 41–46.

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3. 4. 5. 6. 7.

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9. 10. 11.

12. 13. 14. 15. 16.

17. 18.

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Australasian Journal of Dermatology (2015) 56 Ingordo V, Gentile C, Iannazzone S et al. The ‘EpiEnlist’ project: a dermoepidemiologic study on a representative sample of young Italian males. Prevalence of selected pigmentary lesions. J Eur Acad Dermatol Venereol 2007; 21: 1091–6. Wharton J, Goodheart HP, Carlson JA. Congenital Becker’s nevus of the scalp. J Am Acad Dermatol 2002; 47: e191–4. Sood A, D’Souza P, Verma KK. Becker’s nevus occurring at birth and in early childhood. ActaDermVenerol 1998 Jul; 78(4): 311. Picascia DD, Esterly NB. Congenital Becker’s melanosis. Int J Dermatol 1989; 28: 127–8. Glinick SE. Congenital Becker’s Melanosis. J Dermatol Surg Oncol 1987 Jun; 13(6): 601. Book SE, Glass AT, Laude TA. Congenital Becker’s nevus with a familial association. Paediatric Dermatol 1997 Sept–Oct; 14(5): 373–5. Becker SW. Concurrent melanosis and hypertrichosis in distribution of nevus uniuslateris. Arch DermatolSyphil 1949; 60: 155–60. Puri S, Nanda S, Grover C et al. Congenital Becker naevus with lichen planus. Paediatr Dermatol 2005; 22: 328–30. Copeman PWM, Wilson Jones E. Pigmented hairy epidermal naevus (Becker). Arch Dermatol 1965; 92: 249–52. Joshi A, Garg VK, Agrawal S, Agarwalla A, Thakur A. Port-wine-stain (nevus flameus), congenital Becker’s nevus, café-au-lait-macule and lentigines: phakomatosispigmentovascularis type Ia – a new combination. J Dermatol 1999 Dec; 26(12): 834–6. Ro YS, Ko JY. Linear congenital Becker nevus. Cutis 2005; 75: 122–4. Bolognia JL, Orlow SJ, Glick SA. Lines of Blaschko. J Am Acad Dermatol 1994; 31: 157–90. Entwistle BR, Nurse DS. Becker’s melanosis and hypertrichosis. Australas J Dermatol 1967; 9: 198–203. Glinick SE, Alper JC, Bogaars H et al. Becker’s melanosis: associated abnormalities. J Am Acad Dermatol 1983; 9: 509–14. Moore JA, Schosser RH. Becker’s melanosis and hypoplasia of the breast and pectoralis major muscle. Pediatr Dermatol 1985; 3: 34–37. Bolognia JL, Jorizzo JL, Rapini RP, Dermatology 3rd Edition. Mosby, 2003; 1983. Johnson MD & Jacobs AH. Congenital smooth muscle hamartoma. A report of six cases and a review of the literature. 1989 Arch Dermatol Jun; 125(6): 820–2. Santos-Juanes J, Galache C, Curto JR et al. Acneiform lesions in Becker’s nevus and breast hypoplasia. Int J Dermatol 2002; 41: 699–700. Van Gerwen HJ, Koopman RJ, Steijlen PM, Happle R. Becker’s nevus with localized lipoatrophy and ipsilateral breast hypoplasia. Br J Dermatol 1993; 129: 213. Angelo C, Grosso MG, Stella P et al. Becker’s nevus syndrome. Cutis 2001; 68: 123–4. Hoon Jung, Chan Kim Y, Joon Park H, Woo Cinn Y. Becker’s nevus with ipsilateral breast hypoplasia: improvement with spironolactone. J Dermatol 2003; 30: 154–6. Urbani CE. Paradominant inheritance, supernumerary nipples and Becker’s nevus: once again. Eur J Dermatol 2001; 11: 597. Jones AC, Ford MJ. Simultaneous occurrence of segmental odontomaxillary dysplasia and Becker’s nevus. I Oral Maxillofac Surg 1999; 57: 1251–4. Angelo C, Grosso MG, Stella P et al. Becker’s nevus syndrome. Cutis 2001; 68: 123–4. Happle R, Koopman RJ. Becker nevus syndrome. Am J Med Genet 1997; 68: 357–61. Danarti R, Konig A, Salhi A et al. Becker’s nevus syndrome revisited. J Am Acad Dermatol 2004; 51: 965–9.

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Parasramani SG, Aurangabadkar S. Use of Lasers for Becker’s Naevus and Keratosis Pilaris. J Cutaneous Aesthetic Surg 2008; Jul–Dec; 1(2): 112.

Familial melanoma and links with other cancers J. Read1,2, N.K. Hayward1 1 QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia 2 The University of Queensland, Brisbane, Queensland, Australia Approximately 10% of melanoma cases report an affected relative, and a positive family history is associated with an increased risk of developing melanoma. Although the majority of genetic alterations underlying melanoma are sporadic, the presence of heritable melanoma risk genes is an important component to disease susceptibility for some families. In addition to cutaneous melanoma, some predisposition genes have been linked to other cancers, with cancer clustering observed in melanoma families at rates greater than expected by chance. The most extensively documented association is between cyclin-dependent kinase inhibitor 2A (CDKN2A) and pancreatic cancer, and a cancer syndrome including cutaneous melanoma, uveal melanoma, and mesothelioma has been proposed for BRCA1-associated protein-1 (BAP1) mutations. Other rare but highly penetrant melanoma predisposition genes have been connected with additional cancers, including renal cell carcinoma and glioma. In a cohort of 180 families originally ascertained as part of the Queensland Familial Melanoma Project, follow up has revealed the development of further melanomas as well as additional non-melanoma cancer types. In these families, an over-representation of other cancers has been observed, particularly haematological malignancies, renal cell carcinoma, and thyroid cancer. Associations between melanoma and other cancers hint at the possibility of common pathways for oncogenesis, and may improve our understanding of the genetic basis underpinning familial melanoma. In the future, it is plausible that melanoma risk genes could be used for both melanoma and the other cancers they influence in terms of genetic counseling.

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 Apremilast, an oral phosphodiesterase 4 inhibitor, in patients with moderate to severe psoriasis: 52-week results of the ESTEEM 2 Trial C. Paul1, M. Gooderham2, J. Cather3, Y. Poulin4, G. Girolomoni5, C. Ferrandiz6, A.B. Gottlieb7, U. Mrowietz8, CC. Hu9, R.M. Day9, S. Richter10, J. Crowley11 1 Toulouse University, Hôpital Larrey, Toulouse, France 2 SKiN Centre for Dermatology, Peterborough, Ontario, Canada 3 Modern Research Associates, Dallas, Texas, USA 4 Centre de Recherche Dermatologique du Québec métropolitain, Québec, Québec, Canada 5 University of Verona, Verona, Italy 6 Hospital Germans Trias i Pujol, Barcelona, Spain 7 Tufts Medical Center, Boston, Massachusetts, USA 8 University Hospital Schleswig-Holstein, Kiel, Germany 9 Celgene Corporation, Warren, New Jersey, USA 10 Celgene Corporation, Melbourne, Victoria, Australia 11 Bakersfield Dermatology, Bakersfield, California, USA In ESTEEM 2, 413 patients with moderate to severe plaque psoriasis (PASI ≥ 12, BSA ≥ 10%, sPGA ≥ 3) were randomized (2:1) to apremilast 30 mg BID (APR30) or placebo. At Week 16, placebo patients switched to APR30. At Week 32, APR30 patients who achieved PASI-50 were re-randomized (1:1) to continue APR30 or receive placebo. Upon loss of 50% of PASI improvement obtained at Week 32 (loss of response), patients re-randomized to placebo resumed APR30. At Week 16, significantly more APR30 patients achieved PASI-75 (28.8%) and PASI-50 (55.5%) vs. placebo (5.8% and 19.7%, respectively; P < 0.0001). Mean/ median percent change from baseline in PASI was −50.9/56.0% (APR30) vs. −15.8%/-18.0% (placebo; P < 0.0001, mean change). PASI responses were generally maintained through Week 32. Similar PASI responses were achieved at Week 32 in placebo/APR30 patients. 80.3% of patients re-randomized to APR30 at Week 32 achieved PASI-50 at Week 52; mean percent change from baseline in PASI was −73.5% to −76.7% (Weeks 32–52). Median time to loss of response in patients re-randomized to placebo was 12.4 weeks. 65.6% of patients re-randomized to placebo who lost response regained PASI-50 response after restarting APR30. AE incidence did not increase over time. Nausea, diarrhea, nasopharyngitis, and upper respiratory tract infection were the most frequently reported AEs. Most AEs were mild/ moderate and did not lead to discontinuation. There were no clinically meaningful changes in laboratory parameters. Over 52 weeks, APR30 was effective for moderate to severe plaque psoriasis. APR30 demonstrated an acceptable safety profile and was generally well tolerated.

