The Australasian College of Dermatologists 47th Annual Scientific Meeting, 18-21 May, 2014, Melbourne, Victoria.

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Australasian Journal of Dermatology (2014) 55 (Suppl. 1), 1–58

Registrars’ Training Day Rheumatologic/dermatological disease in children A.S. Paller Departments of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America Pediatric dermatologists often make the diagnosis of rheumatologic disease because of the prominent mucocutaneous manifestations in this group of disorders. Four of the newer and now validated criteria for systemic lupus erythematosus are dermatologic manifestations (malar rash/photosensitivity; discoid rash; oral ulcerations; nonscarring alopecia), and the risk of developing SLE when the presentation is discoid lupus erythematosus is greater in children than in adults. Lupus has been linked with activation of interferon signaling, and new therapies that suppress IFN are now being tested. Babies with neonatal lupus most commonly present with annular lesions, and do not have a risk of LE after clearance beyond that of family members. The telangiectatic manifestations of juvenile dermatomyositis are usually the earliest clue to diagnosis. Early aggressive management is key to reduction in the occurrence of calcifications and long-term sequelae. Pediatric JDM patients generally do not show the myositisspecific antibodies seen in adults, although newer antibodies seen in JDM have been described in children. Linear morphea is much more common in children than in adults, and lead to problems when on the face or over joints. Methotrexate remains the treatment of choice for complicated morphea, although mycophenolate mofetil and UVA1 are additional useful monotherapy or adjunctive therapy. Most patients have permanent sequelae and a long-term risk of recurrence, leaving the optimal timing for cosmetic correction still unclear.

References 1.

Robinson, A.B., Reed, A.M. (2011) Clinical features, pathogenesis and treatment of juvenile and adult dermatomyositis. Nat Rev Rheumatol. 7: 664–75. 2. Foeldvari, I. (2013) New developments in juvenile systemic and localized scleroderma. Rheum Dis Clin North Am. 39: 905–20. 3. Hon, K.L., Leung, A.K. (2012) Neonatal lupus erythematosus. Autoimmune Dis. 2012: 301274.

Oral mucosal disease J. Tversky Dental Specialist in Oral Medicine, Melbourne, Victoria, Australia The oral cavity is a small area but has a large number of tissue types. It is subjected to both systemic and local influences and is at the beginning of the upper aero-digestive tract. In this overview I will focus on a range of commoner diseases. The lecture will cover traumatic lesions, common infections, oral allergies, oral Lichen Planus and dysplastic & malignant disease.

Approach to diffuse hair loss in women L. Yip St Vincent’s Hospital Melbourne, Fitzroy, Victoria; Skin and Cancer Foundation Inc., Carlton, Victoria; Barkers Road Dermatology, Kew, Victoria, Australia Diffuse hair loss in women is a very common and often complex presentation seen in daily practice. The four main differentials of this presentation are female pattern hair loss, acute and chronic telogen effluvium, and diffuse alopecia areata. This talk aims to provide a “street-wise” systematic clinical approach with important differentiating clues and clinical tips to help develop more efficient strategies to better assess and manage these conditions.

Immunosuppression and systemic therapy: A practical approach E. Veysey Melbourne, Victoria, Australia The decision making process regarding systemic immunosuppressive therapy will be addressed using case based scenarios. An evidence based, pragmatic approach will be taken, focusing on common clinical complexities, the role of quality of life assessment and drug transitions and sequencing.

Selected topics in male genital dermatology C.B. Bunker Departments of Dermatology, University College and Chelsea & Westminster Hospitals, London, UK

Male genital lichen sclerosus (MGLSc) Men with MGLSc present with dyspareunia, urinary dysfunction and rash. The differential diagnosis includes psoriasis, eczema, lichen planus, Zoon’s balanitis and carcinoma in situ. Diagnosis is clinical and biospy is rarely needed. Goals in the management of MGLSC are restitution of normal sexual and urinary function, abolition or significant reduction in the risk of penis cancer and preservation of the foreskin. MGLSc could be a largely preventable disease or, at the very least, could be completely cured if diagnosed and treated early by medical and surgical means. Fundamental to the achievement of these goals is the recognition of the pernicious role played by chronic occluded urinary irritation of susceptible keratinized epithelium in the initiation and progression of MGLSc. These pathogenetic insights affect medical and surgical management strategies. Medical management constitutes ultrapotent topical steroid treatment, soap substitution and minimisation of urinary exposure and induces remission in 50–60%. Failure or relapse are strong indications for circumcision and this is curative in the majority. Topical calcineurin inhibitors are contraindicated.

© 2014 The Authors Australasian Journal of Dermatology © 2014 The Australasian College of Dermatologists

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Australasian Journal of Dermatology (2014) 55 (Suppl. 1)

‘Idiopathic’ penile oedema and cellulitis Chronic penile lymphedema is a rare situation with an uncertain pathogenesis and important differential diagnosis. It creates significant physical and psychosexual morbidity and presents considerable therapeutic challenges. The literature is limited. A recent retrospective study of 30 cases seen in a specialized clinic has been undertaken. Over a third had Crohn’s disease (occult in 50%). Over a third had serological evidence of streptococcal infection. Other causes include sarcoid, anogenital/pelvic disease eg neoplasia and its treatment, STD eg HSV, lichen sclerosus, filariasis, foreign bodies and implants eg parafinoma. Rigoorous investigation is necessary. All patients responded to protracted rotating systemic antibiotics (± short courses of systemic steroids and specialised urological surgery – circumcision and excision.

References 1.

2. 3.

4. 5. 6. 7.

Edmonds E, Hunt S, Hawkins D et al. Clinical parameters in male genital lichen sclerosus: a case series of 329 patients. J. Eur. Acad. Dermatol. Venereol. 2012; 26: 730–7. Rao A, Bunker CB. Male genital skin biopsy. Int. J. STD AIDS 2011; 22: 418–19. Neill SM, Lewis FM, Tatnall FM et al. British Association of Dermatologists’ guidelines for the management of lichen sclerosus. Br. J. Dermatol. 2010; 163: 672–82. Bunker CB. Comments on the BAD guidelines for the management of lichen sclerosus. Br. J. Dermatol. 2011; 164: 894–5. Bunker CB. Male genital lichen sclerosus and topical tacrolimus. Br. J. Dermatol. 2007; 157: 1079–80. Porter WM, Dinneen M, Bunker CB. Chronic penile lymphoedema: a report of 6 cases. Arch. Dermatol. 2001; 137: 1108–10. Bunker CB, Shim TN. Male genital oedema in Crohn’s disease. J. Am. Acad. Dermatol. 2014; 70: 385.

Dermatological emergencies K. Armour Melbourne, Victoria, Austraila Dermatological emergencies are one of the many rewarding areas in our discipline where specialist input can hugely improve patient outcomes. This talk will focus on clinical presentation, differential diagnoses, investigations and treatment of the core dermatological emergencies and will provide practical tips to assist with dealing with this problem in the written examination setting as well as in the real world.

Mohs’ Peer Review Session Defining incidental perineural invasion: The need for a national registry L. Buchanan1,2, B. De’Ambrosis3, K. DeAmbrosis1,2, T. Warren4, S. Huilgol5, H.P. Soyer1,2, B. Panizza4 1 Dermatology Research Centre, School of Medicine, Translational Research Institute, University of Queensland, Brisbane, Queensland, Australia 2 Department of Dermatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia 3 South East Dermatology, Carina Heights, Brisbane, Queensland, Australia 4 Queensland Skull Base Unit and Department of Otolaryngology – Head and Neck Surgery, School of Medicine, Princess Alexandra Hospital, University of Queensland, Brisbane, Queensland, Australia 5 Department of Dermatology, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia This presentation by the Perineural Invasion (PNI) Registry aims to clarify clinical and histopathological ambiguities surrounding perineural invasion in nonmelanoma skin cancer (NMSC). PNI is reportedly present in approximately 2–6% of cases of NMSC and is associated with greater rates of morbidity and mortality. The distinction between clinical PNI and incidental PNI is somewhat unclear, especially in regard to management and prognosis. One important objective of the PNI registry, is to develop a standardised method of classifying perineural invasion. Hence, in this presentation we propose a definition for PNI and for its subclassification. This presentation also provides a critical analysis of the current literature regarding the treatment of incidental PNI by evaluating the key cohort studies that have investigated the use of surgery and/or radiotherapy in the management of incidental PNI. At present, there are no universal clinical guidelines that specify acceptable treatment of NMSC exhibiting incidental PNI. Subsequently, patients often receive surgery with varying wider margins, and/or radiotherapy despite the limited evidence substantiating such management options. It is evident from the existing literature that current opinion is divided regarding the benefit of adjuvant radiotherapy. Certain prognostic factors have been proposed such as the size and depth of tumour invasion, nerve diameter, the presence of multifocal PNI and the type of tumour. The PNI registry is a web-based registry that has been developed to assist in attaining further data pertaining to incidental PNI in NMSC. It is envisaged that this information will provide the foundation for identifying and defining best practice in managing incidental PNI.


ACD 47th Annual Scientific Meeting 2014 Differences in complexity of Mohs’ surgery between primary versus recurrent non-melanoma skin cancers: A retrospective analysis C. Lin, S. Richards, R. Paver Skin and Cancer Foundation Australia, Westmead, New South Wales, Australia Introduction: Mohs surgery utilises intra-operative frozen sections to control tumour margins, thus achieving a high clearance rate for non-melanoma skin cancers. It is traditionally reserved for recurrent cancers, those with illdefined clinical margins, or for sites where tissue conservation is of paramount importance. Method: Retrospective analysis was performed on 500 consecutive Mohs surgery patients who attended the Skin and Cancer foundation in Sydney from May 2013. Basic demographic data, previous treatments, stages and sections required for clearance, tumour types and sizes, and final defect sizes were collected from patient files. Comparisons between primary and recurrent tumours are made, and sub-analysis for recurrent tumours performed according to previous treatments. Results: To be discussed at the Mohs Meeting. The results may potentially encourage practitioners to consider Mohs surgery as a treatment option earlier on in the patient management pathway. A cost comparison of Mohs’ surgery and traditional excision for basal cell carcinoma in Australia D. Sebaratnam1,2, B. Choy1, M. Lee2, R. Paver1,2, P. Fernández Peñas1,2 1 Department of Dermatology, Westmead Hospital, Westmead, New South Wales, Australia 2 Skin and Cancer Foundation Australia, Westmead, New South Wales, Australia Introduction: The cost-effectiveness of Mohs micrographic surgery (MMS) in the setting of non-melanoma skin cancer is a contentious topic. The studies published to date offer mixed conclusions with no clear consensus regarding its economic utility available. Aim: To complete a direct cost comparison of MMS and traditional excision (TE). Methods: A prospective study was undertaken comparing the true costs of MMS with projected costs of TE. Over one year, 416 consecutive patients receiving MMS were reviewed by the MMS Fellow pre-operatively with surgical management of their BCC with TE and associated closures planned. The projected costs associated with this (including pathological review and further TE in the case of incomplete excision) were compared with the true costs of MMS and associated closures. All costs were determined according to the Medicare Benefits Schedule. Results: The mean cost of MMS was AUD$882.85 ± 21.46. The mean cost of TE was AUD$683.83 ± 21.21. Of note, 32% of the patients who would have received TE were projected to have had incomplete margins requiring further surgery. Overall, there was a significant difference between the cost of MMS and TE (P < 0.01).

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Discussion: MMS was associated with a higher cost than TE. The difference between interventions is in keeping with what has previously been reported in the literature. To truly determine the cost-effectiveness of MMS compared with TE, a consideration of effectiveness must be incorporated and is mandatory for further work in this area.

A cost-utility analysis of Mohs surgery versus traditional excision for head and neck basal cell carcinoma: An update B. Choy1, R.L. Morton2, D.F. Sebaratnam1,2,3, R. Paver1,3, P. Fernández Peñas1,2,3 1 Department of Dermatology, Westmead Hospital, Westmead, New South Wales, Australia 2 University of Sydney, Camperdown, New South Wales, Australia 3 Skin and Cancer Foundation Australia, Westmead, New South Wales, Australia To determine the cost-effectiveness of Mohs micrographic surgery (MMS) compared with traditional excision (TE) for head and neck basal cell carcinoma (BCC), a modelled cost-utility analysis was performed from the perspective of the Australian healthcare system. The gold standard in economic evaluations is to present cost per quality adjusted life year (QALY) and this outcome was accordingly sought. A Markov model simulating the natural history of BCC was constructed and populated with the likely outcomes for primary BCC treated with MMS or TE. Recurrence rates were identified from published Skin and Cancer Foundation Australia data. Where required data were not available, a systematic review was performed and best available figures utilised. A 5 year recurrence rate of 1% for primary BCC and 4% for recurrent BCC was employed for MMS and 5% for primary BCC and 17% for recurrent BCC employed for TE. Literature review was performed to determine a QALYweighting associated with BCC recurrence of 0.98. Costs were obtained in a separate study comparing true costs of MMS with projected costs of TE yielding a mean MMS cost of AUD$882 and mean TE cost of AUD$515. The mean cumulative cost of MMS was AUD$1185 while the mean cumulative cost of TE was AUD$1105: a difference of AUD$80 over five years. Further work is being completed by our group to better define the difference in QALYs between interventions. At this stage, MMS is a much more financially viable intervention for head and neck BCC compared to TE than previously appreciated.

Plenary Session 1 Genetic disorders update: Therapeutic advances A.S. Paller Departments of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America The underlying molecular cause has been determined for hundreds of monogenic genodermatoses. The more recent availability of next-generation sequencing, in particular, is rapidly leading to the discovery of the cause of rare monogenic disorders, helping to analyze more complex genetic disorders, illuminating genotype-phenotype corre-


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lations, and uncovering the basis for mosaic genetic disease, helping us to understand how gene changes translate into clinical manifestations. Our great progress in understanding genetic disease has revolutionized prenatal diagnosis, and has allowed families to avoid termination through preimplantation diagnosis, which utilizes in vitro fertilization. Importantly, our understanding of gene and resultant protein changes is translating into new pathogenesis-based therapy for our patients through pharmacogenomics (to pharmacologically adjust gene and protein expression), signaling pathway manipulation, and by directly altering gene expression (through gene introduction or by suppressing specific gene overexpression or mutations). Examples of pharmacologic therapy are use of small molecule inhibitors to block activated signaling pathways in tumor syndromes, replacement therapy (or replacement therapy coupled with pathway inhibition), and theoretically agents that may induce a compensatory proteins, such as for epidermolysis bullosa simplex or ichthyosis vulgaris. Gene therapy approaches range from cell therapy through direct injection, grafting or stem cell introduction to suppression of dominant negative defects by siRNA introduction or Talens. Finding areas of revertant mosaicism or use of induced pluripotent stem cells can facilitate these genetic approaches. Ultimately, new technologies for identification of genetic alterations and managing their results are rapidly moving us into the area of personalized pharmacologic-based and gene-based therapy.

References 1.

Dyer, J.A. (2013) New findings in genodermatoses. Dermatol Clin. 31: 303–15. 2. Schaffer, J.V. (2012) Molecular diagnostics in genodermatoses. Semin Cutan Med Surg. 31: 211–20.

Melanoma Symposium 1 New horizons in melanoma management G.A. McArthur Peter MacCallum Cancer Centre, St Andrews Place, East Melbourne, Victoria, 3002, Australia The understanding of the key molecular events controlling the hosts immune response to cancer and the in depth understanding of the cellular and molecular biology of melanoma have led to major changes in the therapeutic paradigm in metastatic melanoma. There are now a large number of immunological targets that can be modulated by therapeutic antibodies to stimulate a host immune response against tumours. The CTLA4-inhibitory antibody ipilimumab can improve overall survival in patients with advanced disease leading to 20% of patients obtaining longterm clinical benefit. Even more promising are antibodies to the programmed death-1 receptor (PD-1) or its ligand PD-L1 that generate responses in an even higher proportion of patients. The melanoma genome is now well annotated with over 60% of patients having genomic events that activate RAS/RAF/MEK/ERK pathway. This has led to systemic therapies that improve overall survival in the advanced disease setting, and potentially offer even more significant

impact in the adjuvant setting. Perhaps the greatest promise to impact mortality from melanoma, a disease characterized by the development of metastases from small primary tumours, is the combination of systemic therapies. The new systemic therapies for melanoma have generated a paradigm shift in the management of patients with metastatic disease and are poised to transform care in the adjuvant setting if clinical trial data from adjuvant studies shows similar results to patients with advanced disease.

Intrapatient evolution of melanoma C. Fedele, S. Boyle, M. Shackleton Melanoma Research Laboratory, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia Following cancer formation, disease progression is often driven by additional genetic changes that enable Darwinian-style selection of more aggressive clones – a process called clonal evolution – that subsequently dominate a patient’s disease burden. Understanding how this occurs and how to counter evolutionary change in cancer are high priorities in cancer research. In preliminary work, we have found that high proportions (∼70%) of tumorigenic melanoma cells can generate striking molecular diversity within tumors. This is potent fuel for evolutionary adaptation in this disease and raises the fundamental question as to thus whether, during evolution, melanomas have large or only limited potentials to hijack a variety of molecular mechanisms for promoting tumor progression. Indeed, although adaptive evolution during BRAF-targeted therapy mostly converges on (MAPK) pathway reactivation, it is poorly understood if and/or how melanomas evolve without the selective pressure imposed by therapy, and, if so, whether many or only a few molecular signalling pathways are involved. Addressing these questions and elucidating those pathways will be critical to increasing cancer cure rates. Accordingly, we have identified a convergent evolutionary trajectory taken by progressing melanomas in the absence of therapy. In high proportions of patient and patientderived xenografted (PDX) melanomas in NSG mice, we have observed consistent changes in melanomas during disease progression, characterized by increased tumor aggressiveness and de-differentiation phenotypes. Genotyping of tumors suggests classical clonal evolution as the basis for the changes, which are associated with downregulated molecular signalling of specific pathways. These data contrast with epigenetically based models of melanoma progression that propose plastic interconversion among melanoma cells between states of more and less melanocytic differentiation, or the unidirectional generation in melanomas of more differentiated and less tumorigenic cells from cancer stem cell sub-populations.

Driver mutations: phenotypic associations and prognostic significance V. Mar Melbourne, Victoria, Australia Recent molecular studies suggest two distinct groups of cutaneous melanomas: those with a low mutation burden, which tend to be BRAF or NRAS mutant; and those with a


ACD 47th Annual Scientific Meeting 2014 high (UV induced) mutation burden, which tend to be wildtype for both BRAF and NRAS. Clinical and histological associations of these two groups will be discussed. In a cohort of 196 patients with long-term follow-up, we were able to show that patients with BRAF mutant tumors have poorer survival than patients with BRAF/NRAS wild-type tumors independent of other prognostic variables. Interestingly, BRAF mutant tumors in this cohort were thinner at diagnosis and tended to grow more slowly compared to wild-type tumors. BRAF mutant tumors were also significantly thinner in a larger cohort of 764 patients enrolled in the Melbourne Melanoma Project, but were more likely to present with nodal disease (P = 0.001). RAC1 mutations were also associated with nodal disease at diagnosis (P = 0.03). The presence of a dominant oncogene ‘drives’ tumor progression and metastasis, but does not necessarily dictate the rate of primary tumor growth or tempo of disease progression.