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Apremilast, an oral phosphodiesterase 4 inhibitor, in patients with nail, scalp, and palmoplantar psoriasis: 52-week ESTEEM 2 study results J. Crowley1, M. Gooderham2, N. Wasel3, J. Weisman4, S. Tyring5, CC. Hu6, R.M. Day6, S. Richter7, C. Ferrandiz8 1 Bakersfield Dermatology, Bakersfield, California, USA 2 SKiN Centre for Dermatology, Peterborough, Ontario, Canada 3 Probity Medical Research and Stratica Medical, Edmonton, Alberta, Canada 4 Peachtree Dermatology Associates, Atlanta, Georgia, USA 5 Department of Dermatology, University of Texas Health Science Center at Houston, Houston, Texas, USA 6 Celgene Corporation, Warren, New Jersey, USA 7 Celgene Corporation, Melbourne, Victoria, Australia 8 Hospital Germans Trias i Pujol, Barcelona, Spain 413 patients with moderate/severe plaque psoriasis (PASI ≥ 12, BSA ≥ 10%, sPGA ≥ 3) were randomized (2:1) to apremilast 30 mg BID (APR30) or placebo. At Wk16, placebo patients switched to APR30 (placebo/APR30). At Wk32, APR30 patients achieving PASI-50 were re-randomized (1:1) to continue APR30 or receive placebo. Upon loss of 50% of PASI improvement obtained at Wk32, patients re-randomized to placebo resumed APR30. At baseline, 64.7% of patients had nail psoriasis (NAPSI ≥ 1), 65.5% had moderate to very severe scalp psoriasis (ScPGA ≥ 3), and 10.2% had moderate/severe palmoplantar psoriasis (PPPGA ≥ 3). At Wk16, significantly more patients receiving APR30 achieved PASI-75 (28.8%) and PASI-50 (55.5%) vs. placebo (5.8% and 19.7%; P < 0.0001). At Wk16, mean percent change from baseline in NAPSI was significantly greater with APR30 (−29.0%) vs. placebo (−7.1%; P = 0.0052); at Wk32, mean percent changes in NAPSI were −60.0% (APR30/APR30) and −47.6% (placebo/APR30). Mean percent change in NAPSI was −59.7% for re-randomized patients continuing APR30 to Wk52 (APR30/APR30/APR30). At Wk16, ScPGA ≤1 achievement was significantly greater with APR30 (40.9%) vs. placebo (17.2%; P < 0.0001). ScPGA ≤1 achievement was 32.4% (APR30/APR30) and 50.7% (placebo/APR30) at Wk32 and 54.1% (APR30/APR30/APR30) at Wk52. At Wk16, PPPGA ≤1 achievement was significantly greater with APR30 (65.4%) vs. placebo (31.3%; P = 0.0315). PPPGA ≤1 achievement was 53.8% (APR30/APR30) and 69.2% (placebo/APR30) at Wk32 and 100.0% (APR30/ APR30/APR30) at Wk52. Most common AEs were nausea, diarrhea, nasopharyngitis, and URTI. APR30 significantly reduced the severity of nail, scalp, and palmoplantar psoriasis at Wk16, with improvements to Wk52 for patients continuing APR30 from baseline.

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Scabies and impetigo prevalence and risk factors in Fiji: a national survey L. Romani1, J. Koroivueta2, A.C. Steer3, M. Kama4, J.M. Kaldor1, H. Wand1, M. Hamid5, M.J. Whitfeld6 1 Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia 2 Ministry for Social Welfare, Fiji 3 Centre for International Child Health, University of Melbourne, Victoria, Australia 4 Ministry of Health, Fiji 5 Mugda 500 Bed General Hospital, Dhaka, Bangladesh 6 Department of Dermatology, St Vincent’s Hospital, Sydney, New South Wales, Australia Background: Scabies is recognised as a major public health problem in many countries, and is responsible for significant morbidity due to secondary bacterial infection of the skin causing impetigo, abscesses and cellulitis, that can in turn lead to serious systemic complications such as septicaemia, kidney disease and potentially rheumatic heart disease. Despite the apparent burden of disease in many countries there have been few large scale surveys of scabies prevalence or risk factors. We undertook a populationbased survey in Fiji of scabies and impetigo to evaluate the magnitude of the problem and inform public health strategies. Methods: A total of 75 communities, including villages and settlements in both urban and rural areas were randomly selected from 305 communities across the four administrative divisions, and all residents in each location invited to participate in skin examination by trained personnel. Results: The study enrolled 10,887 participants. The prevalence of scabies was 23.6%, and when adjusted for age structure and geographic location based on census data, the estimated national prevalence was 18.5%. The prevalence was highest in children aged five to nine years (43.7%), followed by children aged less than five (36.5%), and there was also an indication of prevalence increasing again in older age. The prevalence of scabies was twice as high in iTaukei (indigenous) Fijians compared to Indo-Fijians. The prevalence of impetigo was 19.6%, with a peak in children aged five to nine years (34.2%). Scabies was very strongly associated with impetigo, with an estimated 93% population attributable risk. Conclusions: As far as we are aware, this is the first national survey of scabies and impetigo ever conducted. We found that scabies occurs at high levels across all age groups, ethnicities and geographical locations. Improved strategies are urgently needed to achieve control of scabies and its complications in endemic communities. Cognitive function in patients with psoriasis while on biologic therapies: pilot study A. Ross, G. Varigos, A. Braue, D. Darby, A. Gorelik University of Melbourne, Royal Melbourne Hospital, Melbourne, Victoria, Australia Background: An understanding of the immunopathogenesis of psoriasis has led to the discovery of novel biologic

agents that alter the TNF-α pathway to treat psoriasis. No studies looking at shared pathways between psoriasis and cognition have been able to illustrate a clear link between the two. We aim to investigate a potential link between psoriasis and cognition. We hypothesise that participants with psoriasis treated with biologic agents will achieve higher cognitive scores than those treated with non-biologic agents. Methods: Royal Melbourne Hospital Dermatology outpatients currently receiving biologic (n = 19) and non-biologic (n = 4) treatment for psoriasis were asked to complete the CogState Brief Battery, a game-like computerised cognitive performance test designed to be useful in evaluations of cognitive function. The results of this test will be compared to participant haemoglobin results, Psoriasis Area and Severity Index scores and Dermatology Life Quality Index Questionnaire results to further investigate the effect psoriasis may have on cognition. Results: Participants on biologic therapies achieved significantly higher scores than participants on non-biologic therapies on the one Card Learning Task, which focuses on visual learning and memory. Conclusions: Despite the small sample size of the nonbiologic group, this pilot study may help clarify whether there is a significant link between psoriasis and cognitive impairment, and whether biologic therapies may potentially lessen the effect psoriasis has on cognition.

Psychological impact of chronic childhood skin disease on caregivers and families: a review C. Rowe1,2, L. Byrom1, J.Scott2, T. Zappala1 1 Dermatology Department, Mater Childrens Hospital, Mater Misericordiae Health Services, Brisbane, Queensland, Australia 2 The University of Queensland Centre for Clinical Research, Herston, Queensland, Australia For paediatric patients it is accepted that chronic skin disease and its management has a significant negative impact on the child’s quality of life. However, there is less attention paid to the impact on the family unit. The implications for the child’s caregiver and family also need to be highlighted and considered when formulating a comprehensive management plan for the child. In this review we will summarise the literature to date on what is currently known about the impact of childhood skin disease, such as atopic dermatitis, on the family. We will do this in four sections: section one will include the types of impact thought to be affecting families and caregivers (financial, psychological, physical, and social functioning); section two will describe the current assessment tools used to grade and monitor this impact; section three reflects back on the impact these system breakdowns have on the child (treatment adherence, relationships etc); section four explores the different support and education programs that are in place to address this. Finally we will discuss the future directions revealed by this review.