Genetic polymorphisms associated with clinical and dermoscopic naevus signature patterns H.P. Soyer Dermatology Research Centre, The University of Queensland, School of Medicine, Translational Research Institute & Dermatology Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia The focus of our research is concerned with investigations of the naevus phenotype (number, size, distribution, profile and dermoscopic pattern) in melanoma patients/families and cases and their correlation with melanocyte biology and pigmentation genetics in relation to human skin cancer. Major goals are to understand the genetic basis of the naevus phenotype as well as human pigmentation and to assess the phenotypic association of these physical traits including skin, hair and eye colour with skin UV-sensitivity and for skin cancer risk. We have imaged clinically and dermoscopically 570 patients so far and have accrued a database of naevus phenotypes which we are correlating with the genotype. The group has isolated, characterised and searched for polymorphism within several human genes that encode enzymes, structural proteins, signalling molecules and receptors that are involved in the regulation and formation of the melanin biosynthetic pathway. Functional analysis of the human pigmentation gene set will ultimately provide a full appreciation of this biological system linking genotype with phenotype. Specifically the role of the MC1R gene variants in directing skin phototype and response to UV-induced ligand binding and receptor activation is a major area of investigation. Preliminary results of our research will be presented.

Paediatric Symposium 2 What’s new in atopic dermatitis A.S. Paller Departments of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America Our increased understanding of the underlying mechanism of atopic dermatitis (AD) will change the landscape of

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therapy in the next decade. The key role of emollients and increasing hydration, given barrier insufficiency, has been emphasized. Emollients containing deficient epidermal components, such as ceramides, are now available, and wet wraps have received increasing attention. The possibility of pro-actively improving the barrier through topical application in at-risk neonates and infants has also received attention. Topical steroids remain the mainstay of therapy, with topical calcineurin inhibitors (TCIs) as steroid-sparing agents. Concern about the effects of topical steroids on barrier function and the risk of local burning with TCI application has led to rotational schemes, with mediumstrength or potent topical steroids used briefly for acute flares, followed by TCIs, preferential use of TCIs for the face and neck, and “pro-active” therapy with application of either medium-strength topical steroid or TCIs applied two to three times weekly to prevent flares. Topical PDE4 inhibitors are promising nonsteroidal anti-inflammatory topical approach. Given the importance of S. aureus as a trigger of inflammation, maintenance therapy with dilute sodium hypochlorite (bleach) baths decreases both the risk of infection and the severity of the dermatitis; alternative forms are now available for use in the shower. Systemically administered IL4R inhibition leads to significant improvement in moderate to severe disease and reverses the AD biomarker abnormalities.

References 1.

Boguniewicz, M., Leung, D.Y. (2013) The ABC’s of managing patients with severe atopic dermatitis. J Allergy Clin Immunol. 132(2): 511–2. 2. Paller, A.S., Simpson, E.L., Eichenfield, L.F., Ellis, C.N., Mancini, A.J. (2012) Treatment strategies for atopic dermatitis: optimizing the available therapeutic options. Semin Cutan Med Surg. 31(3 Suppl): S10–7. 3. Paller, A.S. (2012) Latest approaches to treating atopic dermatitis. Chem Immunol Allergy. 96: 132–40.

Managing treatment adherence confounders in paediatric atopic dermatitis A. Sokolova1, S. Smith2,3 1 Gosford District Hospital, Gosford, New South Wales, Australia 2 Department of Dermatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia 3 The Dermatology and Skin Cancer Centre, Gosford, New South Wales, Australia Atopic dermatitis (AD) is a chronic relapsing inflammatory disease of the skin and is the most common pediatric dermatological condition.1 While no cure is available, it can be treated effectively if adherence to a therapeutic plan is maintained.2,3 Despite this, poor adherence to treatment is common4 and is one of the main causes of treatment failure. Poor treatment outcomes in AD have important implications for patients, their families and society.5 Therefore, it is important to identify potential treatment adherence confounders and know the evidence based strategies to manage them.


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References

Genital Dermatology Symposium

1. 2.

Bieber T. Atopic dermatitis. N. Engl. J. Med. 2008; 358: 1483–94. Krakowski AC, Eichenfield LF, Dohil MA. Management of atopic dermatitis in the pediatric population. Pediatrics 2008; 122: 812– 24. 3. Gupta G, Mallefet P, Kress DW et al. Adherence to topical dermatological therapy: lessons from oral drug treatment. Br. J. Dermatol. 2009; 161: 221–7. 4. Krejci-Manwaring J, Tusa MG, Carroll C et al. Stealth monitoring of adherence to topical medication: adherence is very poor in children with atopic dermatitis. J. Am. Acad. Dermatol. 2007; 56: 211–16. 5. Carroll CL, Balkrishnan R, Feldman SR et al. The burden of atopic dermatitis: impact on the patient, family and society. Pediatr. Dermatol. 2005; 22: 192–9.

Update on male genital dermatology A. Hall Geelong, Victoria, Australia This presentation will update knowledge of common dermatoses that may involve male genitalia (dermatitis, psoriasis, lichen planus), some infective and non-infective dermatoses with a predilection for male genitalia (not covered by other speakers) and important pre-malignant and malignant genital diseases not to be missed by clinicians.

Plenary Session 2

Facial Beauty Symposium Body image disorders in dermatology settings: More than skin deep D.J. Castle St Vincent’s Mental Health Service, The University of Melbourne, Melbourne, Victoria, Australia Objective: To review the research pertaining to body image disorders in dermatological practice, and to provide tips for screening in such settings. Content: Some degree of concern with appearance is normal. However, for some people, the concern becomes extreme and causes subjective distress and impairment in social and other life roles. In such extreme cases, individuals are considered to have body dysmorphic disorder (BDD). BDD can be very distressing and disabling, but is treatable using a combination of psychological and pharmacological interventions. BDD patients see their ‘problem’ as cosmetic rather than psychiatric so tend to seek interventions from cosmetic specialists. This talk concentrates on BDD in dermatological settings and provides pointers to screening in such settings.

Ethnicity and beauty M. Rodrigues Laser Dermatology, Box Hill and Frankston Dermatology, Frankston, Victoria, Australia Australia is already one of the most multi-cultural countries in the world with an increasing ethnic population noted in most parts of the country every year. This ethnically and racially diverse group may strive for fairer, flawless skin, desire particular facial aesthetics and revere certain physical attributes.

Contemplative dermatology: Skin with soul? A.C. Lim Department of Dermatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia As knowledge of skin diseases steadily improve with technological and biomedical progress, the overall quality of patient care should correspondingly increase. But has it? A greater understanding of skin diseases should be matched with a meaningful insight into the psychosocial and spiritual aspects of patient welfare. Contemplative dermatology is the practice of effective clinical dermatology in the setting of compassion and respect for the patient. The attainment of clinical wisdom comes with a progressively maturing outlook where egocentric goals become attenuated by humanitarian priorities for the betterment of our patients, the community and beyond. As the specialty of dermatology matures, it is desirable that the profession advocates a more integrative practice where the focus on dermatological disease is broadened to include the patient’s physical and metaphysical makeup. Factors conducive to the practice of contemplative dermatology include: attentiveness, empathy and compassion. Less orthodox traits include: emotional honesty, vulnerability and the development of the healing-touch. The practice of contemplative dermatology is potentially beneficial, possibly transformational, for both patient and dermatologist. Any proposed link between skin and spirituality would at first appear tenuous and counterintuitive. However, the boundaries of skin, psyche and its personal space and aesthetics reflect a fascinating duality reminiscent of the paradox between a sense of ‘self’ versus that of shared humanity. Further contemplation will yield other surprising metaphors ranging from quantum physics to new-age mysticism.

It is therefore imperative that the treating dermatologist is aware of the most commonly desired cosmetic dermatology procedures in this group, the reasons behind such choices and the best management approaches to these problems.


ACD 47th Annual Scientific Meeting 2014

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References

Psoriasis Symposium Paediatric psoriasis: Co-morbidities and complex management A.S. Paller Departments of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America Psoriasis in children has been associated with several co-morbidities. In addition to psoriatic arthritis, inflammatory bowel disease (particularly Crohn’s), and depression, metabolic issues are increasingly being recognized, as they have been in adults with psoriasis. Children of any psoriasis severity are at risk for being overweight or obese, with the risk of obesity increased by greater disease severity. Recent data shows that the obesity precedes the psoriasis in virtually all affected children with psoriasis and excess adiposity. Early evidence suggests other metabolic risks, including central adiposity, hyperlipidemia and possibly hypertension. For severe patients recalcitrant to topical management alone, phototherapy and methotrexate have shown excellent efficacy. Biologics, particularly etanercept and adalimumab, have become a more convenient alternative, albeit costly, in management; the long-term safety of all of systemic interventions in children is unknown.

References 1.

Paller, A.S., Mercy, K., Kwasny, M.J., Choon, S.E., Cordoro, K.M., Girolomoni, G., Menter, A., Tom, W.L., Mahoney, A.M., Oostveen, A.M., Seyger, M.M. (2013) Association of pediatric psoriasis severity with excess and central adiposity: an international cross-sectional study. JAMA Dermatol. 149: 166–76. 2. Marqueling, A.L., Cordoro, K.M. (2013) Systemic treatments for severe pediatric psoriasis: a practical approach. Dermatol Clin. 31: 267–88.

Metabolic syndrome in children with psoriasis: Prevalence in an Australian cohort A. Lee, S. Dixit, S. Smith, S. Venugopal, G. Fischer Department of Dermatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia Introduction: A recent international cross-sectional study of a cohort of children aged 5–17 from the Americas, Europe and Malaysia has concluded that metabolic syndrome is a risk in children with psoriasis. This has important implications for management. We investigate the prevalence of metabolic syndrome in a cross-sectional study of Australian children presenting to the authors with psoriasis, dividing the cohort into pre-pubertal and pubertal children. A control group of children with non-inflammatory conditions will be compared to the group with psoriasis. Method: All children with psoriasis presenting to the authors between January and March 2012 were assessed for severity using Static Physician Global Assessment, Body Mass Index percentile and central adiposity (waist circumference percentile to waist to height ratio). Results: The results of the study will be presented.

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Paller AS, Mercy KM, Kwasny MJ et al. Association of pediatric psoriasis severity with excess and central adiposity. JAMA 2013; 149: 166–76. 2. Goldminz AM, Buzney CD, Kim N et al. Prevalence of the metabolic syndrome in children with psoriatic disease. Pediatr. Dermatol. 2013; 30: 700–5.

RNA sequencing and psoriasis S. Gilmore Dermatology Research Centre, University of Queensland, Brisbane, Queensland, Australia RNA sequencing (RNA-Seq) is a next-generation technology capable, in principle, of detecting and accurately quantifying all RNA species within a biologic specimen. Unlike microarrays, which provide approximate abundance levels of known RNA species, RNA-Seq can identify novel RNA, hitherto unknown exons, and splice variants. In addition, RNA-Seq operates at the resolution of single base pairs, permitting the accurate identification of single nucleotide polymorphisms. Here I introduce the methodology of RNASeq and discuss its application in psoriasis. I briefly describe two important research agendas: first, its utility in identifying the key genetic network motifs that underpin both the predisposition to and persistence of disease; and second, its implementation in personalised medicine: the prediction of individuals’ responses to targeted therapy. Review of safety response to progressive multifocal leukoencephalopathy associated with biologics to treat severe chronic plaque psoriasis and multiple sclerosis J.R. Sullivan Holdsworth House Medical Practice, Darlinghurst, New South Wales, Australia The medical/pharma safety response to progressive multifocal leukoencephalopathy (PML) associated with biologics to treat severe chronic plaque psoriasis and multiple sclerosis are reviewed. PML due to the JC virus highlights the importance and potentially devastating consequences of latent viral infections. These can represent a delayed adverse event or reaction with immune targeting therapies for chronic conditions. When several severe psoriasis patients treated for several years with continuous efalizumab developed PML the biologic was rapidly withdrawn. The occurrence of PML in multiple sclerosis patients on natalizumab resulted in stakeholder discussions, and a risk minimization approach that continues to be refined. A greater focus subsequently was placed on developing biologics targeting disease-associated cytokines over lymphocyte tissue migration mechanisms. PML also highlights why immune active therapies require safety specific considerations that take into account the duration of therapy, the study of older patient cohorts, prior immunosuppressive exposures and disease specific considerations.


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Thus with new novel pharmaceutical agents we should remain vigilant for the occurrence of delayed treatment associated reactions and atypical disease presentations. It is also important that we learn from serious adverse drug reactions, how they were handled and apply the lessons to our established and new novel therapies and disease management strategies.

Update on biologics P. Foley Melbourne, Victoria, Australia The 2006 PBS-listing of efalizumab represented the first approved advancement in the management of moderate to severe chronic plaque psoriasis for over a decade. Whilst efalizumab has come and gone, four further biological agents have been listed for psoriasis: tumour necrosis factor antagonists – etanacept, infliximab and adalimumab, and the anti-p40 common subunit of interleukins 12 and 23 monoclonal antibody ustekinumab. There are currently six molecules in late phase development for moderate to severe psoriasis; two oral small molecules – apremilast (phosphodiesterase E4 inhibitor) and tofacitinib (janus kinase 1 & 3 inhibitor), and four monoclonal antibodies – two to interleukin-17A (secukinumab and ixekizumab), one to the interleukin 17RA (brodaumab) and one to the p19 subunit of interleukin 23 (tildrakizumab). Mode of action, and topline safety and efficacy will be presented, along with an update on currently available therapies.

Melanoma Symposium 2 Solaria in Perth, Western Australia: Compliance with the Australia/New Zealand Standard N.A. O’Sullivan1, C.P. Tait1,2 1 Royal Perth Hospital, Perth, Western Australia, Australia 2 Dermatology Specialist Group, Ardross, Western Australia, Australia There is a robust body of evidence that links tanning bed use to an increased risk of both melanoma and nonmelanoma skin cancer. An increase in restrictions and legislation has been introduced globally in response to this. However, poor compliance with and enforcement of, both state and federal legislation has been widely documented. Currently all but two States (Western Australia and The Northern Territory) have proposed complete bans on indoor tanning based upon increasing evidence of a causal link with both melanoma and non-melanoma skin cancer. There is sufficient current evidence to suggest anything short of a complete ban will not be effective in modification of artificial tanning behaviour. In the context of negative publicity surrounding tanning beds, our aim was to determine the compliance with the Australia/New Zealand Standard guidelines for tanning bed safety in Perth, Western Australia.

observation e.g. presence /absence of warning signs/ consent forms. The adherence to age restrictions, skin type restrictions, skin cancer warnings, use of consent forms was recorded. The results will be discussed and should strengthen the ban for a complete Australasian ban on tanning bed use and have important implications globally.

Skin self-examination with mobile teledermoscopy: A new consumer triage tool? M.N. Manahan1,3, C. Horsham1, M. Janda1, L.J. Loescher2, H.P. Soyer3 1 School of Public Health and Social Work, Queensland Institute of Technology, Brisbane, Queensland, Australia 2 The University of Arizona Skin Cancer Institute, Tucson, Arizona, USA 3 Dermatology Research Centre, School of Medicine, Translational Research Institute, The University of Queensland, Brisbane, Queensland, Australia Background: Smartphones with sophisticated camera optics are ubiquitous. Attachments for these phones allow them to become mobile teledermatoscopes. However, can mobile teledermoscopy (MTD) safely aid skin selfexamination (SSE)? Is MTD an appropriate triage method to identify lesions at risk of being a melanoma? Methods: From May to November 2013, 50 participants between ages 50 and 66 years with access to an iPhone™ received: (a) a dermatoscope attachment for their iPhone; (b) educational materials on the asymmetry-color (AC) rule; and (c) instructions for photographing and emailing images for telediagnosis. All participants later had a clinical skin examination (CSE) with a dermatologist. Results: Participants submitted 312 photographs (median of 5 per person; range 0–21). Two images were of insufficient quality and three were photographs without the dermoscopic image. For 34 patients, SSE aided by MTD detected suspicious lesions that under any circumstance would require follow up. CSE detected 39 additional lesions (in 25 study participants) not submitted for telediagnosis that required management or close monitoring, including 14 pigmented lesions and 28 non-pigmented lesions. As a screening tool for further intervention, SSE with MTD had a sensitivity of 81.8% ± 13.16 when compared to clinical diagnosis during CSE. Conclusions: Consumers receiving brief education can identify suspicious lesions and submit dermoscopic images of sufficient quality for telediagnosis. This method may be useful for triaging lesions to enable prompt follow up care. Randomised trials of SSE aided by MTD are required before this method can be recommended for screening.

Researchers approached tanning salons in Perth by telephone and in person posing as prospective customers. Compliance to the Australia/New Zealand Standard was assessed using a standardised set of direct questions or © 2014 The Authors Australasian Journal of Dermatology © 2014 The Australasian College of Dermatologists

ACD 47th Annual Scientific Meeting 2014 The correlation of skin colour with dermoscopic naevus patterns in a Queensland high risk melanoma cohort N. Ong1, D. Duffy2, E. McEniery1, P. McClenahan1, K. Jagirdar3, R. Sturm3, H.P. Soyer1 1 Dermatology Research Centre, School of Medicine, Translational Research Institute, The University of Queensland, Brisbane, Queensland, Australia 2 Queensland Institute of Medical Research, Brisbane, Queensland, Australia 3 Institute of Molecular Biosciences, The University of Queensland, Brisbane, Queensland, Australia The average Australian has a 1 in 17 risk of developing melanoma by age 85. In the risk stratification process, the intrinsic link between the rising incidence of cutaneous melanoma and constitutive skin colour is considered. There are also established genes associated with melanoma risk phenotypes. Melanocortin-1 receptor (MC1R) is a receptor responsible for production of the darker eumelanin pigment and the tanning response. The aim of the study was to examine the relationship between counts of naevi of each dermoscopic pattern (globular, reticular, nonspecific) and the individual’s signature naevus pattern with Fitzpatrick Skin Type and constitutive skin colour. The influence of MC1R on phenotypic characteristics, such as freckling, was investigated. In this cross-sectional study, 175 patients were recruited. Constitutive skin colour was measured using a spectrophotometer, and a device for standard and dermoscopic sequential imaging was utilised for total body images and dermoscopic images of naevi. Fitzpatrick Skin Type and freckling were scored from total body images. Our results established significant differences between constitutive skin colour and signature naevus pattern (Kruskal Wallis test, P = 0.001), and there was considerable variation between naevus pattern counts and freckling score (P = 5.37 × 10−12). Between MC1R genotypes, differences in freckling scores for various body sites were significant(face P = 0.001; shoulders P = 2.91 × 10−5, hands P = 5.67 × 10−10). These findings demonstrate that variations in skin colour exhibit differences in dermoscopic naevus pattern. This study may aid in melanoma risk stratification, whilst exemplifying the influence of genetics on phenotype.