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 Immune cell infiltrate subtypes inform on melanoma survival in stage Ib and II melanomas C. Rowe1,2, F. Tang3, M. Rodero1, M. Malt4, D. Lambie5, M. Smithers6, A. Green4, K. Khosrotehrani1,2 1 The University of Queensland Centre for Clinical Research, Herston, Queensland, Australia 2 The University of Queensland Diamantina Institute, Translational Research institute, Woolloongabba, Queensland, Australia 3 Department of Anatomical Pathology, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia 4 QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia 5 IQ Pathology, West End, Brisbane, Queensland, Australia 6 Princess Alexandra Hospital Melanoma Unit, Woolloongabba, Queensland, Australia Introduction: Despite the current staging guidelines for melanoma, there remains a significant level of variability in prognosis for patients with locally invasive disease, requiring identification of additional prognostic factors. Methods: Proteins associated with major elements of the tumour microenvironment and immune response, suspected to influence progression were analysed by immunohistochemistry. Melanoma tissue samples were collected from a cohort of melanoma patients (Stage Ib and II) referred for sentinel lymph node biopsy at the Princess Alexandra Hospital between 1998–2007. Information on disease progression was obtained prospectively until February 2013 and information on death was obtained through the National Death Index. Results: 189 tissue samples were obtained. Average Breslow thickness was 2.5 mm. 52 patients had recurrent disease and 32 patients died from melanoma during the follow up period. High expression of Ki67 was associated with reduced disease free survival (HR2.26, p = 0.011). Regarding the tumour immune response, high infiltration of FoxP3 expressing regulatory T cells or high levels of cytokine receptor signalling revealed by Phospho-STAT5 staining were not associated with survival. However, on multivariate analysis, high CD163 expressing cell infiltration reflecting M2 tumour associated macrophages was associated with increased risk of recurrence and melanoma specific death (HR2.204, p = 0.014, HR3.108, p = 0.005 respectively), independently from known prognostic markers. Conclusions: CD163 a macrophage marker, predict survival in patients with stage Ib and II cutaneous melanoma unlike other markers of immunosuppression. The identification of new, independent prognostic markers will allow for the identification of high risk patients, permitting a more targeted, personalised treatment approach for patients.

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A review on uncommon malignancies associated with dermatomyositis A. Sahebian1,2, P. Peters2,3 1 Dermatology Research Centre, School of Medicine, The University of QLD, Brisbane, Queensland, Australia 2 Dermatology Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia 3 The University of Queensland, School of medicine, Brisbane, Queensland, Australia Dermatomyositis is a multisystem disorder mainly affecting skin, muscle and blood vessels in which characteristic erythematous and oedematous changes in the skin are usually associated with muscle weakness and inflammation. Malignancy is associated with dermatomyositis in 23% to 43% of adult patients, highly supporting the paraneoplastic nature of this disease. Malignancy can occur before, concomitantly or after the onset of myositis. The diagnosis of dermatomyositis must lead to a meticulous search for an associated cancer. The malignancies most commonly associated with dermatomyositis are carcinomas of the ovary, lung, stomach, colorectal, pancreas and nonHodgkin’s lymphoma. We review the literature for less common malignancies associated with dermatomyositis. Dermatologists, as a part of a multidisciplinary team involved in the treatment of dermatomyositis need to be familiar with the appropriate investigations including full malignancy screening based on the age and the gender of their patients. Prevalence of actinic keratosis and the risk factors for skin cancer in lung transplant recipients in Queensland, Australia A. Sahebian1,2, C. Morze1, M. Grant3, P. Hopkins3,4, S. Yerkovich3, D. Chambers3,4, H. P Soyer1,2 1 Dermatology Research Centre, The University of Queensland, School of Medicine, Translational Research Institute, Brisbane, Queensland, Australia 2 Dermatology Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia 3 Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Queensland, Australia 4 The University of Queensland, School of Medicine, Brisbane, Queensland, Australia Introduction: The general population and organ transplant recipients (OTR) in Queensland, Australia, have the highest prevalence of actinic keratosis (AK) and nonmelanoma skin cancer (NMSC) in the world. The presence of AK has been identified as the most important risk factor for development of squamous cell carcinoma (SCC). Nonmelanoma skin cancer risk and especially SCC risk, increases significantly after transplant. There are currently no published studies concerning the prevalence and risk factors for AK in lung transplant recipients in Queensland. Our aim was to investigate the prevalence and risk factors for AK in this population. Methods: 122 lung transplant recipients were examined at Prince Charles Hospital, Brisbane, Australia. Patients completed a questionnaire in regard to the risk factors of actinic keratosis. A trained examiner completed a full skin examination.

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Results: The prevalence of actinic keratosis in our study population is 61%. In terms of anatomical body sites, AKs found to be more prevalent on sun exposed areas. Out of 72 patients with ≥1 AK, 47% were transplanted because of COPD (P < 0.001). Patients with ≥1 AK had a slightly longer time post-transplant. Among 72 patient with ≥1 AK, 42 (58%) reported a history of at least one NMSC (P < 0.001). Compliance with the sun protection measures was found to be poor. We found a positive correlation between the number of AK and age. The burden of actinic keratosis, which is a strong predictor of squamous cell carcinoma remains high in lung transplant recipients. Skin cancer education, compliance with photoprotection measures and regular skin surveillance should be specifically targeted at this high risk group to reduce the burden of AK and NMSC. Palisading neutrophilic granulomatous dermatitis secondary to a novel anti-diabetic medication, dapagliflozin R.B. Saunderson, C. McKay Department of Dermatology, John Hunter Hospital, Newcastle, New South Wales, Australia Palisading neutrophilic granulomatous dermatitis describes the histological appearance of a rare skin disorder associated with a number of autoimmune, inflammatory and malignant conditions. We describe the first case of this condition secondary to the novel anti-diabetic drug, dapagliflozin. Antibiotic therapy for Staphylococcus aureus colonised vascular catheter tips and the occurrence of bacteraemia – implications for hospital policy R.B. Saunderson, E.J.P. Cartwright, D. Limmathurotsakul, S.J. Peacock, M.E. Török Abstract withdrawn. Correction made here after initial online publication April 2, 2015. There is ongoing revision of this work and further statistics may need to be undertaken. Therefore it would not be appropriate for this work to be published at the current time.

Sun protection practices of undergraduate university students A. Shahnam1, I. Samarawickrema2, S. Ali3 1 Medical School, The Australian National University, Canberra, Australian Capital Territory, Australia 2 Visiting Fellow, Research School of Population Health, ANU, Canberra, Australian Capital Territory, Australia 3 The Canberra Hospital, Canberra, Australian Capital Territory, Australia Introduction: Currently, there are no published reports to identify gaps in the sun protection practices of university students in Australia to guide future sun protection campaigns Methods: This cross-sectional study assessed undergraduate university students’ use of five sun protection practices (sunscreen, hat, sunglasses, shade and clothing) whilst outdoors. Emails containing links to the online questionnaire were sent to 3341 randomly selected students from all academic areas aged 18–24 years. Those who travelled to a winter location were excluded. The response rate was 19% and 507 students met the inclusion criteria. Results: Mean age of the sample was of 20.5 years (Standard deviation ±1.9). Any method of sun protection was used always or often by 32% of respondents. Majority used 0.05) who achieved EQ-5 D VAS response at week 12. Conclusions: Results showed a meaningful reduction of the DLQI associated with better improvements in objective skin clearing (PASI90 versus PASI75).

Use of mobile app for patient information in solid organ transplantation – minimising gaps in patient education S. Sinnya1, A. Finnane2, H.P. Soyer1 1 Dermatology Research Centre, The University of Queensland, School of Medicine, Translational Research Institute, Brisbane, Queensland, Australia 2 Centre of Online Health, Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Queensland, Australia Patient education is a process of enabling individuals to make an informed decision about their health-related behaviours.1 This is extremely important element in health care as it empowers individuals to participate in improving their own health through better understanding about their disease processes and thus improves compliance. Traditionally this was done via verbal or written means but in this information age, there have been significant technological advancements that have enabled us to use Internet-based technologies to access information at ease. Solid organ transplant recipients (SOTRs) are at an increased risk of getting a range of malignancies of which cutaneous malignancies are the most pronounced. Given the need for ongoing education and reinforcement of photoprotection and skin surveillance behaviours, we explored the concept of using a mobile app device for provision of such information to improve compliance amongst patients in Queensland, Australia. The next step in the process would be to test the mobile app to test if this resource improves compliance and overall patient satisfaction. Reference 1.

Naldi L, Sassi F. (2009) Evaluation of Patient Education. In: Stockfleth E, Ulrich C, Euvard S, Proby C, Bouwes Bavinick JN, Geissler EK (ed) Skin Cancer after organ Transplantation. Springer, 23–41.