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Naevus phenotypes in homozygous MC1R RHC-variant allele carriers R.A. Sturm1, P. McClenahan2, K. Jagirdar1,2, K. Sivakumaran2,3, E. McEniery2, S. Beh2, B. Burke2, D.L. Duffy4, H.P. Soyer2,3 1 Melanogenix Group, Institute for Molecular Bioscience, The University of Queensland, Brisbane, Queensland, Australia 2 Dermatolgy Research Centre, School of Medicine, Princess Alexandra Hospital, The University of Queensland, Brisbane, Queensland, Australia 3 Department of Dermatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia 4 QIMR-Berghofer Medical Research Institute, Brisbane, Queensland, Australia Introduction: The total number count (TNC) of acquired melanocytic nevi is the strongest risk factor for cutaneous malignant melanoma (CMM). An increased risk is also seen with individuals with red hair, fair skin and poor tanning ability, the RHC phenotype; and also those carry variant alleles of the MC1R gene designated as R. We wished to determine if there is any commonality in the genotype and naevus phenotype. Method: Patients with personal or first degree family history of melanoma formed a high risk cohort with a control group of lacking melanoma history, 500 individuals in total. Clinical assessment using pigmentation characteristics and classification of nevi including individual dermoscopic images was performed. Genotyping was performed with particular attention to the MC1R gene. Results: 31 individuals were MC1R R/R homozygotes. Body mass index (BMI), body surface area (BSA), TNC and MC1R genotype were analysed and found that participants with personal melanoma history had higher TNC (P = 0.005). We found no association between MC1R genotype and BMI but there exists a weak association between BSA and higher TNC. Within the MC1R R/R cohort, melanoma patients are more likely to have high TNC than controls (P = 0.02). The signature dermoscopic pattern for the individuals in the MC1R R/R group is at increased odds of being a non-specific pattern (P = 0.015). A significant difference in MC1R R/R TNC dependent on melanoma history exists and there is a predisposition towards a non-specific signature naevus pattern. Ultimately the TNC is still the strongest prediction of melanoma risk and overrides the influence of the MC1R gene. Melanoma prognosis differs according to sex: An Australian population study L. Byrom1, P. Dasgupta2, D. Youlden2, P. Baade2, A. Green3, K. Khosrotehrani1 1 UQ Centre for Clinical Research and Diamantina Institute, The University of Queensland, Brisbane, Queensland, Australia 2 Cancer Council Queensland, Brisbane, Queensland, Australia 3 QIMR Berghofer Medical Research Centre, Brisbane, Queensland, Australia Introduction: Women diagnosed with melanoma have been reported in European and American cohorts to have a


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survival advantage over men. This has been shown to persist at all stages of the disease even upon occurrence of regional nodal or distant metastases. Although biological rather than socio-economic factors have been suspected to explain this difference, there has been no clear explanation to date. We here aimed at comparing survival of men versus women in an Australian cohort and further hypothesized that pregnancy may be an important influencing factor and thus aimed to compare survival rates between men and women within and outside childbearing years.

with complete clinical information and details of primary tumour thickness, ulcerative state and mitotic rate (mitoses/mm2) were studied. Factors predicting melanomaspecific survival were analyzed using the Cox proportional hazards regression model. To determine the prognostic significance of MR in the multivariate analysis, three separate methods were used. For Method A, MR was examined as a continuous variable. For Method B, MR was grouped into 7 categories and for Method C, MR was categorically coded prior to analysis as a continuous variable.

Methods: We conducted a retrospective registry based cohort study identifying patients who were diagnosed with locally invasive melanoma between 1982 and 2008. 10-year melanoma specific survival rates in men and women were adjusted for major clinicopathological prognostic factors. They were grouped as per age category (15–44 years and >45 years) representing different reproductive phases in life.

Results: By univariate analysis, survival times declined as mitotic rate increased. 5-year survival ranged from 94% for patients whose tumours had 0 mitoses/mm2 to 71% for those with ≥ 10 mitoses/mm2. By multivariate regression analysis, MR did not reach independent statistical significance when examined according to Method A and Method B, however it did in Method C. Ulceration was a stronger predictor of survival than mitotic rate.

Findings: We analysed 14 177 males and 11 300 females diagnosed with melanoma. There was a significant increased risk of melanoma death in the male group (HR 1.70 95%CI 1.46–1.98, P < 0.001). However, when grouped as per age category, men and women aged 15–44 years did not differ in survival regardless of tumour thickness. The influence of gender on survival was however persistent for patients over 45 years of age.

Conclusion: Tumour thickness and ulceration remained as dominant prognostic factors for primary invasive melanoma. The prognostic value of MR varied depending on the method of statistical analysis.

Limitations: Smaller numbers of melanoma patients in groups below 45-years old might reduce statistical power.

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Conclusion: Our study reproduces previous observations of improved survival rates in women diagnosed with melanoma in both European and American cohorts. Our results also suggest that gender differences in survival are more prominent after childbearing years. Further studies are needed to evaluate a long lasting effect of pregnancy on melanoma outcome.

References Balch CM, Gershenwald JE et al. Final version of 2009 AJCC melanoma staging and classification. J. Clin. Oncol. 2009; 27: 6199–206. 2. Thompson JF, Soong SJ et al. Prognostic significance of mitotic rate in localized primary cutaneous melanoma: an analysis of patients in the multi-institutional American Joint Committee on Cancer melanoma staging database. J. Clin. Oncol. 2011; 29: 2199–205.

Aim: This study was designed to investigate MR as a prognostic factor in a large cohort of Australian patients.

A genome wide association study of survival in locally invasive melanoma C. Rowe1, M. Law2, J. Palmer2, S. MacGregor2, N. Hayward2, K. Khosrotehrani1 1 UQ Diamantina Institute and UQ Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia 2 QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia Introduction: For patients with locally invasive cutaneous melanoma, current staging guidelines lack the ability to fully identify those high risk patients likely to progress despite surgical excision of the primary tumour. Tumour progression towards metastasis is controlled by a range of tumour and host related factors that cannot be encompassed by studies focusing on tumour cells or tissue only. We here conducted a genome wide single nucleotide polymorphism (SNP) association study in non-tumoural DNA to identify the host genetic determinants of survival in locally invasive melanoma.

Methodology: This is a retrospective cohort study of patients treated at the Victorian Melanoma Service between January 1st, 2006 and December 31st, 2011. 1396 patients

Methods: Patients with a single primary invasive lesion and existing genotype data were sourced from a preexisting database, the Queensland Study of Melanoma:

The role of mitotic rate in melanoma survival in a cohort of 1396 Australian patients S. Shen1, R. Wolfe2, C.A. McLean3, V. Mar1, M. Haskett1, J.W. Kelly1 1 Victorian Melanoma Service, Alfred Hospital, Melbourne, Victoria, Australia 2 Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia 3 Department of Anatomical Pathology, Alfred Hospital, Melbourne, Victoria, Australia Background: Mitotic rate (MR), a quantifiable measure of tumour cell proliferation, has been shown to further define the risk categories for patients with primary localized melanoma.1,2


ACD 47th Annual Scientific Meeting 2014 Environmental and Genetic Associations. Information on disease progression was obtained from the Queensland Cancer Registry and death status was confirmed with the National Death Index. A genome-wide analysis of SNPs was performed to identify variants associated with survival. A cox proportional hazards model was used for survival analysis, using imputed genotype data. Results: A total of 878 patients fulfilled the inclusion criteria. The cohort was comprised of 413 males and 465 females. Average age at diagnosis was 43 years; average Breslow thickness was 0.82 mm. Average follow-up time for metastasis was 21 years (± 0.18) and average follow-up time for death was 24 years (± 0.15) 59 patients developed a metastasis and 173 died during follow-up with 27 deaths being caused by melanoma. In cox proportional hazards analyses, Breslow thickness was associated with death from melanoma. Analysis of association of genotype data with survival revealed 30 single nucleotide variants with P-values less than 5e−5 threshold, with chromosome 19 most strongly represented. Conclusion: This is the first genome wide association study on survival in melanoma. Although the power of analysis was reduced due to the small number of deaths from melanoma, it shows for the first time that melanoma survival is in part determined by the host genome. Our findings might lead the way to better identification of prognostic indicators.

Increased risk of melanoma mortality in pregnancy-associated tumours: A systematic review and meta-analysis L. Byrom1,2,3, C. Olsen2, L. Knight2, K. Khosrotehrani1,3. A.C. Green2,4 1 UQ Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia 2 QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia 3 UQ Diamantina Institute, The University of Queensland, Brisbane, Queensland, Australia 4 Institute of Inflammation and Repair, University of Manchester, Manchester, UK Background: Melanomas diagnosed during pregnancy have been suspected to have a poorer prognosis than those occurring in women outside pregnancy but evidence is inconsistent. We conducted a systematic review and metaanalysis to assess the effect of intercurrent pregnancy on melanoma prognosis. Methods: Five databases (Cochrane Database, MEDLINE, EMBASE, CINAHL, and PUBMED) were searched for studies assessing the effect of pregnancy on prognosis of localised invasive melanomas. “Pregnancy” was defined as during gestation and up to 12 months post-partum. To evaluate the effect of intercurrent pregnancy on the course of melanoma, we compared outcomes for melanomas occurring in pregnant women and those occurring in nonpregnant women. Individual study effect estimates were pooled using the weighted average method.

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Findings: Of 305 citations identified, 22 studies involving 19832 patients met the inclusion criteria. Of these, four contributed towards the pooled estimate of effect for risk of melanoma death for melanomas occurring during pregnancy and all were adjusted for patient age and anatomical site, thickness and level of invasion of melanoma. There was an increased risk of death from melanomas diagnosed in women during pregnancy compared with melanomas unrelated to pregnancy (HR 1·56, 95% CI 1.23–1.99). Of the remaining 18 studies with qualitative results, 3 demonstrated an increased risk of melanoma death and recurrence in women who had intercurrent pregnancy while 11 showed no apparent effect of intercurrent pregnancy on melanoma outcome, though most of the studies without quantitative results lacked statistical power and adequate adjustment for confounding factors. Interpretation: On balance, the evidence suggests that melanomas coinciding with pregnancy are associated with poorer outcome than those occurring outside pregnancy.

Rose Bengal melanoma therapy: Phototoxicity versus intrinsic cytotoxicity P.R.B.B. Nascimento1, K. Baesler1, J. Knuever1, G. Douglas1, A. Anfosso1, W. Weninger1,2, N. K. Haass1,2,3 1 The Centenary Institute, Sydney, New South Wales, Australia 2 Discipline of Dermatology, University of Sydney, Sydney, New South Wales, Australia 3 The University of Queensland Diamantina Institute, Translational Research Institute, The University of Queensland, Brisbane, Queensland, Australia Introduction: Rose Bengal (RB) is a fluorescent compound that has been used in ophthalmology for diagnostics of corneal damage. RB is a photosensitizer and its phototoxicity is well characterized. Recently, it has been tested as an intralesional agent for the treatment of cutaneous melanoma metastases and is currently undergoing a Phase II trial. However, the mechanism of action of RB on melanoma is poorly understood. Method: In addition to standard assays we also used more unique approaches. We transduced melanoma cells with fluorescently labeled LC3 to visualize the accumulation of LC3II in the membrane of autophagosomes. Further, we combined the fluorescent properties of RB with live/dead stains to perform 3-colour fluorescence imaging of 3D melanoma spheroids. Results: RB had a dose-dependent cytotoxic effect on melanoma cells but not fibroblasts in the absence of light or upon exposure to red light (633 nm). In contrast, exposure to UV or green light (561 nm) caused profound phototoxicity. In 3D melanoma spheroids, RB had a time- and dosedependent effect on melanoma cell death. In addition, RB exerted its toxicity through necrosis without perturbation of the cell cycle and the effects observed in the dark were independent of the phototoxic generation of ROS. Finally, we showed that RB induced autophagy in melanoma cells indicating a possible mechanism of action.


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Conclusion: In contrast, to RB’s phototoxicity its intrinsic cytotoxicity has a wider therapeutic window. Here we showed that an interplay of necrosis and autophagy is one possible mechanism of action for RB.

Nicotinamide enhances DNA repair by replenishing cellular energy B. Kim1,2, G.M. Halliday1,2, D.L. Damian1,2 1 Dermatology Research Laboratories, Bosch Institute, The University of Sydney, Sydney, New South Wales, Australia 2 Department of Dermatology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia Skin cancers remain a major public health burden, despite increased public awareness of the causative role of UV radiation (UVR). UVR is a potent environmental carcinogen. It causes both genetic damage and suppresses cutaneous immunity. Nicotinamide, the amide form of niacin (vitamin B3), is a promising agent shown to be immunoprotective and to enhance DNA repair. Nicotinamide may be protective via its role in cellular energy pathways, as it is the primary precursor of NAD+, which is an essential coenzyme in ATP production. UVR decreases cellular energy through glycolytic blockade and ATP depletion, and nicotinamide is thought to reverse this cellular energy depletion. We have investigated the effect of nicotinamide on genetic damage by performing a series of DNA repair assays on several human cell lines. We assessed the effect of a highly selective nicotinamide phosphoribosyltransferase inhibitor, FK866, on nicotinamide protection from cyclobutane pyrimidine dimer (CPD) and 8-oxo-7,8-dihydroguanine (8oxoG) DNA photolesions. Solar simulated UVR and immunofluorescence antibody assays were used. FK 666 has been shown to modulate the NAD rescue pathway by blocking NAD production. We found that nicotinamide enhances repair of both CPDs and 8oxoG in UV-irradiated HaCaT keratinocytes (P < 0.001), pheomelanin-producing primary melanocytes (P < 0.001), eumelanin-producing primary melanocytes (P < 0.001) and normal human epidermal keratinocytes (P < 0.001). These protective effects are reversed in all cell lines by the addition of FK 866 (P < 0.001). Hence nicotinamide seems to exert its protective effects by preventing UV-induced cellular ATP loss. Nicotinamide is a promising agent for chemoprevention of melanoma and nonmelanoma skin cancers.

Surgery Symposium Time saving tips E. Upjohn Melbourne, Victoria, Australia Dermatologic surgery often involves the use of standard techniques, processes and systems that are then applied to individual patients. The efficient performance of these processes can result in savings of time for the patient and surgeon and also lead to the optimal cosmetic and functional outcome. Techniques for managing anaesthesia,

grafts and their donor sites, haemostasis, scalp closures and the follow up of results will be discussed.

Antimicrobial stewardship and surgical site infection: An evidence based approach C. Vinciullo Perth, Western Australia, Australia The modern imperative of antimicrobial stewardship (AMS) requires that the use of antimicrobials is optimized in order to improve patient outcomes, ensure cost-effective therapy and reduce adverse sequelae of antimicrobial use, including antimicrobial resistance. A large prospective randomized controlled trial (RCT) was undertaken to assess the impact of targeted topical decolonization on the rate of surgical site infection following Mohs surgery. The increased relative risk (RR) of surgical site infection in nasal carriers of staphylococcus aureus versus non-carriers is 3.4 (P = 0.001) irrespective of surgical site, surgical defect size, type of reconstruction or associated medical co-morbidity.1 Carriers were randomized to either 5 days of pre-operative topical decolonization with intranasal mupirocin ointment and full face and body 4% chlorhexidine gluconate wash or no treatment. The RR of SSI in decolonized carriers versus non-decolonized carriers is 0.3 (P = 0.05). The RR of infection in a decolonized carrier versus a non carrier is 1.2 A second large prospective RCT has shown that the use of oral antibiotic prophylaxis with 2g cephalexin preoperatively and 1g 6 hours post operatively in nasal carriers of staphylococcus aureus is ineffective at reducing SSI following Mohs surgery when compared to 5 days of topical decolonization2 (P = 0.003) In these studies, patient risk of SSI is stratified according to nasal carriage of staphylococcus aureus (25-30% of all patients). In previously published reports endogenous carriage of staphylococcus aureus has been shown to be the source of SSI in up to 85% of cases3 Patients with negative nasal swabs are not immune to infection. Endogenous staphylococcus aureus is carried in other sites such as the oropharynx, flexures, web spaces, groin and perineum which has the potential to lead to colonization of wounds and SSI. The background SSI rate in noncarriers of staphylococcus aureus reported in these studies varies between 3–6%. This is within the accepted range for SSI (30%. Seven of the nine patients were also administered systemic steroids and half were commenced on systemic antimicrobials. Nanocrystalline silver impregnated gauze dressings (Acticoat™) were used in all patients.

References 1.

Downey A, Jackson C, Harun N et al. Toxic epidermal necrolysis: review of pathogenesis and management. J. Am. Acad. Dermatol. 2012; 66: 995–1003. 2. Garcia-Doval I, LcCleach L, Bocquet H et al. Toxic epidermal necrolysis and Stevens-Johnson syndrome: does early withdrawal of causative drugs decrease the risk of death? Arch. Dermatol. 2000; 136: 323–7. 3. Palmieri T, Greenhalgh D, Saffle R et al. A multicenter review of toxic epidermal necrolysis treated in U.S. burn centers at the end of the twentieth century. J. Burn Care Rehabil. 2002; 23: 87–96. 4. Huang S, Yang P, Wu S et al. Aquacel ag with Vaseline guaze in the management of toxic epidermal necrolysis (TEN). Burns 2009; 56: 121–6.


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Hidradenitis suppurativa: Effect on quality of life, continuum of cutaneous presentations, and hope for future treatment options E. McMeniman1,2, L. Buchanan1,2, H.P. Soyer1,2 1 Dermatology Research Centre, School of Medicine, Translational Research Institute, The University of Queensland, Brisbane, Queensland, Australia 2 Department of Dermatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia Hidradenitis suppurativa (HS) is a chronic, relapsing suppurative skin disease. It can be severely disabling to normal functioning and enjoyment of life.1–3 The quality of life scores for patients with this disease are worse than those of most other dermatological diseases, with reported mean of 12.67 ± 7.7.1,2 Issues include psychological effects of the disease and stigmatization.4 We report quality of life findings from a cohort of 8 patients with HS who enrolled in a phase 3 trial for use of adalimumab to treat their condition. Smoking is a known risk factor and we found very high rates of urinary nicotine metabolites in 7 of our 8 patients, even in patients reporting very low intake of cigarettes. There are various forms of this disease, including early lesions of single follicular occlusion, progressing to polyporous comedones, and inflammatory lesions such as nodules, abscesses and fistula. From our case series we report the various patterns which emerge in severe HS. Two patients had severe, confluent inflammatory lesions confined to the buttock and groin, they both ooze copious amounts of odorous pus. Other patients have multiple polyporous comedones, spread over many body sites, but little in the way of discharge and less inflammation. The Hurley stage is traditionally used however provides no information about variations in nodule or fistula count. A much better clinical score is the satorius scoring method, example cases and how to calculate score will be discussed. The documentation of this scoring is imperative to monitoring of treatment outcomes. Treatment options are many and will be reviewed.

References 1.

Wolkenstein P, Loundou A, Barrau K et al. Quality of life impairment in hidradenitits suppuritiva: a study of 61 cases. JAAD 2006; 56: 621–3. 2. Matusiak L, Bieniek A, Szepietowski J. Psychophysical Aspects of Hidradenitis Suppurativa. Acta Dermato-Venerologica 2010; 90: 264–8. 3. Wollina V, Koch A, Heinig B et al. Acne inversa (hidradenitis suppuritiva): a review with focus on pathogenesis and treatment. Indian J. Online 2013; 4: 2–11. 4. Esmann S, Jemec G. Psychosocial impact of hidradenitits suppurativa: a qualitative study. Acta Derm. Venereal. 2011; 91: 328–32.

Oral manifestations and management of dental health in autoimmune blistering diseases N.G. Maher1, D. F. Murrell1,2 1 Department of Dermatology, St George Hospital, Kogarah, New South Wales, Australia 2 Facuty of Medicine, University of New South Wales, Sydney, New South Wales, Australia Autoimmune blistering diseases (AIBD), including particularly pemphigus vulgaris, mucous membrane pemphigoid and epidermolysis bullosa acquisita, may afflict the oral environment with a variety of lesions and clinical presentations. This includes blisters, erosions, ulcerations, atrophy, desquamative gingivitis, enamel hypoplasia, microstomia, ankylogossia, and vestibular obliteration.1–3 These manifestations have implications for oral health care provision and the systemic well being of the patient. Oral symptoms are one of the most significant issues affecting quality of life in patients with AIBD.4 Strategies should be in place to promote remineralization, and prevent demineralization of the tooth enamel. Dietary advice is crucial, given the altered clearance of food, the cariogenic nature of different foods, the difficulty with maintaining adequate nutrition, and the friable nature of the oral tissues in autoimmune blistering disease.1 Prophylaxis may be indicated to prevent against opportunistic oral infection, due to the compromised mucosal barrier and immunosuppressive therapies. Interventional dental treatment approaches, such as local anaesthetic administration and restorative procedures, need to be modified to adapt to the clinical scenario in autoimmune blistering disease.1

References 1.

Wright J, Fine J, Johnson L. Hereditary epidermolysis bullosa: oral manifestations and dental management. Pediatr. Dent. 1993; 15: 242–8. 2. Ata-Ali F, Ata-Ali J. Pemphigus vulgaris and mucous membrane pemphigoid: Update on etiopathogenesis, oral manifestations and management. J. Clin. Exp. Dent. 2011; 3: e246–50. 3. Gupta R, Woodley DT, Chen M. Epidermolysis Bullosa Acquista. Clin. Dermatol. 2012; 30: 60–9. 4. Sebaratnam DF, Hanna AM, Chee SN et al. Development of a quality-of-life instrument for autoimmune bullous disease: the Autoimmune Bullous Disease Quality of Life questionnaire. JAMA Dermatol. 2013; 149: 1186–91.

Treatment of autoimmune blistering diseases following the lymphoma protocol for rituximab: A case series of 9 patients M.C. Doria1,2, Y.N. Loh2, D.F. Murrell2,3 1 St George Hospital, Kogarah, New South Wales, Australia 2 University of New South Wales, Kensington, New South Wales, Australia 3 Department of Dermatology Head, St George Hospital, Kogarah, New South Wales, Australia Introduction: Rituximab is increasingly used as an off label treatment in patients with autoimmune blistering diseases. However, the existing protocols for rituximab are for lymphoma and rheumatoid arthritis only. The lymphoma protocol has four weekly infusions at a dose of 375 mg/m2.


ACD 47th Annual Scientific Meeting 2014 Objective: The goal of this study is to determine the efficacy and safety of rituximab treatment following the lymphoma protocol as an adjuvant, for patients who were recalcitrant to other treatments for autoimmune blistering diseases. Methods: This is a retrospective study including 9 patients who underwent rituximab treatment. Efficacy was assessed through the following: onset of control of disease, best clinical outcome, decrease in ABSIS (Autoimmune Blistering Severity Index Score), PDAI (Pemphigus Disease Area Index) scores and if present, the desmoglein autoantibody levels. The ABQOL (Autoimmune Blistering Quality of Life) and TABQOL (Treatment – Autoimmune Blistering Quality of Life) were also recorded. Results: In this case series, 5 had pemphigus vulgaris, 2 had pemphigus foliaceous, 1 had mucous membrane pemphigoid and another with Linear IgA disease. The onset of disease control was achieved as early as 1 month postrituximab in 5 patients and the latest at 17 months in 1 patient. The best clinical outcomes were complete remission on minimal therapy in 2 patients, partial remission on minimal therapy in 4 patients and control of disease in 3 patients. Majority had a decrease in ABQOL and TABQOL post-rituximab. Conclusion: Treatment with rituximab following the lymphoma protocol is effective and well tolerated as an adjuvant in autoimmune blistering diseases.

Medical Symposium 3 Isotretinoin and mental health in adolescents: Australian consensus C.J. Rowe1, L. Spelman2, M. Oziemski3, A. Ryan1,4, S. Manoharan5, P. Wilson6, M. Daubney7, J. Scott1,8 1 The University of Queensland Centre for Clinical Research, Herston, Queensland, Australia 2 Queensland Institute of Dermatology, Greenslopes, Queensland, Australia 3 Morris Towers, 6th Floor, Suites 61 and 62 / 149 Wickham Terrace, Spring Hill, Queensland, Australia 4 Queensland Centre for Mental Health Research, Wacol, Queensland, Australia 5 Westside Dermatology, 185 Moggill Road, Taringa, Queensland, Australia 6 Toowoomba Skin and Eye Clinic, 59 Margaret St, Toowoomba, Queensland, Australia 7 Griffith University Logan Campus, Meadowbrook, Queensland, Australia 8 Metro North Mental Health, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia Acne is a common condition amongst adolescents and has the potential to negatively impact the psychological wellbeing of those who suffer from the condition. Adolescents suffering from acne are more likely to be affected by psychiatric disorders such as depression. Successful treatment of acne has the potential to reduce levels of depression in these individuals and improve quality of life. Isotretinoin is currently the treatment of choice for severe or refractive

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acne. Whilst controversial, there is evidence to suggest a possible causal association between isotretinoin and mental illness.1 A group of dermatologists and psychiatrists have collaborated to develop a set of six recommendations to aid in the safe prescribing of isotretinoin in adolescents. The aim of these recommendations is to increase the awareness of the possible association between isotretinoin and mental illness and to emphasise the importance of appropriate patient assessment with a focus on mental health issues, prior to commencement of isotretinoin and also during and following the treatment period.

Reference 1.

Bremner JD, Shearer KD, McCaffery PJ. Retinoic acid and affective disorders: the evidence for an association. J. Clin. Psychiatry 2012; 73: 37–50.

Uganda: The village, the orphanage and the clinic T. O’Brien Geelong Dermatology, Geelong, Victoria, Australia The problem of providing skin health care in resource-poor countries can be addressed through education and training at different levels. The village: In countries, such as Uganda, where the population is mostly rural, community dermatology is the only practical option for provision of dermatology care. Common skin problems need to be identified, and the communities in general, as well as local health workers, need basic education. In one village tinea capitis, scabies and podoconiosis were identified, and treatment approaches were discussed. Basic educational posters were made for distribution to the village community. The orphanage: Several visits were made to an orphanage housing 65 abandoned babies and young children. A clinical diagnosis of scabies was made in a number of children and staff members. Pyoderma, usually ecthyma, was common and tinea capitis started to appear in children over the age of one year. All children and staff were treated with oral ivermectin. Gentian violet paint was extensively used for pyoderma and eczematous lesions. Oral griseofulvin was given to children with tinea capitis. The clinic: The dermatology training program at Mbarara currently has five trainees. The majority of patients seen in the clinic during a one month visit were examined together by the visiting dermatologist and trainees. Simple devices, such as LED torches for oral examination, improved clinical skills. Photographs were taken and many of the cases were then discussed in a tutorial session the following morning. This enabled time for reflection and literature searching. A hierarchical visual perceptual model was used to teach the trainees and also medical students.


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A case series of the use of Timolol in chronic ulceration P. Burke1, S. Korn2 1 Wyndham Health Care, Werribee, Victoria, Australia 2 The University of Melbourne, Melbourne, Victoria, Australia Chronic leg ulcers occur from number of different aetiologies but are mainly due to impaired blood supply to a localised area of the skin. They most commonly occur on the lower limbs and are usually quite painful. A number of therapies have been approved for treatment and minimisation of chronic leg ulcers depending on the severity and duration of the injury. Recent literature reports the successful use of topical timolol to manage a number of diverse chronic non-healing wounds.1–3 We present a case series of 4 patients with chronic foot ulceration of different aetiologies treated with topical timolol with varying degrees of success. References 1.

Manahan M, Peters P, Scuderi S et al. Topical timolol for chronic ulceration, a case with its own control. Australasian Journal of Dermatology Biennial Spring Conference; October 2013; Cairns: Wiley; 2013; 1–17. 2. Braun LR, Lamel SA, Richmond NA et al. Topical Timolol for recalcitrant wounds. JAMA Dermatol. 2013; 149: 1400–2. Epub 2013/11/01. 3. Tang JC, Dosal J, Kirsner RS. Topical timolol for a refractory wound. Dermatol. Surg. 2012; 38: 135–8.

Multiple lichen planus-like keratoses; an under recognised cause of pruritic eruptions in the elderly L.K. Pitney1, D. Weedon2, M.J. Pitney3 1 RMO Nambour Hospital, Nambour, Queensland, Australia 2 Senior Dermatohistopathologist, Sullivan & Nicolaides, Brisbane, Queensland, Australia 3 Sherwood Road Dermatology, Toowong, Brisbane, Queensland, Australia Solitary lichen planus-like keratoses (LPK) are relatively frequently encountered lesions on the sun damaged skin of elderly individuals, and seldom caused diagnostic dilemmas. Multiple LPK have been infrequently reported,1,2 and can cause difficulties in differentiation from other eruptions, including drug eruptions, in elderly pruritic patients. We present three patients in which multiple lichen planuslike keratoses provided diagnostic difficulties in elderly medicated patients, and suggest strategies for diagnosis and treatment. References 1.

Barranco P. Multiple benign lichenoid keratoses simulating photo dermatosis. J. Am. Acad. Dermatol. 1985; 13: 201–6. 2. Toll A, Gilaberte F, Gallardo F et al. Multiple and extensive lichen planus-like keratoses: an underestimated cutaneous eruption observed in patients with intense sun damage. J Eur Acad Dermatol Venereol 2006; 20: 472–3.

A review on uncommon malignancies associated with dermatomyositis A. Sahebian1,2, P. Peters2,3 1 Dermatology Research Centre, School of Medicine, University of Queensland, Brisbane, Queensland, Australia 2 Queensland Institute of Dermatology, Brisbane, Queensland, Australia 3 School of Medicine, University of Queensland, 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 was associated with dermatomyositis in 23% to 43% of adult patients, highly supporting the paraneoplastic nature of the disease. The malignancies most commonly associated with dermatomyositis are carcinomas of the ovary, lung, stomach, colorectal, pancreas and non-Hodgkin’s lymphoma. We reviewed the available literature for the rare malignancies which has been reported in association with dermatomyositis. We review the literature for less common malignancies reported with dermatomyositis. As a part of a multidisciplinary team involved in the treatment of dermatomyositis, appropriate investigations need to be conducted as part of age and gender appropriate malignancy screen.

A review of antimalarial agents in dermatology R. Templeman1, P. Piliouras1,2, I. Robertson1 1 Dermatology Department, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia 2 Dermatology Department, Cairns Hospital, Cairns, Queensland, Australia Hydroxychloroquine and Chloroquine (4-aminoquinolones) are oral antimalarial medications derived from quinine commonly used by dermatologists in treating many cutaneous disorders. Hydroxychloroquine has less side effects compared to other antimalarials. The pharmacology and adverse effect profile of antimalarials will be reviewed in this paper. Ocular toxicity will be reviewed in depth. Although rare, ocular toxicity is of serious concern because of the potential for permanent retinopathy. Dermatologists prescribing this medication and their patients must be aware of this potential complication and take steps to avoid it. The overall safety, practicality and cost-effectiveness of current recommendations for monitoring patients receiving antimalarials will be examined and updated guidelines proposed, with a particular focus on ophthalmological review.

Prevalence of osteoporosis and the use of bone protective therapies in dermatology clinic patients on long-term glucocorticoids S. Abell1, R.J. MacIsaac1, H. Zeimer1, A. Chong2 1 Department of Endocrinology, St Vincent’s Hospital, Fitzroy, Melbourne, Victoria, Australia 2 Department of Dermatology, St Vincent’s Hospital, Fitzroy, Melbourne, Victoria, Australia Background: Long-term glucocorticoid therapy is the most common cause of secondary osteoporosis with up to


ACD 47th Annual Scientific Meeting 2014 30–50% of patients sustaining a fracture. However, the extent to which bone protective strategies are implemented in dermatology clinic patients treated with long-term glucocorticoids is not well documented. Method: We performed a retrospective cohort study of patients attending a dermatology outpatient clinic over six months. Inclusion criteria required continuous prednisolone therapy (≥5 mg/day), for ≥3 months to treat a dermatological condition. We reviewed patient demographics, skin diagnoses, prednisolone use, vitamin D and bone mineral density (BMD) measurements, use of bone protective agents, fracture prevalence and referral to a bone specialist. Results: Eighty patients were included (total 1405 patients screened) with a mean age of 62 years (range 24-91). Fortysix patients (57.5%) were female and 34 (74%) were postmenopausal. Vitamin D was measured in 34 patients (44%), with a mean level of 75 mmol/L. The majority of patients were treated for Pyoderma Gangrenosum (38%), Connective Tissue Diseases (12.8%) and Atopic Eczema (11.3%). Overall 36 patients (45%) had a BMD measurement, with results available for review in 28 cases. Eight patients were osteoporotic and 13 were osteopaenic by BMD criteria, and 22.5% of the cohort were treated with bisphosphonates. Ten patients (12.5%) had a fracture recorded. Thirty-four patients (42.5%) were referred to a bone specialist. Conclusion: There is a high prevalence of osteoporosis in dermatology patients on long-term glucocorticoids, and urgent need to improve awareness and implementation of bone preserving strategies.

Poster Presentations Cutaneous side effects in long term survivors on BRAF inhibitor based therapies for metastatic melanoma R. Anforth1,2, G. Carlos1,2, A. Clements2,3, R. Kefford2,3,4, P. Fernandez-Peñas1,2 1 Department of Dermatology, Westmead Hospital, Sydney, New South Wales, Australia 2 University of Sydney, Sydney, New South Wales, Australia 3 Westmead Institute for Cancer Research, Westmead Hospital, Sydney, New South Wales, Australia 4 Melanoma Institute Australia, Sydney, New South Wales, Australia The BRAF inhibitors vemurafenib and dabrafenib have been approved by the FDA for treatment of V600 metastatic melanoma. Dabrafenib dosed in combination with the MEK inhibitor trametinib has also been shown to been beneficial, prolonging median progression free survival. BRAFi have been shown to induce cutaneous toxicities such as cutaneous squamous cell carcinomas through the paradoxical activation of the mitogen activated protein kinase pathway in wild type cells. These effects appear to onset early in treatment and reduce in frequency the longer the patient is on treatment. In this study we aim to determine if ongoing dermatological assessment is required in patients who have remained on BRAFi based therapies for longer than 52 weeks.

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All patients treated with the BRAF inhibitors vemurafenib or dabrafenib or combination BRAF inhibitor and MEK inhibitor therapy at Westmead Hospital, Sydney, Australia underwent regular dermatological assessments for the duration of therapy. Most patients underwent a baseline assessment prior to the commencement of therapy and every eight weeks thereafter. Patient’s side effects were recorded in a specific database. Patients continued to develop cutaneous side effects after 52 weeks of continuous therapy. Patients on single agent BRAF inhibitors continued to suffer from Grover’s disease (44.7%), plantar hyperkeratosis (44.7%), verrucal keratosis (18.4%) and even cuSCC (15.8%). The most dominant side effect seen in patients in the combination BRAF and MEK inhibitor group was an acneiform eruption (30.7%). Patients on BRAF inhibitor based therapies need to continue to have regular dermatological follow-up for the duration of their therapy.

Eruptive naevi in a patient treated with LGX818 for BRAF mutant metastatic melanoma R. Anforth1,2, G. Carlos1,2, S. Chou3, R. Scolyer2,4,5, P. Fernandez-Peñas1,2 1 Department of Dermatology, Westmead Hospital, Sydney, New South Wales, Australia 2 University of Sydney, Sydney, New South Wales, Australia 3 Department of Tissue Pathology and Diagnostic Oncology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Sydney, New South Wales, Australia 4 Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia 5 Melanoma Institute Australia, Sydney, New South Wales, Australia LGX818 is a new generation BRAF inhibitor (BRAFi) that is currently undergoing phase 1 trials for the treatment of V600 mutant melanoma. Cutaneous side toxicities have been associated with the use of alternate BRAFi, including vemurafenib and dabrafenib, and are induced via paradoxical activation of the mitogen activated protein kinase pathway in wild type BRAF cells. Changes in naevi, including new naevi, hyperpigmentation and fading of existing naevi, have been reported in a number of patients treated with vemurafenib. As a result there has been emphasis placed on the importance of sequential digital dermoscopy in all patients treated with a BRAFi. A 61 year old male with V600E positive stage IV metastatic melanoma was commenced on the phase 1 trial of LGX818 at 300mg daily in August 2013. After two months of therapy, the patient was noted to have developed eruptive naevi, fading of existing naevi and darkening of others. Excision of a new naevi from the back was reported on histology as a compound naevus and immunohistochemistry analysis of the same naevus for the presence of the BRAF V600E mutation was negative. This is the first case of eruptive naevi in a patient treated with the BRAFi LGX818. The absence of the V600E BRAF mutation within the changing naevus, supports the theory


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that BRAFi stimulates proliferation of wild type BRAF cells. Close dermatological surveillance is important for all patients treated with any type of BRAFi.