Emergence of squamous cell carcinomas post-Nilotinib therapy for chronic myelogenous leukemia – a rare adverse effect of a second-generation tyrosine kinase inhibitor S. Sinnya1,2, P. Peters2, D. Rabbolini3, K. Khosrotehrani4, G. Wagner5 1 Dermatology Research Centre, The University of Queensland, School of Medicine, Translational Research Institute, Brisbane, Queensland, Australia 2 Dermatology Department, The Princess Alexandra Hospital, Brisbane, Queensland, Australia 3 Haematology Department, The Canberra Hospital, Garran, New South Wales, Australia 4 The University of Queensland Diamantina Institute, Translational research Institute, Brisbane, Australia 5 Queensland Institute of Dermatology, Brisbane, Queensland, Australia Nilotinib is a second-generation Bcr-Abl tyrosine kinase inhibitor, used in the treatment of chronic myelogenous

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 leukaemia resistant to imatinib. Numerous cutaneous adverse events have been noted with Nilotinib such as pruritus, drug eruption, skin papillomas and dry skin to name a few. We report the case of a 72-year-old female who in the year post-commencement of Nilotinib developed 8 squamous cell carcinomas on her lower limbs. This is a previously unreported adverse reaction to Nilotinib and highlights the need for evaluation of risk factors for patients needing this therapy as well as close surveillance for possible development of these malignant lesions.

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Assessment of the attitude of dermatologists to the use of topical corticosteroids in paediatric atopic dermatitis S.D. Smith1,2,3, A. Lee2, A. Blaszczynski4, G. Fischer2,3 1 The Dermatology and Skin Cancer Centre, Gosford, New South Wales, Australia 2 Department of Dermatology, Royal North Shore Hospital, Sydney, New South Wales, Australia 3 Northern Clinical School, Sydney Medical School, University of Sydney, New South Wales, Australia 4 School of Psychology, University of Sydney, New South Wales, Australia

Reference 1.

Kantarjian HM, Giles F, Gattermann N, Bhalla K, Alimena G, Palandri F, Ossenkoppele GJ, Nicolini FE, O’Brien SG, Litzow M, Bhatia R, Cervantes F, Haque A, Shou Y, Resta DJ, Weitzman A, Hochhaus A, le Coutre P (2007) Nilotinib (formerly AMN107), a highly selective BCR-ABL tyrosine kinase inhibitor, is effective in patients with Philadelphia chromosome-positive chronic myelogenous leukemia in chronic phase following imatinib resistance and intolerance. Blood 110: 3540–6.

Cutaneous melioidosis E.J. Smith, B.J. Currie Global and Tropical Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia Burkholderia pseudomallei is a soil dwelling bacteria that is endemic in northern Australia. It causes melioidosis- a severe infection with a wide range of clinical presentations. It is a common cause of pneumonia, sepsis and death in this region. Primary cutaneous melioidosis occurs in 12% of melioidosis patients and lesions are highly variable in size and appearance- from dry or crusted lesions to abscesses. Secondary cutaneous melioidosis associated with sepsis may present with extensive skin pustulosis. The most significant risk factor for melioidosis is diabetes. Other known risk factors include immunosuppression, chronic renal and lung disease and excess alcohol use. Patients with primary skin melioidosis tend to be younger, less unwell, have less risk factors and have better outcomes than patients with other forms of melioidosis. Patients with pre-existing skin disease may be at increased risk of contracting cutaneous melioidosis whilst travelling in northern Australia due to immunosuppressive therapy or pre-existing compromised skin barrier function. Dermatologists in any part of the country may be asked to review unidentified lesions in a patient who has recently visited northern Australia. Therefore, it is vital for Australian dermatologists to be familiar with cutaneous melioidosis as a cause of skin disease to ensure timely diagnosis and optimal treatment commencement.

Background: Atopic dermatitis is the most common paediatric dermatology condition with topical corticosteroids (TCS) critical in its management. Treatment adherence issues lead to poor outcomes. Dermatologists play a key role to educate parent/patients about the use, safety and efficacy of TCS Objectives: To assess current attitudes and experience of practicing dermatologist about the use and safety of TCS in managing paediatric atopic dermatitis (pAD). Methods: 455 Australian-based practicing dermatologist surveyed at the Australasian College of Dermatologists (ACD) Annual Scientific Meeting May 2014 and two subsequent follow up emails. The survey assessed as to their attitude towards the use and safety of TCS in treatment pAD. Results: Overall response rate was 43.5% (198 out of 455). Of the completed survey’s, 98.9% were filled completely with participant responses excluded if there was no answer, or if there were multiple answers. Of responders, 52% write 6–10 for TCS daily. Dermatologists prescribe potent (17.7%) or superpotent (80.3%) as their strongest TCS. Periorificial dermatitis (69.2%) was the most common side effect sighted with only 5.6% sighting cutaneous atrophy. The surveyed dermatologist state pharmacists (64.2%) are the most common source of TCS phobia. The majority (75.8%) strongly agree with the statement that if used as directed at an appropriate dose and time for skin site and severity of disease, topical corticosteroids are very unlikely to cause cutaneous atrophy. Furthermore, 50.5% strongly agree with the statement that the term sparingly should not be written on the label of prescribed tubes of topical corticosteroid Conclusions: The experience dermatologists have with TCS enables them to educate parent/patients about the use and safety of TCS and dispelling the fears about TCS. This protects parent/patients from misinformation from pharmacists who are seen as the main contributor patient/ parent TCS phobia.

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Assessment of attitudes towards sun-protective behaviour in Australia: a cross-sectional study A. Lee1, K.B. Garbutcheon-Singh1, S. Dixit1, P. Brown1,2, S.D. Smith1,3,4 1 Deparment of Dermatology, Royal North Shore Hospital, Sydney, New South Wales, Australia 2 Northern Beaches Dermatology, Mona Vale, New South Wales, Australia 3 The Dermatology and Skin Cancer Centre, Gosford, New South Wales, Australia 4 Discipline of Dermatology, Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia Objective: To assess the knowledge, attitudes, and behaviours towards sun protection measures in an Australian population of adults. Design and setting: A multicentre cross-sectional study was undertaken during 2014 using a population-based survey of 416 individuals over the age of 18. Outcome measures: The knowledge, behaviour and attitudes regarding sun protection measures amongst a group of adults were assessed. The impact of educational level and employment status on responses was also evaluated. Results: Sunscreen is the most common sun protective measure. Daily sunscreen use is below 20%. Forgetfulness was the largest barrier to sunscreen use. 85% of individuals did not apply a sufficient amount of sunscreen. Only 32% of individuals reapplied sunscreen every two hours and 20% of individuals never reapplied. In the preceding year, one or more sun burns were suffered by 46% of individuals in the survey. 36% of individuals rarely or never check their sunscreens expiry date and less than 50% of individuals replaced their sunscreen each year. Also 65% were unaware that sunscreens stored above 25°C were less effective. Conclusions: This study highlights a number of significant deficiencies that future sun-protection programs could target in order to improve the general public’s knowledge and attitudes towards sun-protection. There is also a need for this to be translated into sun-protection behaviours that are implemented by the public.

Trends In thickness and survival of primary in situ and invasive cutaneous melanoma In Victoria, Australia S.L. Smithson1, J.R. Thomson2, Y. Pan1, V. Mar1, H. Roberts1, R. Wolfe1,2, J.W. Kelly1 1 Victorian Melanoma Service, The Alfred Hospital, Melbourne, Victoria, Australia 2 Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia Background: Australia has the highest incidence of melanoma in the world, with >12,500 new cases diagnosed every year. We have previously shown in Victoria, nodular melanoma (NM) accounted for 43% of all melanoma deaths, despite only attributing 13.5% to total melanomas.

Methods: Four separate population case series were retrospectively collected from a database that included all cases of melanoma reported to the Victorian Cancer Registry (VCR) from 1989–2004. Trends in survival were estimated. Results: A total 5775 cases of primary invasive and 3649 in-situ melanomas were reported. Incidence of all types of melanoma increased over time, with a marked increase in the proportion of in-situ melanomas from 33% in 1989, to 43% in 2004. Incidence of thick (>4 mm) NM increased by 3.8% per annum, with the majority of that increase occurring in the ≥70-year age group. Median thickness of NM at diagnosis was 2.6 mm, compared to invasive non-NM, 0.6 mm. Thickness of NM increased by +1.2% per annum (95%CI = 0.2–2.2, p = 0.01) from 1989–2004. Thickness of non-NM remained stable (APC −0.3% [95%CI = −0.70–−0.10, p = 0.17]) with a trend for improved survival (HR = 0.98 [95%CI = 0.97–1.00, p = 0.08]). Conclusion: Diagnosis of in-situ melanomas has increased, in part explaining a trend towards improved survival of non-NM. Early detection of NM remains challenging, with a significant increase in the mean thickness of this subtype over time. Whilst public health education and improved screening has led to improved diagnosis of in-situ lesions, greater awareness and earlier detection of NM is still required to reduce melanoma mortality.