Cutaneous effects of decorative tattoos E. Anthony1,2, E. McMeniman2, A. Freeman1 1 Department of Dermatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia 2 Queensland Institute of Dermatology, Brisbane, Queensland, Australia Decorative permanent tattooing involves the introduction of exogenous pigments and/or dyes into the dermis to produce a permanent design. In 2004–5, one in seven Australians had a tattoo.1 Cutaneous side effects of the decorative tattoos include infective and inflammatory reactions, and there are reports of neoplastic changes.2,3 Herein lies illustrative case series of the different type of reactions that are seen. Infections can occur acutely or present latter in longstanding tattoos. Such microorganisms involved include: staphylococcus, streptococcus, mycobacteria, herpes simplex virus and human papilloma virus. Transmission of blood infections can also occur such as syphilis, leprosy, viral hepatitis and human immunodeficiency virus. There are a number of inflammatory patterns that can occur, many of them likely to be caused by hypersensitivity to tattoo inks.4,5 These include acute inflammatory, eczematous, hypersensitive, photo-aggravated, granulomatous, lichenoid and pseudolymphomatous reactions. Basal cell and squamous cell carcinoma have been reported in association with tattoos.4,5 There have been 17 cases of melanoma in a decorative tattoo reported in English literature to date. The pathogenesis of cutaneous malignancies in a tattoo is unknown, and the possibility of an association between melanocytic proliferation and tattoos remains an area of further study.

Dermatology life quality index use by dermatology registrars E. Anthony1,2, E. McMeniman2, H.P. Soyer2,3 1 Department of Dermatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia 2 Queensland Institute of Dermatology, Brisbane, Queensland, Australia 3 Dermatology Research Centre, School of Medicine, Translational Research Institute, The University of Queensland, Brisbane, Queensland, Australia Dermatology Life Quality Index (DLQI) was developed in 1994 and is today is most commonly used dermatologyspecific quality of life measure in clinical trials of skin disease. It has been used in more than 36 skin diseases, inflammatory, non-inflammatory and skin cancers.1 The DLQI has been used in descriptive and evaluative studies, incorporated into various treatment guidelines,2 as well as cost-of-illness3 and cost-effectiveness analysis studies.4 The DLQI has been shown to be easy to use in clinical practice because of its simplicity and brevity.5 Dermatology training registrars at two practice locations in Queensland completed a tick box survey, to assess their frequency, reasons and influences of use of the DLQI questionnaire. The average reported use of the DLQI was 0.411 per 100 patients, ranging from 0–2 per 100 patients. Psoriasis was the most common condition reported for DLQI questionnaire use. Factors influencing use of the DLQI questionnaire included: time consumption (62.5%); difficult access (50%). Reasons for DLQI use included: 100% to define impact of disease on quality of life; 87.5% to monitor progress; and 75% to aid management and treatment choice. Limitations of the survey are discussed. Methods to reduce time and aid access are discussed. In a time period where biologic agents are available in the treatment of psoriasis, the DLQI is being incorporated into evaluation, management and treatment of patients.

References References 1.

2.

3.

4. 5.

Heywood W, Patrick K, Smith A et al. Who gets tattoos? Demographic and behavioural correlates of ever being tattooed in a representative sample of men and women. Ann. Epidemiol. 2012; 1: 51–6. Paradisi A, Capizzi R, De Simone C et al. Malignant melanoma in a tattoo: case report and review of the literature. Melanoma Res. 2006; 16: 375–6. Varga E, Korom I, Varga J et al. Melanoma and melanocytic nevi in decorative tattoos: three case reports. J. Cutan. Pathol. 2011; 38: 994–8. Kruger N. Cutaneous complications related to permanent decorative tattooing. Expert Rev. Clin. Immunol. 2010; 6: 363–71. Shinohara M, Nguyen J, Gardner J et al. The histopathologic spectrum of decorative tattoo complications. J. Cutan. Pathol. 2012; 39: 1110–18.

1.

2.

3.

4.

5.

Basara MK, Fenech R, Gatt RM et al. The dermatology life quality index 1994-2007 a comprehensive review of validation data and clinical results. Br. J. Dermatol. 2008; 159: 997–1035. Smith CH, Anstey AV, Barker JN et al. British association of dermatologists’ guidelines for biologic interventions for psoriasis 2009. Br. J. Dermatol. 2009; 161: 987–1019. Colombo G, Altomare G, Peris K et al. Moderate and severe plaque psoriasis cost-of-illness study in Italy. Ther. Clin. Risk Manag. 2008; 4: 559–68. Heinen-Kammerer T, Daiel D, Stratmann L et al. Costeffectiveness of psoriasis therapy with etanercept in Germany. J. Dtsch Dermatol. Ges. 2007; 5: 762–9. Both H, Essink-Bot ML, Busschbach J et al. Critical review of generic and dermatology-specific health–related quality of life instruments. J. Invest. Dermatol. 2007; 127: 2726–39.


ACD 47th Annual Scientific Meeting 2014 Diphenylcyclopropenone: Cutaneous effects E. Anthony, S. Webber Department of Dermatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia Diphenylcycloprenone (DPCP) can be used to treat extensive or locally advanced cutaneous melanoma metastases that are unsuitable for other treatment modalities.1,2 Traditionally DPCP has been used in the treatment of alopecia areata and resistant viral cutaneous warts.3 DPCP is a potent contact sensitiser that is inexpensive and relatively noninvasive. Its use for metastatic melanoma was first reported more than 30 years ago. A review of the literature on DPCP in treatment of metastatic melanoma and the cutaneous effects reported to date are described. Common cutaneous effects include local eczema with blistering and contact urticaria.4 Rare effects include erythema multiforme-like reaction, hyperpigmentation, hypopigmentation and vitiligo.4,5 In treatment of alopecia areata, DPCP-induced severe eczema / blister formation was reported in 40.7%6 and DPCP-induced vitiligo was reported in 4 to 9%.7,8 We describe the first case reported in English literature of DPCP-induced bullous pemphigoid. An 86-year-old female with metastatic melanoma was referred to the dermatology department for DPCP treatment. She developed a bullous reaction to the same site and leg treated. Histopathology confirmed bullous pemphigoid. DPCP treatment was ceased.

References 1.

2.

3.

4. 5.

6.

7.

8.

Damian DL, Thompson JF. Treatment of extensive cutaneous melanoma metastases with topical diphencyprone. J. Am. Acad. Dermatol. 2007; 56: 869–71. Damian DL, Shannon KF, Saw RP et al. Topical diphencyprone immunotherapy for cutaneous metastatic melanoma. Australas. J. Dermatol. 2009; 50: 266–71. Buckley DA, Du Vivier AWP. The therapeutic use of topical contact sensitizers in benign dermatoses. Br. J. Dermatol. 2001; 145: 385–405. Buckley DA, du Vivier AW. Topical immunotherapy in dermatology. Int. J. Clin. Pract. 1999; 52: 130–7. Pires MC, Martins JM, Montealegre F et al. Vitiligo after diphenycprone for alopecia areata. Dermatol. Res. Pract. 2010; 2010: 171265. Aghaei S. Topical immunotherapy of severe alopecia area with diphenylcyclopropenone (DPCP) experience in an Iranian population. BMC Dermatol. 2005; 4: 6. Henderson CA, Ilchyshyn A. Vitilgo complicating diphencyrpone sensitization therapy for alopecia universalis. Br. J. Dermatol. 1995; 133: 496–7. Hatzis J, Gourgiotou K, Tosca A et al. Vitiligo as a reaction to topical treatment with diphencyprone. Dermatologica. 1988; 177: 146–8.

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Association of Sweet’s syndrome with pustular psoriasis P. Banan1,2, T. Darben1 1 Robina Skin Specialist Centre, Gold Coast, Queensland, Australia 2 Dermatology Research Centre, School of Medicine, Translational Research Institute, The University of Queensland, Brisbane, Queensland, Australia Sweet’s syndrome (acute febrile neutrophilic dermatosis) is characterized by fever, neutrophilia, and tender erythematous skin lesions. Histology usually shows an upper dermal infiltrate of mature neutrophils. Whereas some cases are idiopathic, others have been associated with a variety of disorders. Here we describe a patient with Sweet’s syndrome and discuss the association between Sweet’s syndrome with preexisting pustular psoriasis.

Dermoscopy, RCM and histopathology of a regressive melanoma in situ from an individual with a GSTP1 rs1695 polymorphism P. Banan1, P. McClenahan1, D. Duffy2, R. Sturm2, H.P. Soyer1 1 Dermatology Research Centre, School of Medicine, Translational Research Institute, The University of Queensland, Brisbane, Queensland, Australia 2 Melanogenix Group, Division of Molecular Genetics and Development, Institute for Molecular Bioscience, The University of Queensland, Brisbane, Queensland, Australia Glutathione S-transferase (GSTs) are multifunctional enzymes responsible for detoxification of reactive oxygen species produced during melanin synthesis and oxidative stress processes. The Recent studies have shown polymorphisms in exon 5 (p.Ile 105Val, rs1695) of the GSTP1 to have reduced efficacy, proposing GSTP1 as a new MM susceptibility gene. We present a patient with history of multiple MMs but a total of just nine naevi larger than 5 mm. We also discuss the role of genetics versus environmental factors contributing to development of multiple melanomas in this patient.

Sirolimus for Kaposi’s sarcoma in a renal-transplant recipients P. Banan1,2, T. Darben1 1 Robina Skin Specialist Centre, Gold Coast, Queensland, Australia 2 Dermatology Research Centre, School of Medicine, Translational Research Institute (TRI), The University of Queensland, Brisbane, Queensland, Australia The incidence of Kaposi’s sarcoma among recipients of solid organs is about 500 times the rate in the general population, and among men with the acquired immunodeficiency syndrome (AIDS) it is up to 20,000 times the rate in the general population, suggesting a role for immunosuppression in the development of the disease. Sirolimus has shown to inhibit the progression of dermal Kaposi’s sarcoma in kidney-transplant recipients while providing effective immunosuppression. Here we investigate clinical effects of sirolimus on Kaposi’s sarcoma in a renaltransplant recipient.


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IgG4 sclerosing disease presenting with cutaneous plaques F. Bhabha, M. Sladden Launceston, Tasmania, Australia IgG4 sclerosing disease is a newly recognized systemic fibroinflammatory condition with a lymphoplasmacytic infiltrate.1,2 We report a case of a 61 year old lady who presented with a gradually enlarging erythematous plaque on her left cheek. Her past history was significant for a left parotidectomy eight years prior. A skin biopsy demonstrated dermal lymphoid proliferation with a subsequent CT scan showing extensive cutaneous thickening of the cheek, frontal scalp, right parotid gland and left parotid scar. A diagnosis of IgG4 sclerosing disease was made, and she was commenced on oral azathioprine and prednisolone with prompt resolution of symptoms. This case demonstrates the possibility of cutaneous IgG4 sclerosing disease presenting as a pseudolymphoma.

Reference 1.

Stone JH, Zen Y, Deshpande V. IgG4-related disease. N. Eng. J. Med. 2012; 366: 539–51. 2. Khosroshahi A, Stone JH. A clinical overview of IgG4-related systemic disease. Curr. Opin. Rheumatol. 2011; 23: 57–66.

A case of acute generalised exanthematous pustulosis (AGEP) after unprotected sexual intercourse on holidays in Bali T. Blake, S. Scuderi Department of Dermatology, Royal Brisbane and Womens Hospital, Brisbane, Queensland, Australia We present a 43 year old man with a clinical diagnosis of Acute Generalised Exanthematous Pustulosis (AGEP) in the setting of a recent nine day holiday to Bali to visit a female partner with whom he has visited five times this year for unprotected sexual intercourse and contracted an STI. He also gives a history of taking some Indonesian cold and flu medications and the use of Ibuprofen.

Quantifying the orientation of acquired melanocytic naevi on the back P. McClenahan, T. Blake, N. Douglas, S. Gilmore, H.P. Soyer Dermatology Research Centre, School of Medicine, Princess Alexandra Hospital, The University of Queensland, Brisbane, Queensland, Australia Acquired melanocytic naevi are a well-known risk factor in the development of melanoma with their increased frequency associated with increased risk. The clinical appearance of naevus orientation has not been a target of investigation. Although not aiming to identify new phenomena, we are looking to quantify and explain the orientation patterns of acquired melanocytic naevi on the back. Using full body imaging and subsequent dermoscopic imaging in a cohort of 20 Caucasian participants (10 female), naevi were assessed for size and angle of orientation (long axis). We observed a specific and reproducible pattern of acquired

melanocytic naevus orientation and have confirmed this observation by identifying a mathematical model relating naevus orientation to vertical location on the back. Given the documented correlations between Blaschko’s lines, Langer’s lines and previously described epidermal lesions and pigmentation patterns, our orientation data did in fact reasonably match Langer’s line patterns, independent of size and eccentricity. This may lead to a better understanding of the underlying factors involved in naevus growth.

Bullous variant of disseminated superficial actinic porokeratosis Z. Boyce1, N. Collins2 1 Dermatology Registrar, Department of Dermatology, Cairns Base Hospital, Cairns, Queensland, Australia 2 Consultant Dermatologist, Cairns, Queensland, Australia Porokeratosis is a chronic disorder of keratinisation characterised by hyperkeratotic papules or plaques with an annular appearance surrounded by a fine sharply demarcated hyperkeratotic border known as a cornoid lamella. The condition encompasses at least five clinical variants, one of which is referred to as disseminated superficial actinic porokeratosis (DSAP). DSAP is distinguished by its relatively high incidence, appearance of multiple small papules involving the extremities bilaterally in sun exposed areas, and sparing of the palms, soles, and mucous membranes. I present a patient who was diagnosed with a very rare bullous variant of DSAP, for which there is only one other reported patient in the literature.1 Reference 1.

Ricci C, Rosset A, Panizzon R. Bullous and pruritic variant of disseminated superficial actinic porokeratosis: successful treatment with grenz rays. Dermatology 1999; 199: 328–31.

Dapsone-induced methaemoglobinaemia in a patient with dermatitis herpetiformis secondary to coeliac disease P. Burke1, T. O’Brien2, S. Korn3 1 Wyndham Health Care, Werribee, Victoria, Australia 2 Geelong Dermatology, Geelong, Victoria, Australia 3 The University of Melbourne, Melbourne, Victoria, Australia Dapsone is a commonly used anti-inflammatory and antiparasitic that is used in the treatment of dermatitis herpetiformis, as well as being used in the treatment of leprosy and a variety of other blistering skin diseases.1,2 Methaemoglobinaemia is a rare, potentially life threatening disease. It is charaterised by an increase in the ferric form of iron (Fe3+) causing a decreased ability of the blood to transport oxygen (3). It generally presents clinically with unexplained low oxygen saturations on pulse oximetry. Dapsone-induced methaemoglobinaemia is usually the result of acute poisoning secondary to either accidental ingestion or suicidal intent. According to recent research at


ACD 47th Annual Scientific Meeting 2014 several tertiary centres, dapsone has been shown to be the major cause of drug-induced methaemoglobinaemia.1,3–5 We present a case of dapsone-induced methaemoglobinaemia in a 51 year old caucasian man on long-term dapsone therapy for dermatitis herpetiformis secondary to a 30 year history of coeliac disease. The diagnosis was made during general anaesthesia for a urological procedure. He had unexplained low oxygen saturations despite hyperoxaemia on blood gas analysis. His blood gas revealed methaemoglobinaemia of 9.1% and subsequently this was attributed to long-term dapsone treatment for dermatitis herpetiformis. He made a full recovery after a period of prolonged oxygenation in intensive care. Subsequently his dapsone therapy was discontinued but given the severity of his dermatitis herpetiformis this has necessitated intermittent low-dose dapsone therapy with ongoing regular pulse oximetry in the community.

References 1.

2. 3. 4.

5.

Coleman MD, Rhodes LE, Scott AK et al. The use of cimetidine to reduce dapsone-dependent methaemoglobinaemia in dermatitis herpetiformis patients. Br. J. Clin. Pharmacol. 1992; 34: 244–9. Leonard JN, Fry L. Treatment and management of dermatitis herpetiformis. Clin. Dermatol. 1991; 9: 403–8. Rehman HR. Methemoglobinemia. West. J. Med. 2001; 175: 193–6. Ash-Bernal R, Wise R, Wright SM. Acquired methemoglobinemia: a retrospective series of 138 cases at 2 teaching hospitals. Medicine (Baltimore) 2004; 83: 265–73. Szeremeta W, Dohar JE. Dapsone-induced methemoglobinemia: an anesthetic risk. Int. J. Pediatr. Otorhinolaryngol. 1995; 33: 75–80.

Scabies and recurrent skin infections in a family of 14: A detailed cost analysis over a three year period P. Burke1, M.J. Whitfeld2, S. Korn3 1 Wyndham Health Care, Werribee, Victoria, Australia 2 St Vincents Hospital, Sydney, New South Wales, Australia 3 The University of Melbourne, Melbourne, Victoria, Australia Scabies is caused by a host-specific skin dwelling mite (Sarcoptes scabiei) and is characterised by miniature papules, pustules and excoriations that appear on the skin.1 It is highly contagious and proliferates in crowded conditions. Scabies is a global problem and occurs universally regardless of age, race, sex, socio-economic status or standards of living. Current estimations from the WHO suggest scabies affects 300 million people worldwide.2 Scabies is associated with a significant decrease in quality of life, notably with feelings of shame, needing to dress differently, restrictions on leisure activities, various aspects of social exclusions and sleep loss.3 In addition to the effect on quality of life there is a considerable economic burden, both to the individual and to the community.4 Scabies is therefore an important public health issue.

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Their history involved 165 visits to a total of 21 different general practitioners in a single family practice and 136 GP prescriptions. There were multiple paediatric emergency department presentations, acute admissions and dermatology clinic visits at the Royal Children’s Hospital. A detailed cost analysis outlineded the large economic burden incurred by the family and the health services of Victoria.

References 1.

Gould D. Prevention, control and treatment of scabies. Nurs. Stand. 2010; 25: 42–6. 2. WHO. Water-related diseases – scabies. 2013. Available from: http://www.who.int/water_sanitation_health/diseases/scabies/ en/ (accessed 14 November 2013). 3. Worth C, Heukelbach J, Fengler G et al. Impaired quality of life in adults and children with scabies from an impoverished community in Brazil. Int. J. Dermatol. 2012; 51: 275–82. 4. Whitehall J, Kuzulugil D, Sheldrick K et al. Burden of paediatric pyoderma and scabies in North West Queensland. J. Paediatr. Child Health 2013; 49: 141–3.

Vancomycin induced linear IgA with mucosal and ocular involvement: A case report L. Byrom1, L. Dang2, J. Muir1, P. Griffith2 1 Department of Dermatology, Mater Misericordiae Hospital, Brisbane, Queensland, Australia 2 Department of Infectious Diseases, Mater Misericordiae Hospital, Brisbane, Queensland, Australia We present a case of a 74-year-old female who developed linear IgA bullous dermatosis secondary to vancomycin. She also had oral mucosal and ocular involvement. Vancomycin is the most commonly reported medication associated with drug induced linear IgA dermatosis. We suggest that patients avoid vancomycin and other medications in the same class to avoid recurrence. This remains a rare entity, however, may have implications for future management of methicillin-resistant Staphlococcus aureus (MRSA).

We present a case series of 14 family members affected by scabies and recurrent skin infections over a 3 year period. © 2014 The Authors Australasian Journal of Dermatology © 2014 The Australasian College of Dermatologists

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Long-term safety of ustekinumab: Five years of follow-up from the psoriasis clinical development program including patients with psoriatic arthritis K. Papp1, C.E.M. Griffiths2, K. Gordon3, M. Lebwohl4, P.O. Szapary5, Y. Wasfi5, D. Chan5, Y.K. Shen5, V. Ho6, P.D. Ghislain7, B. Strober8, K. Reich9 on behalf of the PHOENIX 1, 2 and ACCEPT Investigators 1 Probity Medical Research, Waterloo, Ontario, Canada 2 Dermatology Centre, University of Manchester, Manchester, UK 3 Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA 4 Mount Sinai School of Medicine, New York, USA 5 Janssen Research & Development, LLC, Spring House, Pennsylvania, USA 6 University of British Columbia, Vancouver, British Columbia, Canada 7 Cliniques Universitaires Saint-Luc. Université Catholique de Louvain, Louvain-La-Neuve, Bruxelles 8 University of Connecticut School of Medicine, Farmington, Connecticut, USA 9 Dermatologikum Hamburg, Hamburg, Germany Introduction: We report long-term safety experience of ustekinumab(UST) in sub-group of psoriasis (PsO) patients with a medical history of psoriatic arthritis (PsA) (PsASubgroup) vs.overall PsO population (Overall Population [OP]) through up to 5 years. Method: Pooled safety data across 1 Ph2&3 Ph3 [PHOENIX 1&2,&ACCEPT] clinical trials in patients with moderate-tosevere PsO were analyzed. Patients received UST45or90mg SC through up to 5 years. The presence/absence of PsA (history of/current) at baseline was reported. No concurrent treatment for PsO/PsA was permitted,except low-potency topical steroids for PsO during open-label long-term extensions of PHOENIX 1&2. All patients who received ≥1dose of UST were included.Data from UST dose groups were analyzed as a combined group. Results are expressed in events/100 pt-years of follow-up(PY)&compared between PsASub-group&OP. Results: The OP included 3117 pts (8998 PY) who received ≥1dose of UST;with 1482 (47.5%) pts treated for ≥4 years or more (including 838[26.9%] for ≥5 years). At baseline, 27.5% 858 pts (2490 PY) of pts had concomitant PsA & were included in the PsASub-group. Through Yr5, event rates for overall safety endpoints&AEs of interest (serious infections, NMSC/other malignancies, MACE) were generally comparable between PsASub-group&OP. Event rates(per 100PY [95% CI]) for PsASub-group vs OP were: AEs 249.40 (243.23, 255.68) vs 232.59 (229.44, 235.76); infections 91.49 (87.77, 95.32)vs 86.52 (84.61, 88.47); AEs leading to d/c 2.77 (2.16, 3.51) vs 2.40 (2.09,2.74); serious AEs 8.59 (7.48,9.83) vs 7.10 (6.56,7.67). For AEs of interest event rates were:serious infections 1.53 (1.08,2.09) vs 1.10 (0.89,1.34); NMSCs 0.48 (0.25,0.84) vs 0.52 (0.39, 0.70); other malignancies 0.72 (0.43,1.15) vs 0.60 (0.45,0.78); MACE 0.56 (0.31,0.94) vs 0.44 (0.32,0.61). With continuous UST exposure for up to 5 years & approx 9000 PY in PsO program, long-term safety in OP were consistent with previous reports at earlier follow-up; event rates were generally comparable to other currently

approved biologic agents.Long-term safety in PsASub-group were generally comparable to those in the overall study population.

Pregnancy outcomes in women exposed to ustekinumab in the psoriasis clinical development program J.C. Cather1,2, K.W. Rahawi3, B.W. Schaufelberger3, D. Chan3, E.J. Horn1, K. Goyal3 1 Modern Research Associates, Dallas, Texas, USA 2 Modern Dermatology, a Baylor Health Texas Affiliate, Dallas, Texas, USA 3 Janssen Research & Development LLC, Spring House, Pennsylvania, USA Introduction: To characterize pregnancy outcomes in women exposed to UST during pregnancy, data from the UST PsO clinical development program are presented. Method: Pregnancies reported with maternal use of UST from 4 PsO studies (Ph2 [n = 320] and Ph3 [PHOENIX 1; n = 766, PHOENIX 2; n = 1230, ACCEPT; n = 903]) were evaluated. Pregnancy outcomes were summarized using descriptive statistics. Results: 981 female patients received ≥1 dose of UST, and 29 pregnancies were reported (despite agreement to use adequate birth control measures).Per protocol, UST treatment was discontinued upon report of pregnancy in all cases. Mean maternal age (MMA) was 30 years (range 21–44), and mean duration of UST exposure prior to reported pregnancy was 72 ± 61 weeks. Pregnancy outcomes were reported for 26 of 29 pregnancies, including 14 (54%) live births (LBs), 5 (19%) spontaneous abortions (SAs), and 7 (27%) elective abortions (EAs). All 5 SAs occurred in the 1st trimester. MMA was older for patients who had SAs (35 ± 5 years) vs. LBs (29 ± 4 years), and UST treatment duration prior to pregnancy report was shorter for patients who had SAs (36 ± 25 weeks) vs. LBs (98 ± 57 weeks). Among LBs, there were no congenital anomalies, and 2 infants had neonatal jaundice treated with phototherapy. Neonatal outcomes were generally healthy with mean birth weight of 7 ± 1 lbs (n = 12), gestation age of 38 ± 0.7 weeks (n = 9), and mean 5-min APGAR of 9 ± 0.6 (n = 8). Rate of SAs was generally comparable to rate reported for the general population(15–20%). SAs in this case series were associated with older maternal age. Longer duration of UST exposure prior to the reported pregnancy was not associated with adverse outcomes. The limited available data suggest that UST exposure may not impact pregnancy outcomes but additional experience is needed.


ACD 47th Annual Scientific Meeting 2014 A case of multiple adjacent pigmented epithelioid melanocytomas S. Chan,1 D. Abeysuriya2 and S.P. Kumarasinghe3,4 1 Sir Charles Gairdner Hospital, Perth, Western Australia, Australia 2 Department of Pathology, Royal Perth Hospital, Perth, Western Australia, Australia 3 Department of Dermatology, Royal Perth Hospital, Perth, Western Australia, Australia 4 School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia Pigmented epithelioid melanocytoma is a term developed in the recent past used to describe a rare melanocytic tumour. The term encompasses both animal-type melanoma and epithelioid blue naevus of Carney complex, which are histologically indistinguishable. Although the biologic potential remains uncertain, it typically has an indolent course after complete excision with lower risk of distant metastases compared with malignant melanomas. We report a case diagnosed in a 49-year-old lady who presented with an unrelated pruritic papular eruption subsequently diagnosed as urticaria. Multiple deeply pigmented nodular lesions on her back were incidentally found. These had the appearance of agminated blue naevi with a differential diagnosis of melanoma and had been present for over five years. No personal or family history of skin cancer or melanoma was reported. The lesions were excised and the diagnosis of pigmented epithelioid melanocytoma was confirmed on histology. Histologically, there were three adjacent nodules (2.4 mm, 7.2 mm and 10.3 mm) within a single specimen with characteristic histological findings of dermal melanocytic lesion composed of spindled and epithelioid melanocytes with heavily pigmented cytoplasm showing infiltrative borders. There was an absence of atypical mitotic figures and necrosis. Clinically she does not have any cardiac anomalies or evidence of metastases however a PET scan is awaited. Histopathological mimics of this condition are also presented.

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There are 140 male and 71 female patients. The median time since first transplant is 9.0 years. At baseline, 50% have a history of at least one SCC, 48% have a history of at least one BCC and 5% have had a melanoma. Histopathology results since August 2011 demonstrate 129 SCCs, 91 BCCs, 59 actinic keratoses, 8 keratoacanthomas and 1 melanoma. 67% of these are from our renal patients. The SCC:BCC ratio is 1.43:1 for renal and 1.39:1 for liver SOTRs. 20% of patients have a baseline DLQI score of 6 or more, reflecting a significant decrease in QOL due to skin concerns. Conclusion: SOTRs have a high incidence of nonmelanoma skin cancers, particularly SCCs. Cutaneous impact on quality of life is also significant. Further research in the Australian SOTR population will ensure optimal evidence-based practice.

Angioimmunoblastic T cell lymphoma – case series P. Chen1, T.M. Lim1, P. Jarrett1, A. Yung2, M. Dray3 1 Departmentof Dermatology, Counties Manukau District Health Board, Auckland, New Zealand 2 Department of Dermatology, Waikato Hospital, Hamilton, New Zealand 3 Department of Anatomical Pathology, Counties Manukau District Health Board, Auckland, New Zealand Angioimmunoblastic T-cell lymphoma (AITL), previously known as angioimmunoblastic lymphadenopathy with dysproteinaemia, is a form of aggressive peripheral T-cell lymphoma recently recognised as a distinct clinical and histological entity by the World Health Organisation. We present 3 cases of AITL seen in 2 tertiary hospitals in New Zealand in the last 2 years. Diagnostic delay is common and the prognosis is poor despite aggressive therapy with a median survival of less than 3 years.1

Reference The first 24 months of an Australian solid organ transplant dermatology database S.N. Chee1, E. Coates1,2, P.M. Lowe1,2 1 Department of Dermatology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia 2 Discipline of Dermatology, University of Sydney, Darlington, New South Wales, Australia Background: Solid organ transplant recipients (SOTRs) have an increased incidence of skin cancers, as well as more aggressive variants. Further research into this at-risk cohort, in high ultraviolet radiation regions such as Australia, is crucial in facilitating local evidence-based practice. Methods: 211 SOTRs attended the Royal Prince Alfred Hospital transplant dermatology clinic from August 2011 to July 2013. Data obtained from attendances was collated in a Filemaker Pro database specifically designed to sequentially record core patient information for subsequent analysis. Results: 127 renal and 84 liver transplant patients are included in the database. The median age is 58.5 years.

1.

Iannitto E, Ferrari AJM, Minardi V et al. Angioimmunoblastic T-cell lymphoma. Crit. Rev. Oncol. Hematol. 2008; 68: 264–71.

Inter-observer reliability of PASI scoring N. Chinniah1, S. Cabrera2, J. Descallar3,4, 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 3 The Ingham Institute, Sydney, New South Wales, Australia 4 South West Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia Introduction: The Psoriasis Area and Severity Index (PASI) is the most widely used tool for the measurement of severity of psoriasis. Due to the subjective nature of this assessment however, the reliability of the PASI as a psoriasis rating tool has been under much debate. Objective: To determine the inter-observer reliability of the PASI at a large tertiary hospital with a psoriasis treatment center.


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Method: Cross-sectional study conducted at a large tertiary hospital with a psoriasis treatment center. 34 patients were independently evaluated by five clinical staff (observers) at the Department of Dermatology. Each observer independently determined the PASI of each patient. The interobserver reliability coefficient was determined by employing intraclass correlation coefficients (ICC). Results: An ICC of 0.804 (IC 95%: 0.706–0.883) showed a significant degree of concordance among evaluators. Conclusion: This suggests that the PASI scale provides a reproducible method of assessing psoriasis severity among our series of patients.

Dabrafenib-induced radiation recall dermatitis B. Choy1,2, R. Anforth1,2, G. Carlos-Minano1, P. Fernández-Peñas1,2 1 Department of Dermatology, Westmead Hospital, Sydney, New South Wales, Australia 2 University of Sydney, Sydney, New South Wales, Australia Radiation recall dermatitis is a rare phenomenon of an acute inflammatory reaction limited to the skin of previous radiation exposure, which is precipitated by the administration of certain drugs. Although the occurrence of radiation recall dermatitis is relatively well known in the medical world, the exact mechanisms causing recall dermatitis have not been documented. There has been only one published report of radiation recall dermatitis induced by dabrafenib to our knowledge. We present a case of a 44 year old man with BRAF-mutation positive metastatic melanoma who received palliative radiotherapy for chest wall pain due to right pulmonary metastasis in May 2012. One week after cessation of radiotherapy, he was commenced on dabrafenib 150mg BD with good response. Two weeks after commencing dabrafenib, he developed a well-defined, erythematous, scaly, inflamed plaque limited to the area of irradiation, thus radiation recall dermatitis was clinically diagnosed. The patient denied use of any other medications in the preceding 2 months. No treatment was required for this case. The patient subsequently became lost to follow up due to non-compliance. Radiation recall dermatitis is a rare side effect of dabrafenib which can be painful and pruritic. Topical corticosteroids and cessation of the precipitating medication are typically adequate for symptom improvement. It is important to be aware of possible side effects caused by the interaction of the different treatment modalities for melanoma patients, especially in a palliative setting.

A cost-utility analysis of Mohs surgery versus traditional excision for head and neck basal cell carcinoma: An update B. Choy1, R.L. Morton2, D.F. Sebaratnam1,2,3, R. Paver1,3, P. Fernández Peñas1,2,3 1 Department of Dermatology, Westmead Hospital, Westmead, New South Wales, Australia 2 University of Sydney, Camperdown, New South Wales, Australia 3 Skin and Cancer Foundation Australia, Westmead, New South Wales, Australia To determine the cost-effectiveness of Mohs micrographic surgery (MMS) compared with traditional excision (TE) for head and neck basal cell carcinoma (BCC), a modelled cost-utility analysis was performed from the perspective of the Australian healthcare system. The gold standard in economic evaluations is to present cost per quality adjusted life year (QALY) and this outcome was accordingly sought. A Markov model simulating the natural history of BCC was constructed and populated with the likely outcomes for primary BCC treated with MMS or TE. Recurrence rates were identified from published Skin and Cancer Foundation Australia data. Where required data were not available, a systematic review was performed and best available figures utilised. A 5 year recurrence rate of 1% for primary BCC and 4% for recurrent BCC was employed for MMS and 5% for primary BCC and 17% for recurrent BCC employed for TE. Literature review was performed to determine a QALYweighting associated with BCC recurrence of 0.98. Costs were obtained in a separate study comparing true costs of MMS with projected costs of TE yielding a mean MMS cost of AUD$882 and mean TE cost of AUD$515. The mean cumulative cost of MMS was AUD$1185 while the mean cumulative cost of TE was AUD$1105: a difference of AUD$80 over five years. Further work is being completed by our group to better define the difference in QALYs between interventions. At this stage, MMS is a much more financially viable intervention for head and neck BCC compared to TE than previously appreciated. What percentage of the population develops skin cancer? P. Clarke1,2, K. Ogden1,2, I. Robertson1,2, R. Davenport1,2 1 Clifford Craig Medical Research Trust, Hobart, Tasmania, Australia 2 University of Tasmania Medical School, Hobart, Tasmania, Australia It is often reported that about 70% of the Australian population will develop skin cancer but this is based on raw numbers of skin cancers and the total population. Many dermatologists are familiar with the clinical situation of individual patients producing large numbers of skin cancers. It is most likely that a small percentage of the population produces the majority of skin cancers. This study has captured all skin cancers removed in northern Tasmania in one calendar year, and has also identified patients producing large numbers of skin cancers. This will enable statistical calculation of the percentage of the population developing skin cancer. It will also help to identify the very small percentage of the population at very high risk of skin cancer. The data base contains over 10,000 skin cancers.


ACD 47th Annual Scientific Meeting 2014 Desmoplastic melanoma associated with lentigo maligna: A challenging case E. Coates1,2, P. Guitera1,2 1 Sydney Melanoma Diagnostic Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia 2 Discipline of Dermatology, University of Sydney, Darlington, New South Wales, Australia Background: Desmoplastic melanoma (DM) is a rare melanoma that is frequently amelanotic in morphology, presenting as a skin-coloured or pink scar-like nodule without classic dermoscopic features that is challenging to diagnose. Additionally 60% of DM are associated with lentigo maligna (LM), further complicating effective management.1 In vivo reflectance confocal microscopy (RCM) is a novel non-invasive diagnostic imaging technique that enables effective diagnosis and surgical mapping due to clearly identifiable diagnostic features that are present even in amelanotic DM. Case report: A 74 year old Caucasian man presented with a 1 year history of increasing right scalp pigmentation and no prior melanoma history. Clinically multiple right scalp pigmented macules were noted with an associated firm nodule that showed brown dots and asymmetrical pigmented follicular openings on dermoscopy, consistent with LM. Punch biopsy from the nodule demonstrated asymmetrical junctional melanocytic proliferation consistent with a 1.6mm Clark 4 desmoplastic melanoma arising in a LM. RCM undertaken to identify a suitable margin for surgical excision demonstrated atypical cells migrating upwards in the epidermis and atypical large round cells and dendritic cells in the upper dermis. A significant extension of the LM margin was also noted around the desmoplastic melanoma nodule, much of which was not visible clinically. Full surgical excision was subsequently completed based on the RCM mapping undertaken. Conclusions: Diagnosis and surgical management of amelanotic DM in association with LM is frequently challenging and definitive management is aided effectively by RCM.

Reference 1.

Chen LL et al. Desmoplastic melanoma: A review. J. Am. Acad. Dermatol. 2013; 68: 825–33.

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Dermatological presentations in an inner regional general practice N. Colgrave1, C. Schofield2 1 Village Family Practice, Samford Village, Queensland, Australia 2 Melbourne City Dermatology, Melbourne, Victoria, Australia Aim: To quantify and classify dermatological presentations in a solo GP clinic in Samford Village, Queensland as a means of providing insight into numbers and types of dermatological conditions commonly seen by general practitioners in inner regional (RA2) areas of the state. Method: Following ethics approval from the National Research and Evaluation Ethics Evaluation Committee (NREEC), all patients presenting to Village Family Practice in Samford Village with a dermatological complaint between 01 August and 13 September 2013 were asked to participate in the study. Those patients consenting to participate had their complaint photographed. At the conclusion of the study period, these photographs, along with de-identified clinical details, were reviewed by a dermatologist (FACD) to obtain feedback on the likely diagnosis of each case. Diagnoses were classified as either Eczema/ dermatitis, Infectious, Inflammatory, Benign skin lesions, Pre-malignant and malignant non-melanoma skin cancers, Disorders of keratinisation, or Other. Results: A total of 759 patients were seen at the practice during the study period, of which 46 patients (6.1%) presented with 47 different dermatological complaints. All patients identified as potential participants agreed to participate in the study. Following review, 15 cases (32.6%) were classified as Eczema/dermatitis, 13 (28.3%) as Infectious, 7 (15.2%) as Benign lesions, 4 (8.7%) as Disorders of keratinisation, 3 (6.5%) as Inflammatory, 2 (4.3%) as Premalignant and malignant non-melanoma skin cancers, and 3 (6.5%) as Other.