Prognosis of melanoma of unknown primary S.L. Smithson1, Y. Pan1, M. McGuinness2, P. McDonald1, C.A. McLean3, J. Kelly1 1 Victorian Melanoma Service, The Alfred Hospital, Melbourne, Victoria, Australia 2 Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia 3 Department of Anatomical Pathology, The Alfred Hospital, Melbourne, Victoria, Australia Background: Melanoma of unknown primary is the finding of melanoma metastasis without a detectable primary melanoma. Literature suggests better survival of melanoma unknown primary, when compared to metastatic melanoma with a known primary (stage III/IV disease).1 Methods: Patients coded as melanoma of unknown primary were identified and reviewed from a prospectively maintained database at The Victorian Melanoma Service. Melanoma-specific mortality was obtained from the Victorian Cancer Registry. Kaplan-Meier survival estimates were used to compare mortality variables, and Cox-proportional hazard models estimated trends in survival. Results: A total of 117 patients were identified. Median follow-up was 78 months. Types of melanoma of unknown primary were categorised as visceral (29%) nodal (42%) or cutaneous (29%). There were 51 deaths from melanoma, with a median time to death, from date of diagnosis, of 14 months. Overall melanoma-specific 5-year survival was 54%. Visceral 5-year survival was 24.3% (95%CI: 10.7– 40.8), nodal was 56.6% (95%CI: 40.4–70.0) and cutaneous 83.9% (95%CI: 62.3–93.7). There was a significant difference between stage III (cutaneous and nodal) [73.7%

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 (95%CI:60.5–83.1)] and stage IV (visceral) [24.7% (95%CI:12.7–38.80] 5-year survival rates (p < 0.0001). Conclusion: Patients presenting with all types of melanoma of unknown primary had a better 5-year survival as compared to published stage-IIIc and IV melanoma of known primary disease.

Reference 1.

Lee CC, Faries MB, Wanek LA et al. Improved survival for stage IV melanoma from an unknown primary site. J Clin Oncol 2009; 27(21): 3489–95.

Porphyria cutanea tarda in a patient on haemodialysis and iron deficiency P. Sobarun, A. Oakley Department of Dermatology, Waikato Hospital, Hamilton, New Zealand Porphyria cutanea tarda (PCT) is the most common type of porphyria that results from an acquired or inherited defect or deficiency of the enzyme uroporphyrinogen decarboxylase. Acquired PCT is more common and at least 80%1 of cases have hepatic iron overload. PCT has been described in dialysis patients. The prevalence of iron overload in this subgroup is unknown. In anuric patients, the diagnosis is made on fractionation of serum porphyrins.2 A 54-year-old Maori male with end-stage renal failure from diabetic nephropathy on home haemodialysis for 4 years developed PCT with typical clinical and histopathological features. Porphyrin screen was positive in blood, urine and faeces. Ferritin level was 8 ng/L and haemoglobin was 115 g/L. Hepatitis C serology was negative. Dialysis was changed to high flux and the haemodialysis lines were discarded, resulting in blood loss of 200–300 ml three times/ week. Blisters and skin fragility resolved within a few weeks. Severe generalised pruritus arose within 3 weeks of change of dialysis regime and was successfully managed with gabapentin 200 mg daily. He is being assessed for renal transplantation. This case illustrates that PCT presents management challenges in dialysis patients with iron deficiency. Phlebotomy is contraindicated in iron deficiency anaemia and iron replacement is contraindicated in PCT. Hydroxychloroquine is ineffective.3 Iron deficiency contributes to renal pruritus, which affects up to 42%4 of haemodialysis patients. Phototherapy for renal pruritus is contraindicated in PCT. Renal transplant is potentially curative in cases refractory to medical treatment3.

References 1.

McKane, W., Green, C. A., & Farrington, K. (2001). Porphyria cutanea tarda precipitated by intravenous iron in a haemodialysis patient. Nephrology Dialysis Transplantation, 16(9), 1936–38.

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2.

Ruggian, J. C., Fishbane, S., Demento, F. J., Maesaka, J. K., & Frei, G. L. (1996). Porphyria cutanea tarda in a patient on chronic ambulatory peritoneal dialysis. Journal of the American Society of Nephrology, 7(3), 397–402. 3. Shieh, S., Cohen, J. L., & Lim, H. W. (2000). Management of porphyria cutanea tarda in the setting of chronic renal failure: a case report and review. Journal of the American Academy of Dermatology, 42(4), 645–52. 4. Pisoni, R. L., Wikström, B., Elder, S. J., Akizawa, T., Asano, Y., Keen, M. L., & Port, F. K. (2006). Pruritus in haemodialysis patients: International results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrology Dialysis Transplantation, 21(12), 3495–505.

Outcomes of pemphigus treatments at the Royal Melbourne Hospital over 5 years on immunosuppressive therapies used over this time: a retrospective analysis S. Sokolovska, G.A. Varigos, L. Scardamaglia Department of Dermatology, Royal Melbourne Hospital, Melbourne, Victoria, Australia Background: Pemphigus is a rare, autoimmune blistering condition, resulting in significant morbidity and mortality. It warrants treatment by various immunosuppressive agents, which also contribute to significant morbidity and mortality. Newer treatment agents such as intravenous rituximab may be more effective or better tolerated. The aim of this study is to determine the patient responses to various pemphigus treatments, and how these treatments have affected the patient’s quality of life during their course of management. Methods: All patients who have been treated for biopsy confirmed pemphigus vulgaris at the Royal Melbourne Hospital qualified to have their medical records retrieved for the purposes of this quality assurance audit. The medical records of the entire cohort of 21 pemphigus patients treated at the Royal Melbourne Hospital for pemphigus vulgaris between May 2009 and May 2014 (inclusive) were retrieved for analysis. Relevant data pertaining to their particular pemphigus treatment and how it affected their quality of life was extracted, as well as details regarding potential confounding factors, including medical co morbidities and concurrent medications. The PDAI (pemphigus disease activity index) (Murrell et al, 2008)1 and the ABSIS (autoimmune bullous skin disorder intensity score) (Pfutze et al, 2007) were retrieved from each patient’s record, with their scores being determined by the lesion extent and severity that was documented in the patient record template (Department of Dermatology, Royal Melbourne Hospital). PDAI and ABSIS values were recorded in Excel Database format as documented for each patient before their pemphigus treatment was commenced, and upon their most current treatment review appointment. Both pre- and posttreatment ABSIS and PDAI scores were then analysed using SPSS (IBM, Armonk, NY, USA) statistical software. Results: With the exception of 2 severe pemphigus cases where treatment is ongoing, all of the Royal Melbourne Hospital patients have their pemphigus treatments documented as significantly improving their overall quality of life. The relevant scoring of disease severity was markedly reduced across all subjects.

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Conclusions: The treatment of Pemphigus Vulgaris at The Royal Melbourne Hospital leads to significant improvement in the quality of life of its pemphigus patients. Potential implications of this study may provide foundations for the development of a formal pemphigus disease and treatment registry to enable adequate patient follow up and monitor their ongoing care. There is also potential for newer measures of pemphigus treatment outcomes, which may be rigorously applied in dermatology clinics to allow a more objective measure of clinical treatment endpoints.

Reference 1.

Murrell D, Dick S, Ahmed A, Amagai M, Barnadas M, Borradori L et al. Consensus statement on definitions of disease, end points, and therapeutic response for pemphigus. Journal of the American Academy of Dermatology 2008; 58(6): 1043–6.

Treatment of Behcets disease with subcutaneous testosterone: a case report S. Sokolovska1, M. Finlay2, G. Varigos1, S. David3 1 Department of Dermatology, Royal Melbourne Hospital, Parkville, Victoria, Australia 2 Anatomical Pathologist, Department of Dermatology, Royal Melbourne Hospital, Parkville, Victoria, Australia 3 NHMRC Research Fellow, Monash Health, Melbourne, Victoria, Australia Introduction: Behçet’s disease is a rare, chronic inflammatory syndrome defined clinically by the presence of recurrent oral ulceration within a 12 month period, in addition to at least two secondary criteria consisting of genital ulceration, uveitis or retinal damage, skin lesions, and a positive pathergy test result. Vasculitic damage to arteries and veins may also be present on histolopathologic examination. At present, therapeutic options for the treatment of Behçet’s disease are limited to relieving symptomatology, and preventing associated complications, including secondary infection, gastrointestinal perforation and vascular aneurysms. Evidence favouring specific treatment modalities is largely anecdotal, with few randomised clinical trials and no treatment consensus. Case report: A 64 year old Caucasian lady living with Behçet’s disease since 1984 presented with recurrent oral and genital ulceration refractory to colchicine, nicotinamide, and topical corticosteroids. She later underwent a hysterectomy for (___), which warranted hormone replacement therapy in the form of topical oestradiol patches (25 mg) and of testosterone (100 mg) via subcutaneous implantation. Incidentally, the patient found marked improvement in the distribution and severity of her oral ulcers within weeks of the insertion of the testosterone implant, with concomitant resolution of all genital ulcers and a marked improvement in her overall quality of life. The patient currently persists with her testosterone therapy in the form of six monthly 50 mg testosterone implants, in addition to nicotinamide and 500 mg of colchicine daily. Earlier this year, ejection of the existing testosterone implant in situ resulted in a severe flare of her oral and