An unusual presentation of secondary syphilis with tertiary features K. Deen, L. Wheller, J. Wu Department of Dermatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia We present an unusual case of syphilis in a 57-year-old caucasian homosexual male who had a generalized erythrosquamous papular eruption involving his face, trunk and extremities with palmar-plantar and genital involvement. The patient had initially been diagnosed with primary syphilis in the 1970s. The clinicopathologic findings confirmed cutaneous involvement of syphilis. Overlapping features of secondary and tertiary stages of the disease were present, with the suspicion of syphilitic valvulitis. The patient was found to have a thickened mitral valve with severe mitral and tricuspid regurgitation on echocardiography. We present a typical presentation of the disease, which was formerly common, but now very rare in Australia, and is important to still consider. The clinical presentation and histopathology are discussed.


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Treatment response of a large Merkel cell carcinoma on the gluteal area with chemotherapy and radiation therapy M.C. Doria1,2,3, D. King-Ismael1, L. Abad-Venida1 1 Depatment of Dermatology, Jose R. Reyes Memorial Medical Center, Manila, Philippines 2 St George Hospital, Kogarah, New South Wales, Australia 3 University of NSW, Keningston, New South Wales, Australia Merkel Cell Carcinoma (MCC) is a rare aggressive cutaneous malignancy.1 This is the case of a 68-year-old, Filipina, female who had a gradually enlarging mass on the right outer gluteal area. Upon presentation, the lesion was 11x8 cm in diameter; with an erythematous, moist, fungating surface. Due to the size of the lesion, excision was not feasible. She received Carboplatin, Etoposide and adjuvant radiation therapy with resolution of the lesion. A few months after diagnosis, she developed jaundice, abdominal pain and ascites. CT scan of the abdomen revealed enlargement of the head of the pancreas. Our patient was considered to have Stage IV MCC; with a lesion of >2 cm in diameter, right inguinal lymphadenopathy and/or primary or metastatic pancreatic new growth. Biopsy of the pancreatic mass is an invasive procedure and not without risk, hence the family declined the procedure. The most common metastatic sites out of 107 MCC are the skin, followed by the lymph nodes.1 Although pancreas is not a common metastatic site, there have been 5 published cases of primary cutaneous MCC with metastasis to the pancreas. Breakthrough studies revealed the existence of a Merkel cell Polyoma virus, which may help explain the link to immunosuppression. Currently there is a consensus among different specialists from the National Comprehensive Cancer Network regarding its management.

Reference 1.

Heath M et al. Clinical characteristics of MCC at diagnosis in 195 patients: the AEIOU features. JAAD 2008; 58: 375–81.

A case of necrobiotic xanthogranuloma with primary liver involvement E. Ellis1, G. Marshman1, T. Thomas2 1 Department of Dermatology, Flinders Medical Centre, Bedford Park, South Australia, Australia 2 Department of Pathology, Flinders Medical Centre, Bedford Park, South Australia, Australia Necrobiotic xanthogranuloma (NXG) is a chronic granulomatous condition first described by Kossard and Winkelmann in 1980. The characteristic cutaneous lesion is a violaceous or yellowish papule, nodule, or plaque a few millimetres to 25 centremetres in size which may be cosmetically disfiguring. To date, there have been 5 reports of NXG occurring in scars (Koch). Diagnosis relies on characteristic histological features which include granulomas composed of foreign body and

Touton giant cells admixed with foci of collagen necrobiosis (Spicknell). Cholesterol clefts within the necrobiosis assist in diagnosis but are not essential. Extra-cutaneous granulomatous disease has been described (Fortson, umbert, hunter, winkelmann, westermann, novak). Liver involvement has been reported in three cases, however histological changes were reactive. To date, there are no known cases of primary liver disease. We present the first known case of NXG with primary granulomatous disease occurring in the liver. Additionally, this is the 6th case of NXG occurring in scars.

Apremilast, an oral phosphodiesterase 4 inhibitor, in nail and scalp psoriasis: 52-week results from the ESTEEM 1 study P. Foley1, K. Papp2, K. Reich3, C. Leonardi4, L. Kircik5, S. Chimenti6, P. Rich7, C.C. Hu8, R.M. Stevens8, R.M. Day8, C.E.M. Griffiths9 1 Skin & Cancer Foundation Inc., St Vincent’s Hospital, Melbourne, Victoria, Australia 2 Probity Medical Research, Waterloo, Ontario, Canada 3 SCIderm Research Institute and Dermatologikum Hamburg, Hamburg, Germany 4 Saint Louis University School of Medicine, St Louis, Missouri, USA 5 Physicians Skin Care, PLLC, Louisville, Kentucky, USA 6 University of Rome Tor Vergata, Rome, Italy 7 Oregon Health and Science University, Portland, Oregon, USA 8 Celgene Corporation, Warren, New Jersey, USA 9 The University of Manchester, Manchester, UK ESTEEM 1 randomized patients with moderate/severe plaque psoriasis (PASI ≥12, BSA ≥10%, sPGA ≥3) 1:2 to placebo or apremilast 30 mg BID (APR30). At Week 16, placebo patients switched to APR30. At Week 32, APR30 patients who achieved PASI-75 were re-randomized to continue APR30 or receive placebo (1:1). Upon loss of PASI-75, patients re-randomized to placebo resumed APR30. APR effects were analyzed for nail psoriasis using NAPSI and for scalp psoriasis using ScPGA. At baseline, 558 (66.1%) patients had nail psoriasis and 563 (66.7%) had scalp psoriasis (ScPGA score ≥3). At Week 16 (LOCF), mean percent improvement in NAPSI scores from baseline was significantly greater with APR30 (−22.5%) vs placebo (+6.5%; P < 0.0001). Mean reductions in NAPSI were −43.6% (APR30/ APR30) and −24.6% (placebo/APR30) for patients treated through Week 32. Mean percent change in NAPSI was −60.2% (APR30/APR30/APR30) over 52 weeks. At Week 16 (LOCF), NAPSI-50 achievement was significantly greater with APR30 (33.3%) vs placebo (14.9%; P < 0.0001). At Week 32, 45.2% (APR30/APR30) and 34.9% (placebo/APR30) of patients achieved NAPSI-50. At Week 52, 63.0% (APR30/ APR30/APR30) achieved NAPSI-50. At Week 16 (LOCF), more APR-treated patients (46.5%) achieved ScPGA 0-1 vs placebo (17.5%; P < 0.0001). At Week 32, 37.4% (APR30/ APR30) and 43.6% (placebo/ APR30) of patients achieved ScPGA 0-1. At Week 52, 72.9% (APR30/APR30/APR30) achieved ScPGA 0-1. APR was generally well-tolerated with no new safety or laboratory findings. APR reduced nail and


ACD 47th Annual Scientific Meeting 2014 scalp psoriasis severity over 16 weeks in patients with moderate/severe plaque psoriasis. Patients remaining on APR over 52 weeks maintained or continued improvement.

Apremilast, an oral phosphodiesterase 4 inhibitor, in patients with moderate to severe psoriasis: ESTEEM 1 randomized treatment withdrawal phase results P. Foley1, K. Papp2, K. Reich3, C. Leonardi4, L. Kircik5, S. Chimenti6, C.C. Hu7, R.M. Stevens7, R.M. Day7, C.E.M. Griffiths8 1 Skin & Cancer Foundation Inc., St. Vincent’s Hospital, Melbourne, Victoria, Australia 2 Probity Medical Research, Waterloo, Onrario, Canada 3 SCIderm Research Institute and Dermatologikum Hamburg, Hamburg, Germany 4 Saint Louis University School of Medicine, St. Louis, Missouri, USA 5 Physicians Skin Care, PLLC, Louisville, Kentucky, USA 6 University of Rome Tor Vergata, Rome, Italy 7 Celgene Corporation, Warren, New Jersey, USA 8 Dermatology Centre, University of Manchester, Manchester, UK ESTEEM 1 randomized patients with moderate/severe plaque psoriasis (PASI ≥12, BSA ≥10%, sPGA ≥3) 1:2 to placebo or apremilast 30 mg BID (APR30). At Week 16, placebo patients switched to APR30. At Week 32, APR30 patients who achieved PASI-75 were re-randomized to continue APR30 or receive placebo (1:1). Upon loss of PASI-75, patients re-randomized to placebo resumed APR30. At Week 16, significantly more APR30 patients achieved PASI-75 (33.1%) and PASI-50 (58.7%) vs placebo (5.3% and 17.0%; P < 0.0001). Mean/median percent change from baseline in PASI was −52.1%/−59.0% (APR30) vs −16.7%/−14.0% (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. 61.0% randomized to APR30 at Week 32 maintained PASI-75 at Week 52, 75.3% had ≥70% improvement in PASI from baseline; mean percent change from baseline in PASI was −81% to −88% between Weeks 32–52. 11.7% re-randomized to placebo at Week 32 had PASI-75 at Week 52. Median time to PASI-75 loss in patients re-randomized to placebo was 5.1 weeks. 70.3% re-randomized to placebo who lost response and restarted APR30 regained PASI-75 response after treatment re-initiation. AE incidence did not increase over time. Most common AEs were diarrhea, nausea, URTI, nasopharyngitis, and headache. Most AEs were mild/moderate and did not lead to discontinuation. Serious AEs (serious infections, malignancies, and cardiovascular events) and laboratory changes were consistent with prior APR studies. Over 52 weeks, APR30 was effective in moderate/severe psoriasis. APR30 demonstrated an acceptable safety profile and was generally well-tolerated.

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Adalimumab-induced porokeratosis J.W. Frew1,2, K. Parsi1,2 1 Department of Dermatology, St Vincent’s Hospital, Darlinghurst, Sydney, New South Wales, Australia 2 University of New South Wales, Kensington, New South Wales, Australia Porokeratoses are a group of disorders of terminal epidermal differentiation thought to be largely due to variably expressed, as yet undefined, genetic polymorphism(s). We present a case of a 29 year old male with Crohn’s Disease and a recent eruption of histologically diagnosed porokeratosis whilst undergoing therapy with Adalimumab. Examination revealed multiple well demarcated plaques on the legs and anterior trunk. A clinical diagnosis of eruptive porokeratosis was made. Confirmatory punch biopsy of the periphery of one of these lesions demonstrated a column of parakeratosis with absence of stratum granulosum, consistent with a cornoid lamella confirming the clinical diagnosis of porokeratosis. Recent literature points to an underlying immunological pathogenesis for porokeratosis, with individual cases in association with TNF-alpha inhibitors such as etanercept and adalimumab being recently reported. The decreased immune surveillance is thought to result in the proliferation of abnormal epidermal clones found in porokeratosis. Topical fixed-dose adapalene/benzoyl peroxide plus oral doxycycline: An evidence-based alternative to oral Isotretinoin in the treatment of severe nodular acne Galderma Australia Pty Ltd Jerry Tan1, Shannon Humphrey2, Charles Lynde3, Ronald Vender4, Nabil Kerrouche5, Fabien Audibert5 1 University of Western Ontario and Windsor Clinical Research Inc., Windsor, Ontario, Canada 2 Department of Dermatology & Skin Science, The University of British Columbia, Vancouver, British Columbia, Canada 3 Lynderm Clinical Research, Markham, Ontario, Canada 4 Dermatrials Research Inc., Hamilton, Ontario, Canada 5 Galderma R&D SNC, Sophia Antipolis, France Introduction: Isotretinoin (ISO) is the gold standard for treatment of severe nodular acne. However, despite its unsurpassed efficacy, it may be associated with severe adverse events (AEs). Method: This multicenter, randomized, controlled, noninferiority, investigator-blinded study compared the efficacy and safety of oral ISO plus topical vehicle gel versus doxycycline 200 mg capsules plus adapalene 0.1%/benzoyl peroxide 2.5% gel (D+A/BPO) in treatment of severe nodular acne over 20 weeks (n = 266). Results: D+A/BPO showed a significantly earlier onset of action in reducing nodules, inflammatory, and total lesions at week 2. At 20 weeks, ISO was superior in reducing nodules (96% vs 89%; P < 0.001), inflammatory (95% vs 80%; P < 0.001) and total lesions (93% vs 78%; P < 0.001). D+A/BPO showed a better safety profile, with fewer patients (24 vs 45) reporting treatment-related, medically-relevant AEs (33 vs 73, respectively). A composite endpoint including both efficacy and safety criteria showed that D+A/BPO was non-inferior to


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isotretinoin, with superiority for D+A/BPO demonstrated in the per-protocol population (74.3% vs 58%; P = 0.014). D+A/BPO has a favorable benefit/risk profile compared to ISO in treatment of severe nodular acne and demonstrates an earlier onset of effect in inflammatory and total lesions. This combination may be a reasonable alternative to ISO for severe nodular acne patients.

Evaluation of safety and side-effect profile of Ingenol Mebutate (Picato) in a clinical setting R. George, D. Murrell Department of Dermatology, St George Hospital, Kogarah, New South Wales, Australia Introduction: Picato gel has recently been approved for use as a topical and directed field treatment of Actinic Keratoses in Australia. Its benefit lies in the shorter required duration of use and purported efficacy. It has been reported to be safe in selected tiral patient. We aim to investigate its tolerance and side-effect profile in the general Australian population. Method: 15 patients treated with Picato for Actinic keratoses. Photos were taken prior to treatment, as well as (on average) 5 days and 14 days after application of Picato at a selected site. The photos were then graded by 4 doctors. Grading was performed with regard to 7 parameters: (1) swelling (2) erythema (3) vesiculation (4) crusting (5) scaling and (6) erosion/ ulceration; marking on scale from 0 (none present) to 4 (severe). The data was then analysed to obtain average values of reactions for all 3 phases of treatment. Results: All but one patients reported they found the treatment tolerable. The scores of each patient and overall tabulation will be presented during the talk on pictorial format. Overall, we have found that Picato was found to be safe and tolerable in general community patients in Australia.

Intramatrix triamcinolone injections in a child with nail lichen planus G. Casey, H. Gourier, C. Allen & J. Bowling Department of Dermatology, Oxford University Hospitals, Oxford, UK Lichen planus of the nails in children is an uncommon condition affecting less than 20% of children presenting with lichen planus. Literature on effective treatment of nail lichen planus in children includes systemic and intramuscular corticosteroids, but recurrence of disease and side effects, including cushingoid facies and injection site lipoatrophy, have been reported. We report a 13-year-old boy who has had functional and cosmetic improvement with triamcinolone acetonide 10mg/mL injections into the nail matrix, with sustained benefit over a follow-up period of 18-months. Intramatrix corticosteroid injections appear to be a safe and effective treatment option in selected children with lichen planus localised to the nails.

Developments for a brighter skin tone A.H. Lui, K.A. Greive Ego Pharmaceuticals Pty Ltd, Melbourne. Victoria, Australia While many Australian consumers prefer a bronzed skin tone, a brighter and more uniform appearance is highly desired. Similarly, while Asian and Middle Eastern consumers prefer a lighter skin tone, skin uniformity is also desired. With numerous skin brightening products containing cocktails of ingredients available on the Market, it can be an overwhelming task for consumers to select a safe and efficacious product that is suitable for their needs. With sun exposure being a contributing factor to skin dullness and non-uniformity, a multi-faceted approach is required to efficiently brighten the skin. This includes a skin care regime encompassing a selection of products, each serving a specific function such as the inclusion of a sunscreen to help prevent sun induced pigmentation, and a blend of skin brightening actives that targets multiple sites of melanogenesis. With age spots commonly developing on light exposed areas of the skin, including the back of the hands,1 skin brightening products should be extended to cater for both the facial area and the hands. A well designed skin care regime, supported with clinical testing, offers consumers a safe and efficacious option for a brighter skin tone.

Reference 1.

Lentigo senillis. In: Braun-Falco O, Plewig G, Wolff HH et al. (eds). Dermatology. Chapter 26 Disorders in melanin pigmentation. Berlin, Heidelberg: Springer-Verlag, 1991; 686–709.

Management of atopic eczema flare ups I.R. Heinicke, K.A. Greive Ego Pharmaceuticals Pty Ltd, Melbourne. Victoria, Australia Atopic eczema is one of the most common skin conditions worldwide. It affects both adults and children and its prevalence is increasing. Atopic eczema is a chronic itchy inflamed skin condition which is exacerbated by a number of factors, however proper management of this condition can diminish the sometimes distressing symptoms. Patients with atopic eczema have been found to have skin colonized by Staphylococcus aureus, with levels shown to increase with the severity of the condition. Decreasing the high counts of Staphylococcus aureus on the skin has been associated with an improvement in skin condition. Emollients can be used to effectively treat atopic eczema and minimize flare-ups. Soap free cleansers, bath oils and creams which contain antimicrobial agents can decrease the microbial levels on the skin. These products can also improve barrier function and skin condition which is compromised in atopic eczema patients.



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The safety and efficacy of Omalizumab in chronic idiopathic/dpontaneous urticaria: Results from a phase iii randomized, double-blind, placebo-controlled study C.H. Katelaris1, M. Maurer2, P. Staubach3, M. Ashby4, J. Canvin5, D. Ledford6, A. Kaplan7, T. Jakob8, K. Rosén4 1 University of Western Sydney, Sydney, Australia 2 Charité-Universitätsmedizin, Berlin, Germany 3 Universitätsmedizin Mainz, Mainz, Germany 4 Genentech, South San Francisco, USA 5 Novartis Pharmaceuticals Ltd., Horsham, UK 6 University of South Florida, Tampa, USA 7 Medical University of South Carolina, Charleston, USA 8 Universitats Klinikum Frieburg, Freiburg, Germany Objectives: Many chronic spontaneous urticaria (CSU) patients remain symptomatic despite H1-antihistamine (AH) treatment, even up to 4 times approved dose. This Phase III, study investigated the safety and efficacy of omalizumab in refractory CIU/CSU patients treated with H1-AHs at up to 4 times approved dose as well as H2-AHs and/or LTRAs.

Cases of orf in deer have been reported from Italy, Finland and Norway, but never have been previously reported in Australia, where the common source of infection is from contact with sheep and goats (orf virus) and cattle (bovine papular stomatitis virus and pseudocowpox virus).1,2 We report a case of orf in an 8-year-old boy, occurring two weeks after contact with a deer at an Australian zoo. With only 3 reported cases all from North America, we report the first probable Australian case, highlighting the need to consider deer as a source of orf.