genital ulceration. Reinsertion of the testosterone implant subsequently resulted in complete resolution of all the patient’s ulcerated lesions within a two week period. To date, there have been no reports of the use of testosterone for the treatment of the symptoms of Behçet’s disease, despite a range of immunomodulatory therapies being reviewed in prior literature. Discussion: Saleh et al(1) reported that the etiology of Behçet’s disease remains multifactorial, predominantly due to genetic susceptibility and infectious triggers in combination with immune dysregulation. The pathogenesis of Behçet’s disease was investigated prior to this by Tursen(2), in which he highlighted the potential significance of testosterone in the activation of neutrophils with subsequent oxidative burst. It was noted that male patients with Behçet’s disease manifested increased burst response before testosterone treatment compared with females. Interestingly, Aksu et al(3) reported two cases of Behçet’s disease without neurological findings, but with erectile dysfunction. The authors argued that the erectile dysfunction of their patients was most likely attributable to venous leak, rather than neuro- Behçet’s disease, given that the erectile dysfunction was adequately managed with deep dorsal vein ligation in response to the venous leak. Similar to our case report, both of these patients were on long duration colchicine for the management of oral and genital ulceration, and had no other iatrogenic or pathologic risk factors for peripheral neuropathy. There is a possibility that a deficiency in testosterone may be either a cause or a manifestation of Behçet’s disease in patients who present with oral and genital ulceration, and are managed with colchicine. Unfortunately, the case reports of Aksu et al did not mention measurements of the patient’s testosterone levels at time of presentation. Although there is a lack of clinical evidence and randomised clinical trials for the use of testosterone in Behçet’s disease, there may be a potential therapeutic role of testosterone in the minimisation of apoptosis and ulceration, with resultant optimisation of quality of life. Within their review, Malkin et al(4) advocate that androgens have been shown to suppress pro-inflammatory cytokine activity, inhibit apoptosis and enhance vascular smooth muscle cell proliferation with respect to the development of atherosclerotic plaques. The most recent analysis of treatment modalities pertaining to Behçet’s disease by Saleh(1) and colleagues reviewed a series of randomized clinical trials from 1988–2010 inclusive, in which improvement in oral ulceration was noted with various systemic therapies including colchicine, etanercept, rebamipide, dapsone, thalidomide, and Interferon 2α. Colchicine and thalidomide were found to result in clinical improvement of genital ulceration also. Evidence for the use of infliximab and etanercept in managing mucocutaneous involvement in Behçet’s disease is limited to case reports, and would be anticipated to be less favourable within the clinical setting due to cost. References 1.

Saleh Z, Arayssi T. Update on the therapy of Behcet disease. Therapeutic advances in chronic disease. 2014;5(3):112–34.

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Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 2.

Tursen U. Pathophysiology of the Behcet’s Disease. Pathology research international. 2012;2012:493015. 3. Aksu K, Keser G, Gunaydin G, Ozbek SS, Colakoglu Z, Gumusdis G, et al. Erectile dysfunction in Behcet’s disease without neurological involvement: two case reports. Rheumatology. 2000;39(12):1429–31. 4. Malkin CJ, Pugh PJ, Jones RD, Jones TH, Channer KS. Testosterone as a protective factor against atherosclerosis – immunomodulation and influence upon plaque development and stability. The Journal of endocrinology. 2003;178(3):373–80.

Secukinumab treatment provides fast relief from patient-reported psoriasis burden L.J. Spelman1, M. Lebwohl2, M. Mordin3, UG. Mallya4, A. Gnanasakthy4, T. Fox5 1 Veracity Clinical Research, Woolloongabba, Queensland, Australia and Probity Medical Research, Waterloo, Ontario, Canada 2 Mt. Sinai Medical Center, New York, New York, USA 3 RTI Health Solutions, Ann Arbor, Michigan, USA 4 Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA 5 Novartis Pharma AG, Basel, Switzerland Introduction and objectives: Secukinumab, an antiinterleukin-17A antibody, was evaluated in two phase 3 clinical studies for efficacy and safety in subjects with moderate-to-severe plaque psoriasis. This analysis focused on the impact of skin clearance at week 12, on speed of response to two patient reported outcome (PRO) measures – the Dermatology Life Quality Index (DLQI) and the visual analog scale (VAS) from the EuroQoL 5-Dimension Health Status Questionnaire (EQ-5D). Materials and methods: Patients aged ≥18 years were randomized 1:1:1 in ERASURE to subcutaneous treatment groups (secukinumab 150 mg, secukinumab 300 mg, and placebo) and 1:1:1:1 in FIXTURE (including an etanercept 50 mg twice-weekly group). For the present analysis, psoriasis clinical improvement was assessed at week 12 by Psoriasis Area and Severity Index (PASI) with PASI75 representing 75–89% reduction in symptoms and PASI90 representing 90%-100% reduction. The DLQI and EQ-5D were administered at baseline and weeks 4, 8, 12, 24, 36, and 52. Time to response was computed as the period from the randomization date to the date when a prespecified response in DLQI (score of 0 or 1) or EQ-5D VAS (increase of at least 7 points) had occurred. Results: The median time to response on the DLQI was significantly faster for the PASI90 group compared to the PASI75 group (DLQI response: 8 weeks vs. 12 weeks; P-value < 0.05). Further, both PASI90 and PASI75 groups achieved a median EQ-5D VAS time to response of 4 weeks. Conclusion: Secukinumab treatment provides fast relief from patient-reported psoriasis quality of life burden in patients with moderate-to-severe plaque psoriasis.

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Secukinumab shows efficacy regardless of baseline disease severity in subjects with moderate-to-severe plaque psoriasis: a pooled analysis from four phase 3 studies L.J. Spelman1, A. Blauvelt2, J. Loffler3, T. Fox3, C. Papavassilis3 1 Veracity Clinical Research, Woolloongabba, Queensland, Australia and Probity Medical Research, Waterloo, Ontario, Canada 2 Oregon Medical Research Center, Portland, Oregon, USA 3 Novartis Pharma AG, Basel, Switzerland Introduction and objectives: Secukinumab, an anti– interleukin-17A antibody, has demonstrated efficacy with an acceptable safety profile in phase 3 trials in moderate-tosevere plaque psoriasis. This pooled analysis evaluated the potential effects of baseline disease severity on the clinical benefit of secukinumab. Materials and methods: Subjects (N = 2400) with moderate-to-severe plaque psoriasis from four randomized, double-blind, placebo-controlled, multicentre, 52-week, phase 3 studies were included in this pooled analysis. Secukinumab 300 mg or 150 mg was administered subcutaneously (sc) once weekly for 4 weeks, then every 4 weeks thereafter, starting at week 4. Etanercept 50 mg sc was administered twice weekly to week 12 and once weekly thereafter. PASI 75/90 and IGA mod 2011 0/1 responses were evaluated at Week 12 (induction period) and Week 52 using non-responder imputation for subgroups determined by baseline PASI (PASI ≤ 20 and PASI > 20). Results: At Baseline, 1249 and 1151 subjects had PASI scores of ≤20 and >20, respectively; 2387/2400 were evaluable for efficacy. Secukinumab treatment resulted in higher PASI 75/90 and IGA mod 2011 0/1 responses in all subjects, irrespective of baseline PASI category, compared to etanercept and placebo at Week 12. Week 52 data indicated that responses were sustained over the long-term. Secukinumab and etanercept were well tolerated with no unexpected clinically significant safety findings. Conclusions: Secukinumab achieved greater clinical improvement than placebo or etanercept regardless of baseline disease severity and sustained the response in subjects with moderate-to-severe plaque psoriasis. Secukinumab 300 mg exhibited greater responses in all efficacy endpoints than the 150 mg dose.

Mycophenolic acid: applications in dermatology S. Strathie Page, C. Tait Royal Perth Hospital, Perth, Western Australia, Australia In the 1970s mycophenolic acid was first developed as an immunosuppressant to prevent organ transplantation rejection and was later used in the treatment of psoriasis. However due to its side effect profile and fears over carcinogenic potential it was abandoned. From the late 1990s a pro-drug, mycophenolate mofetil (MMF), was developed and more recently enteric-coated mycophenolate sodium (EC-MPS), both of which have gained increasing use in the

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field of dermatology for a variety of skin conditions. This poster discusses pharmacology, mechanisms of action, side effects and current clinical applications in dermatology of MMF and EC-MPS.

Ulcerated rapidly involuting congenital haemangiomas: a case series S. Strathie Page, S. Weston Princess Margaret Hospital, Perth, Western Australia, Australia Rapidly involuting congenital haemangiomas (RICH) are uncommon vascular tumours in children and distinct from other, more common types of vascular tumours such as infantile haemangiomas. They are characterised by their presence at birth and involution within the first year of life. We report three neonates with RICH complicated by ulceration at presentation and review the clinical course and management of these tumours in our paediatric dermatology clinic.

Acrodermatitis dysmetabolica S. Strathie Page, R. Foster Princess Margaret Hospital, Perth, Western Australia, Australia Acrodermatitis dysmetabolica (AD) encompasses a group of conditions that result in an erosive periorificial and acral dermatitis that mimics acrodermatitis enteropathica (an autosomal recessive cause of zinc malabsorption). Causes of AD include acquired zinc deficiency, amino acid deficiencies, fatty acid deficiencies and biotin deficiency. In our case, an exclusively breast fed two month old boy with known cystic fibrosis presented with failure to thrive and an erosive dermatitis involving the face, napkin area and limbs with truncal sparing. The dermatitis had a ‘flaky paint’ appearance. Pancreatic enzyme replacement (Creon) and fat-soluble vitamin supplementation had been inconsistent prior to this admission. Investigations revealed a normal zinc level (9 μmol/L; reference range 9–18), but abnormal levels of multiple amino acids. A diagnosis of AD was made. In our patient zinc supplementation resulted in no clinical improvement. Regular Creon before feeds and short-term parenteral nutrition normalised his protein levels and clinical resolution was seen.

Wiskott-Aldrich syndrome in an Australian population S. Strathie Page, M. O’Sullivan Princess Margaret Hospital, Subiaco, Western Australia, Australia Wiskott-Aldrich syndrome is a rare genetic condition which involves a triad of thrombocytopaenia, primary immunodeficiency and eczema. The aim of this study was to investigate the prevalence, genetic mutations, clinical features and outcomes of Wiskott-Aldrich syndrome in Western Australia in the paediatric population at Princess Margaret Hospital from 1990–2014. Nine cases were identified. We discuss the management of these patients and their specific phenotypes.

Non-bullous lichen planus pemphigoides likely induced by venlafaxine A. Tan1, S. Vaidya2,3 1 Lyell McEwin Hospital, Elizabeth Vale, South Australia, Australia 2 St Peters Dermatology, Adelaide, South Australia, Australia 3 Dermatology SA, Adelaide, South Australia, Australia Lichen planus pemphigoides (LPP) is considered an uncommon clinical variant of lichen planus (LP) and it is characterised by the clinical, histological and immunological features of both lichen planus (LP) and bullous pemphigoides (BP). The lesions most commonly observed are vesicles and/or bullae that coexist with LP or form on normal unaffected skin. The histopathological and immunological findings of LPP include subepidermal blisters and features of LP such as direct immunofluorescence (DIF) of perilesional skin showing linear deposition of IgG and/or C3 along the dermo-epidermal junction (DEJ). There have previously only been rare cases of drug-induced LPP reported in the literature involving medications such as angiotensin-converting-enzyme inhibitors (ramipril, captopril), simvastatin, cinnarizine and naproxen.1 We present the first reported case of LPP most likely induced by venlafaxine in a 42-year-old male who had an atypical presentation with no vesicle or bullae formation seen on clinical examination. He had violaceous, excoriated lichenoid papules and confluent plaques associated with koebnerization on his lateral shins bilaterally. In addition, he had similar new lichenoid lesions involving his right extensor surface of his forearm. His histopathological and immunological findings, and complete resolution of his rash after cessation of venlafaxine have led us to conclude that the most likely diagnosis was an atypical presentation of venlafaxine-induced LPP. This case highlights the importance of considering medications as a causative factor in the development of LPP. The early recognition of the possibility of a drug-induced LPP allows prompt cessation of the offending drug hence improving the patient’s clinical outcome. Reference 1.

Zaraa I, Mahfoudh A, Sellami MK et al. Lichen planus pemphigoides: four new cases and a review of the literature. Int. J. Dermatol. 2013; 52; 406–12.

A typical presentation of hypomelanosis of ito – a rare pigmentary chromosomal mosaicism A. Tan1, S. Vaidya2,3 1 Lyell McEwin Hospital, Elizabeth Vale, South Australia, Australia 2 St Peters Dermatology, Adelaide, South Australia, Australia 3 Dermatology SA, Adelaide, South Australia, Australia Hypomelanosis of Ito (HMI) is a rare neurocutaneous condition that is characterized by hypopigmented swirls and streaks distributed along the lines of Blaschko. It was first reported in the literature in 1952 and described as

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 incontinentia pigmenti acrhomians.1 It is believed that HMI is a result of chromosomal mosaicism and that a wide range of mutations can lead to the various phenotypic mosaic patterns seen in dyspigmentation of Blaschkoid distribution.2 HMI typically presents at birth and can involve anywhere on the cutaneous surface of the body. HMI has been associated with highly variable extracutaneous abnormalities affecting the neurological, musculoskeletal and ophthalmological systems.2 We present a 12-year-old Australian dark-skinned male who presented with hypopigmented macules involving the left side of his torso as well as his upper extremities since birth. Both the patient and his parents denied any visual or neurological symptoms. He had no developmental delay and no family history involving this similar skin condition. This young boy was reported to be generally fit and well with no significant past medical history. On examination, he had multiple ill-defined hypopigmented macules distributed along the lines of Blaschko on the left side of his anterior chest, upper shoulder, both upper arms and upper back. A sharp midline cut-off was noted at the pre-sternal level. There were no abnormalities involving his nails, eyes and joints. His typical clinical presentation was most consistent with a diagnosis of HMI.

References 1. Ito M. Studies on melanin. Tohoku J. Exp. Med. 1952; 55; 1–104. 2. Cohen J 3rd, Shahrokh K, Cohen B. Analysis of 36 cases of Blaschkoid dyspigmentation: reading between the lines of Blachshko. Pediatr. Dermatol. 2014; 31; 471–76.

Allergic contact dermatitis and systemic symptoms from wearing the new navy blue South Australian police uniform A. Tan1, C. Ooi2 1 Lyell McEwin Hospital, Elizabeth Vale, South Australia, Australia 2 Dermatology SA, Dulwich, South Australia, Australia Disperse dyes (DD) are used for dyeing synthetic fibres and are regarded as the main causative agents in textile-related allergic contact dermatitis (ACD). DD usually cause type IV hypersensitivity reactions and are rarely associated with Type I IgE-mediated responses. The distribution of occupational ACD due to DD varies but can often occur in areas of friction and increased sweating. We report a case involving a 35-year-old South Australian policewoman who had ACD associated with systemic symptoms after exposure to her new police uniform. She developed intensely pruritic erythematous patches involving her lower abdomen where her gun belt was worn over the top of her shirt. She also experienced severe Type I allergic hypersensitivity symptoms such as asthma and rhinoconjunctivitis when she wore her new uniform or was in proximity to other colleagues wearing the uniform. Patch testing to textile colours and finishes demonstrated positive reactions to Disperse Blue and Disperse Orange dyes. Whilst

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these positive reactions may explain her dermatitis, it did not fully explain her systemic symptoms. Formaldehyde allergy was suspected, however patch testing did not demonstrate reactions to formaldehyde or formaldehyde releasing resins, nor were formaldehyde releasing resins used in the manufacture of the uniform. A provocation challenge was undertaken with her wearing a freshly opened new uniform. This resulted in a recurrence of her systemic symptoms and significant reductions in peak expiratory flow rate measured with both spirometry and peak flow meter. These systemic symptoms have profoundly affected her ability to carry out normal patrol duties.

Histopathological features after topical black salve application J.M. Tan1,2, P. Peters1,3, N. Ong1,2, B. Shepherd4, H.P. Soyer1,2 1 Department of Dermatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia 2 Dermatology Research Centre, The University of Queensland, School of Medicine, Translational Research Institute, Brisbane, Queensland, Australia 3 School of Medicine, Griffith University, Gold Coast, Queensland, Australia 4 Department of Anatomical Pathology, Pathology Queensland, Princess Alexandra Hospital, Brisbane, Queensland, Australia Black salve is a topical product that has been advertised as a natural remedy for many skin ailments including skin cancer. The corrosive form causes non-selective tissue damage and contains either zinc chloride or sanguinarine as the active ingredient, an alkaloid derived from bloodroot extract (Sanguinaria Canadensis). This escharotic agent has been marketed as a safe and effective alternative treatment for skin cancer although no randomised clinical trials on the safety and efficacy of black salve products have been published.1 Black salve and its related products are not listed in the Australian Register of Therapeutic Goods (ARTG)2 and in 2012 the Therapeutic Goods Administration (TGA) released a safety alert to consumers against purchasing or using these products.2 We present the case of a 50-year-old lady referred to the dermatology department for opinion and management of a lesion clinically suspicious for a keratoacanthoma on her left distal arm. Five days prior to her scheduled outpatient review, she applied the black salve to her left distal arm lesion for 24 hours, with a second application 48 hours later. On presentation, clinical examination revealed a hyperkeratotic nodule with a necrotic edge and surrounding erythema. Histopathology features were consistent with a keratoacanthoma associated with superficial necrosis and suppuration. There are few reports describing the histopathological effects following topical black salve application in the literature, and these are focused on the delayed presentation and any residual tumour mass.3 Nil previous reports on the immediate histopathological features of black salve were noted.

References 1.

Eastman KL, McFarland LV, Raugi GJ. A review of topical corrosive black salve. J Altern Complement Med. 2014; 20(4): 284–9.

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2.

Australian Government Department of Health Therapeutic Goods Administration. Black salve, red salves in treating cancer. 19 March 2012. Available from URL: http://www.tga.gov.au/safety/ alerts-medicine-black-salve-120203.htm. (accessed Oct 2014.) 3. Leecy TN, Beer TW, Harvey NT et al. Histopathological features associated with application of black salve to cutaneous lesions: a series of 16 cases and review of the literature. Pathology 2013; 45(7): 670–4.

Eosinophilic folliculitis in a patient receiving chemotherapy for chronic lymphocytic leukaemia – case report and review of the literature J.M. Tan1,2, B. Shepherd3, E. McMeniman1,2 1 Department of Dermatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia 2 Dermatology Research Centre, The University of Queensland, School of Medicine, Translational Research Institute, Brisbane, Queensland, Australia 3 Department of Anatomical Pathology, Pathology Queensland, Princess Alexandra Hospital, Brisbane, Queensland, Australia Eosinophilic folliculitis was first described by Ofuji et al in 1970. It has been associated primarily with HIV seropositivity and haematological malignancies. Drug associations have also been found in the literature and include carbamazepine, minocycline, indeloxazine hydrochloride, allopurinol with timedium bromide and cytotoxic agents cyclophosphamide and 5-fluorouracil. We describe an HIV seronegative 65-year-old man with recurrent chronic lymphocytic leukaemia (CLL) who was referred to the Dermatology department with severe pruritus affecting his head, neck and upper trunk. He had been on a chemotherapy regime consisting of monthly infusions of rituximab and bendamustine in combination with adelalisib or placebo treatment twice daily as part of a clinical trial for CLL. The onset of his symptoms was 9 weeks after commencing chemotherapy. On examination, there were scattered skin-coloured to erythematous oedematous papules and flat nodules mainly on his scalp, neck and upper trunk, as well as excoriated papules on his upper back (clinical photos available). There was an associated peripheral eosinophilia of 1.79 × 109/L (reference range 0.7, p < 0.05) in non-pigmented patients, but not in highly pigmented patients. Coefficient of variation analysis showed erythema perception contributed to the inter-rater variability. Pigmentation perception: In non- and mildly pigmented patients, there were large inter-rater variations. In highly pigmented patients variations were minimal. Conclusion: All AD instruments have unacceptably low reliability and validity in highly pigmented patients, likely

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Australasian College of Dermatologists Abstracts Presented at the 48th Annual Scientific Meeting 2015 due to variations in erythema perception. Contrastingly, for pigmentation assessment, best inter-rater reliability was found amongst patients with highly pigmented skin and decreased as the skin became paler.

Recording of dermatology consults in discharge summaries: an analysis of 218 consults C.Y. Zhao1,2, R.Y. Ang1,2, R. George1, D.F. Murrell1,2 1 Dermatology, St George Hospital, Sydney, New South Wales, Australia 2 Medicine, University of New South Wales, Sydney, New South Wales, Australia Introduction: Discharge summary (DCS) is a critical document. Accurate documentation of dermatology consults in the DCS helps communication with primary care, and to capture the care provided to the patient, in order to facilitate Activity-based Funding. Method: We retrospectively audited all dermatology consults seen at St George Hospital throughout JanuaryDecember 2013 and the associated DCS by the nondermatology teams. Results: Altogether, 218 dermatology consults/admissions were analysed. Of these, 206(94.5%) had a DCS and 188(86.2%) had a punctual DCS (completed before/on the discharge date). Only 143 of 218(65.6%) dermatology consults and 32 of 46(69.6%) skin biopsies were documented on discharge summaries. Of the 234 dermatological diagnoses made, 121(51.7%) were accurately documented, 51(21.8%) undocumented, 45(19.2%) wrongly documented, 11 (4.7%) without DCS and 6(2.5%) had spelling errors. Out of the 51 undocumented diagnoses the commonest groups were dermatitis (N = 16,31.3%) and infections(N = 16,31.3%). Dermatology clearly documented 205 of 218(94.0%) consults; the rest were abbreviated (N = 4,1.8%) or had unclear explanation of biopsy results (N = 9,4.1%). Using an issues list in the DCS gave increased odds of documenting the dermatology consult(OR 1.27,CI 0.70– 2.30). Specialty-wise, paediatrics had the highest percentage of consult documentation(8 of 9,88.9%), followed by critical care(12 of 14,85.7%), surgical(25 of 35,71.4%), medical(95 of 140,67.9%) and psychiatry(3 of 8,37.5%). Discussion: With concern, we found high rates of undocumented or incorrectly documented consults in hospital DCS. Strategies to improve include the use of an issues list, avoidance of diagnoses abbreviations, clearer explanation of biopsy results, as well as the dermatological education of other specialties, especially psychiatry and, surprisingly, medical specialties.

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A prospective comparison study of four outcome measures for atopic dermatitis C.Y. Zhao1,3, A.Q.T. Tran1,3, J.P. Lazo-Dizon1,3, J. Kim1,3, B.S. Daniel1,3, S.S. Venugopal1,3, L.M. Rhodes1,3, M.G. Law2, D.F. Murrell1,3 1 Department of Dermatology, St George Hospital, Sydney, New South Wales, Australia, 2 Kirby Institute, Sydney, New South Wales, Australia 3 Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia Background: There are multiple outcome measures for the clinical severity of atopic dermatitis (AD), but a need to compare the reliability of these measures.1 Aims: 1. Compare the inter-rater and intra-rater reliability of the objective Scoring Atopic Dermatitis (oSCORAD), Eczema Area and Severity Index (EASI), Six Area, Six Sign Atopic Dermatitis (SASSAD) and Three Item Severity index (TIS) 2. Correlate these outcome measures to QoL instruments: Patient-Orientated Eczema Measurement, Dermatology Life Quality Index and SkinDex-29. Methods: Twelve AD patients were attended a scoring session by 5 fully trained clinicians, using the above 4 outcome measures. Statistics were performed using SPSS. Results: Regarding inter-rater reliability, EASI and SASSAD showed good reliabilities with 0.730 (95% CI = 0.500–0.900) and 0.680 (95% CI = 0.440–0.880), respectively. However inter-rater ICCs were only fair for TIS and oSCORAD with 0.497 (95% CI = 0.233–0.785) and 0.498 (95% CI = 0.234– 0.785), respectively. Regarding intra-rater reliability, EASI and TIS showed excellent ICCs of 0.886 (95% CI: 0.744– 0.952) and 0.820 (0.614–0.923), respectively, while SASSAD showed good reliability with ICC of 0.720 (95% CI = 0.424– 0.878). However intra-rater ICCs were only fair for oSCORAD with 0.446 (95%CI = 0.037–0.730). Regarding correlation with QoL instruments, only SASSAD demonstrated moderate correlation with SkinDex-29, ρ = 0.611 (p = 0.035). Conclusions: Consistent wit the latest Harmonising Core Outcome Measures for Atopic Dermatitis Clinical Trials initiative consensus,2 EASI demonstrated the highest interrater and intra-rater reliability, supporting it as the optimal measure. Our study elucidated the need for an outcome measure which eliminates surface area error and independently assesses activity and damage. References 1.

Schmitt J, Langan S, Deckert S et al. Assessment of clinical signs of atopic dermatitis: a systematic review and recommendation. The Journal of Allergy and Clinical Immunology 2013; 132: 1337– 47. 2. Chalmers JR, Schmitt J, Apfelbacher C et al. Report from the Third International Consensus Meeting to harmonise core outcome measures for atopic eczema/dermatitis clinical trials (HOME). The British Journal of Dermatology 2014; 171(6): 1318– 25.

© 2015 The Authors Australasian Journal of Dermatology © 2015 The Australasian College of Dermatologists

Abstracts of the australasian college of dermatologists 48th annual scientific meeting, 16 may 2015, adelaide, australia.

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