Methods: Randomized (3:1) patients received monthly doses of subcutaneous omalizumab (300mg) or placebo for 24-weeks, with a 16-week follow-up period. Safety outcome measures included incidence and severity of adverse events (AEs) and serious AEs (SAEs). Efficacy outcome measures at week-12 included change from baseline in mean weekly itch severity score (ISS), mean weekly number of hives score, and the proportion of patients achieving weekly urticaria activity score (UAS7) of 0.

Recurrent pyogenic granuloma with satellitosis in a patient with adult onset atopic dermatitis M. Khou, T. Phan Department of Dermatology, Concord Repatriation General Hospital, Concord, New South Wales, Australia Recurrent pyogenic granuloma with satellitosis, also known as Warner Wilson-Jones syndrome (WWJS), is a rare complication of pyogenic granuloma characterised by the appearance of satellite lesions post treatment of the primary lesion.1 WWJS typically occurs in children and young adults, commonly on the trunk.1,2

Results: 335 Subjects were randomized to receive either omalizumab 300 mg (n = 252) or placebo (n = 83). Similar numbers of patients experienced ≥1 AE or ≥1 SAE in the omalizumab (AE: 83.7%; SAE: 7.1%) and placebo (AE: 78.3%, SAE: 6.0%) groups. Suspected study-drug related AEs occurred in 11.1% (omalizumab) and 13.3% (placebo) of patients; 1.2% of patients withdrew from the study due to AEs in each group. At week-12, significant improvements were seen in omalizumab vs placebo-treated patients in mean change of ISS (−8.6 vs −4.0: P < 0.0001), mean change in hives score (−10.5 vs −4.5: P < 0.0001), and in the proportion of patients with UAS7 = 0 (33.7% vs 4.8%; P < 0.0001). Conclusions: Omalizumab was well tolerated and significantly improved symptoms in CIU/CSU patients who remained symptomatic despite H1-AHs plus H2-AHs and/or LTRAs.

Orf from a deer: An Australian case M. Khou,1 S. Donoghue,1 S. Mann,2 S. Zagarella1 1 Department of Dermatology, Concord Repatriation General Hospital, Concord, New South Wales, Australia 2 Histopath Pathology, Sydney, New South Wales, Australia Orf, also known as contagious ecthyma, is a rare zoonotic viral infection caused by a member of the genus Parapoxvirus in the family Poxviridae. The genus Parapoxvirus (family Poxviridae, subfamily Chordopoxvirinae) comprises several members: orf virus (OV), bovine papular stomatitis virus (BPSV), pseudocowpox virus (PCPV), and parapox of red deer in New Zealand virus (PVNZ).1

References 1.

Delhon G, Tulman ER, Afonso CL et al. Genomes of the Parapoxviruses Orf Virus and Bovine Papular Stomatitis Virus. J. Virol. 2004; 78: 168–77. 2. Swick BL, DeBates SM. A Solitary Nodule on the Finger. Arch. Dermatol. 2009; 145: 321–6.

We describe a case of a 55 year-old male patient with recurrent pyogenic granuloma with satellitosis in the left eyebrow region associated with adult onset atopic dermatitis. The patient presents with atypical features of WWJS in regards to the age of onset, the unusual site of the lesions and the association with dermatitis.

References 1.

Warner J, Jones EW. Pyogenic granuloma recurring with multiple satellites: a report of 11 cases. Br. J. Dermatol.. 80: 1968; 218–27. 2. Zaynoun ST, Juljulian HH, JKurban AK. Pyogenic granuloma with multiple satellites. Arch. Dermatol. 109: 1974; 689–91.

Multiple subcutaneous nodules: Would you consider tuberculous gumma? A. Kline1, M. Boyle2 1 Department of Dermatology, Royal Newcastle Centre, Newcastle, New South Wales, Australia 2 Department of Medicine, Royal Newcastle Centre, Newcastle, New South Wales, Australia A 64 year old gentleman with longstanding well controlled HIV infection originally from Ireland presented with several month history of tender swollen joints and multiple subcutaneous lumps, several with overlying cellulitic changes.


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Biopsy and culture demonstrated mycobacteria tuberculosis. This patient had obvious destructive lesions in his right foot but no evidence of a primary pulmonary infection suggesting no latent pulmonary reactivation. He was commenced anti-tuberculous therapy and demonstrated marked improvement. Tuberculous gumma is a rare and unusual presentation of cutaneous TB caused by haematogenous dissemination. It nearly always occurs in immunocompromised individuals. It remains an important diagnosis for the dermatologist consider when assessing immunocompromised patients in Australia.

ized exanthematous pustulosis (ALEP) is even rarer, with only a handful of cases reported in the literature. We report a case of a 15 year-old female who presented with severe pustular eruption localized to her face 2 days after exposure to oral Cephalexin. Cessation of the culprit drug resulted in complete resolution of symptoms. Biopsies were supportive of the diagnosis but patch testing with Cephalexin was negative. This is the first reported case of ALEP secondary to oral Cephalexin.

References 1.

Ustekinumab inducing clearance of recalcitrant plaque Psoriasis in an adolescent patient P. Le, K. Gebauer Department of Dermatology, Fremantle Hospital, Fremantle, Western Australia, Australia The first presentation of psoriasis in childhood is not uncommon; with a third of cases occurring before the age of 16years.1 Limited data exists regarding the use of biologics in paediatric psoriasis. Etanercept is the only biologic approved in Europe for children older than 8 years with severe psoriasis inadequately controlled with other systemic therapies or phototherapy.2 Case reports exist for the use of infliximab, adalimumab, and more recently ustekinumab in paediatric psoriasis. We report the clearance of recalcitrant plaque psoriasis with ustekinumab in a 16 year old boy. The patient had failed treatment with multiple topical therapies including betamethasone, calcipotriol, cocois ointment, NB-UVB, bath PUVA; and systemic therapies including acitretin, cyclosporine, and methotrexate, over a 3 year period. His psoriasis had a significant impact on his school attendance, and mental health. With an initial PASI of 34.2, ustekinumab was commenced at 45mg at weeks 0 and 4, then every 12 weeks thereafter. A PASI score of 0 was achieved by week 16 review. The patient has had no significant side effects, and continues to respond well to ustekinumab 2 years on.

References 1.

Raychaudhuri SP, Gross J. A Comparative Study of Pediatric Onset Psoriasis with Adult Onset Psoriasis. Pediatr. Dermatol. 2000; 17: 174–8. 2. Landells I, Paller AS, Pariser D et al. Efficacy and safety of etanercept in children and adolescents aged >/= 8 years with severe plaque psoriasis. Eur. J. Dermatol. 2010; 20: 323–8.

Acute localized exanthematous pustulosis (ALEP) caused by Cephalexin: A case report Q. Le, D. Gan Monash Medical Center, Melbourne, Victoria, Australia Acute generalized exanthematous pustulosis (AGEP) is an uncommon acute severe cutaneous adverse reaction with a clear drug cause in more than 90% of the cases.1 The incidence is only 1-5 patients per million per year.2 Acute local-

Sidoroff A, Dunant A, Viboud C et al. Risk factors for acute generalized exanthematous pustulosis (AGEP)- results of multinational case-control study (EuroSCAR). Br J Dermatol. 2007; 157: 989–96. 2. Sidoroff A, Halevy S, Bavinck JN et al. Acute generalized exanthematous pustulosis (AGEP) – a clinical reaction pattern. J Cutan Pathol. 2001; 28: 113–9.

Pyoderma gangrenosum of the penis: An important lesson E. Ng, M. Lee, N. Dunglison Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia In this case report, we describe an unusual case of localised pyoderma gangrenosum of the penis in a previously healthy 62 year old male. Delayed diagnosis resulted in multiple surgical debridements, a penile skin flap and ultimately a distal penectomy. Pyoderma gangrenosum is an inflammatory ulcerative disease that usually occurs with systemic manifestations. Presently, there are fewer than 15 literature reports of isolated pyoderma gangrenosum of the penis. Early recognition of pyoderma gangrenosum is vital to initiating early appropriate treatment and reduction in the risk of significant complications.

Hypergammaglobulinemic purpura of Waldenstrom S.X. Lee, C.C. Ang Department of Dermatology, Changi General Hospital, Singapore Hypergammaglobulinemic purpura of Waldenstrom (HGPW) is a distinctive dermatosis characterized by the combination of recurring purpura on the lower extremities, anaemia, leukopenia, an elevated erythrocyte sedimentation rate, hypergammaglobulinemia and the presence of rheumatoid factor. HGPW can be primary or secondary, with the latter having an association with autoimmune disorders such as lupus erythematosus and Sjogren’s syndrome. Herein, we report a case of primary HGPW in an elderly Chinese lady. We wish to raise awareness of this condition, which can be mistaken for Schamberg’s purpura. The etiopathogenesis, clinical manifestations, histopathological aspects and treatment options of this condition will be discussed.



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Squamous cell carcinoma and keratoacanthoma: A comparison of dermoscopic features M.J. Lin, Y. Pan, C. Jalilian, J.W. Kelly Victorian Melanoma Service, Alfred Hospital, Melbourne, Australia Introduction: Squamous cell carcinoma (SCC) may present in a variety of morphologies, including as a keratinising nodule which may be indistinguishable from keratoacanthoma (KA) on naked eye examination.

recessive dystrophic EB (RDEB) due to collagen VII deficiency may result in microstomia, ankyloglossia and vestibular obliteration.1,3,4 A number of animal models of RDEB and JEB have also provided further information on the dental manifestations of EB since these teeth can be removed and studied in more detail.

Objective: To compare dermoscopic characteristics of nodular SCC and KA.

1.

Methods: Retrospective analysis of 50 nodular SCC and 8 KA collected from a tertiary dermatology referral center and a private dermatology practice in Melbourne, Australia, from September 2009 to October 2012. All lesions were nodules; defined as firm, elevated, round, palpable tumours with a diameter of 5mm or more. Clinical and dermoscopic images were evaluated by two examiners in consensus. Results: Signs of keratinisation were common in both SCC and KA and included keratin crust/scale (90% SCC vs. 100% KA, P = 0.60), central keratin mass (32% SCC vs 88% KA, P < 0.01), white structureless areas (66% SCC vs. 50% KA, P = 0.44), white circles (32% SCC vs. 38% KA, P = 1), keratin pearls (14% SCC vs. 12% KA, P = 1) and collarette (12% SCC vs. 25% KA, P = 0.58). Vascular structures were often polymorphic in both lesions and included glomerular (42% SCC vs. 25% KA, P = 0.56), linear irregular (36% SCC vs. 25% KA, P = 0.7), atypical (30% SCC vs. 38% KA, P = 0.69) and hairpin vessels (30% SCC and 25% KA, P = 1). Haemorrhage was common in both SCC and KA (72% SCC vs. 88% KA, P = 0.44). Conclusions: Keratinisation, haemorrhage and polymorphic vascular structures (glomerular, hairpin, atypical and linear irregular morphologies) are common dermoscopic features shared by both nodular SCC and KA. Dermoscopy does not reliably differentiate between SCC and KA.

Dental manifestations of epidermolysis bullosa N.G. Maher1, D. F. Murrell1,2 1 Department of Dermatology, St George Hospital, Kogarah, New South Wales, Australia 2 Facuty of Medicine, University of New South Wales, Sydney, New South Wales, Australia Epidermolysis Bullosa (EB) consists of a heterogeneous group of inherited mucocutaneous fragility that may have various manifestations in the oral hard and soft tissues. The teeth can show defects mainly in junctional EB (JEB), consisting of enamel hypoplasia (pitting or generalized thinning of enamel), and be affected by gross carious disease in all forms of EB if the oral environment is not cared for properly.1 Enamel formation may be affected in heterozygote carriers of mutations in the genes encoding lam332 and collagen XVII, known to cause JEB.2 The oral mucosa may demonstrate bullae, erosions/ulcerations, erythema, milia or atrophy (such as of the palatal rugae or lingual papillae). The sequelae of bullae and scarring in

References Wright J. Oral manifestations in the epidermolysis bullosa spectrum. Dermatol. Clin. 2010; 28: 159–64. 2. Kim JW, Seymen F, Lee KE et al. LAMB3 mutations causing autosomal-dominant amelogenesis imperfecta. J. Dent. Res. 2013; 92: 899–904. 3. Fortuna G, Chainani-Wu N, Lozada-Nur F et al. Epidermolysis Bullosa Oropharyngeal Severity (EBOS) score: a multicenter development and reliablity assessment. J. Am. Acad. Dermatol. 2013; 68: 83–92. 4. Serrano-Martinez MC, Bagán JV, Silvestre FJ et al. Oral lesions in recessive dystrophic epidermolysis bullosa. Oral Dis. 2003; 9: 264–8.

Benign lichenoid keratosis – a case series highlighting its expanding presentation to avoid future misdiagnosis D. Maor1, C. Ondhia1, L. Yu2, J. Chan1 1 Department of Dermatology, Sir Charles Gairdner Hospital Nedlands, Western Australia, Australia 2 Department of Histopathology, Cottesloe, Western Australia, Australia Background: Lichenoid Keratosis (LK), also known as benign lichenoid keratosis or lichen planus-like keratosis is commonly a solitary, pink to red-brown scaly papule that can be confused with cutaneous malignancy. It most commonly resembles a basal cell carcinoma (BCC) or Bowen’s disease and to prevent misdiagnosis, these lesions are frequently biopsied. Objective: To analyse whether lichenoid keratosis has a predilection for a particular age, gender and anatomical location. In addition, to determine whether lichenoid keratosis has common coexisting histopathological diagnoses. Methods: Our histopathology database of 263 confirmed diagnoses of lichenoid keratosis from 2008–2009 was accessed to determine age, gender, anatomical location, time of year of presentation, histopathological and coexistent lesion diagnoses. The treating dermatologist’s differential diagnoses based on their clinical assessment were also recorded. Results: The results yielded an average age at presentation of 64 with an age range of 34 to 96. The gender frequency was 58% female, and 42% male. The most common anatomical site of the lesion was the chest/anterior torso followed by the back and legs. The most common coexisting condition with LK was solar keratosis (14%) followed by pigmented basal cell papilloma (7.8%). Clinically, the most common differential diagnoses based on the treating dermatologist’s review of the patient was a basal cell carcinoma predicted in 47% of cases followed by LK (29.5%) and seborrhoeic keratosis (18%).


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Conclusion: The clinicopathologic spectrum of benign lichenoid keratosis is broad. This retrospective case series highlights that an awareness of its expanded presentation is essential to avoid future misdiagnosis.

BRAF mutations in an involuting and non-involuting naevus upon BRAF ± MEK treatment P. McClenahan1, L. Lin1, J.M. Tan1,2, R. Flewell Smith1, H. Schaider1, K. Jagirdar3, D. Lambie4,5, T.W. Prow1, R.A. Sturm3, H.P. Soyer1,2 1 Dermatolgy Research Centre, School of Medicine, Princess Alexandra Hospital, The University of Queensland, Brisbane, Queensland, Australia 2 Department of Dermatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia 3 Melanogenix Group, Institute for Molecular Bioscience, The University of Queensland, Brisbane, Queensland, Australia 4 Diamantina Institute, Translational Research Institute (TRI), Princess Alexandra Hospital, Brisbane, Queensland, Australia 5 IQ Pathology, Brisbane, Queensland, Australia Introduction: BRAFV600E mutations are present in approximately 50% of melanoma and 70% of benign melanocytic naevi. Targeted BRAFV600E inhibition is improving survival of BRAFV600E mutated melanoma by down regulating the mitogen activated protein kinase (MAPK) proliferation pathway. Method: One participant of our naevus surveillance study commenced a trial of dabrafenib ± trametinib therapy following appearance of melanoma metastases. Full body and dermoscopic imaging was used in continuing to monitor the naevi and microbiopsy was performed to sample changing naevi. Results: Following commencement of dabrafenib ± trametinib therapy, 51% of the patient’s naevi involuted while 49% remained unchanged. No increase in pigmentation was observed in any naevus nor any dermoscopic criteria for melanoma. Two naevi were selected for biopsy, one involuting and one unchanged. Histopathology showed both to be junctional naevi without characteristics of malignancy. Molecular analysis of both naevi confirmed the hypothesis that the involuting naevus expressed the BRAFV600E mutation while the unchanged naevus that was biopsied was BRAF wild-type.

Chromoblastomycosis caused by Exophiala spinifera complex in Australia in association with immunosuppression for pyoderma gangrenosum P. McDonald1, Y. Pan2, R. Kelly2 1 The Alfred Hospital, Melbourne, Victoria, Australia 2 Department of Dermatology, St Vincent’s Hospital, Melbourne, Victoria, Australia We present a case of chromoblastomycosis caused by Exophiala spinifera in an 86-year old female with pyoderma gangrenosum in Melbourne, Victoria. The patient’s pyoderma gangrenosum was managed with immunosuppres-

sive therapy, consisting of long-term oral prednisolone and mycophenolate mofetil. The patient presented with an inflamed violaceous plaque on her right elbow, which had evolved from a superficial skin injury she acquired gardening four months prior. Histopathological examination revealed granulomatous inflammation and fungal organisms with sclerotic cells. The fungal tissue culture grew Exophiala spinifera. Diagnosis of chromoblastomycosis due to Exophiala spinifera was made and the patient was managed successfully with voriconazole. Chromoblastomycosis is endemic to tropical and subtropical areas, including northern Australia, however, it has never been reported in the southern regions.1 The association with Exophiala spinifera in our case is remarkable, as although it is a well-known cause of phaeohyphomycosis, it has only been exceptionally reported in chromoblastomycosis and never in Australia.2 Chromoblastomycosis is becoming increasingly associated with immunocompromised hosts, however, the association with pyoderma gangreonsum has not yet been reported.1 This case aims to increase awareness of chromoblastomycosis in Australia and highlight the emerging associated subcutaneous mycoses with immunocompromised patients, including those with pyoderma gangrenosum.

References 1.

Pena-Penabad C et al. Chromomycosis due to Exophiala jeanselmei in a renal transplant recipient. Eur. J. Dermatol.. 2003; 13: 305–7. 2. Tomson N, Abdullah A, Maheshwari M. Chromomycosis caused by Exophiala spinifera. Clin. Exp. Dermatol.. 2006; 31: 239–41.

Fibro-osseous pseudotumour of the digit: Nailing a difficult diagnosis R.E. Meani1, R.J. Bloom2, A.J. Chamberlain1,3 1 Victorian Melanoma Service, The Alfred, Prahran, Victoria, Australia 2 ARC Plastic Surgery Hawthorn East, Hawthorn East, Victoria, Australia 3 Caulfield Skin Cancer & Dermatology Clinic, Caulfield North, Victoria, Australia We present a case of an unusual diagnostic dilemma. An otherwise well 16 year old male presented for assessment of a firm subungual growth of the Left great toe that progressively appeared over 2 years. There was associated discomfort and onycholysis. Polymorphic vessels were visible on dermoscopy of the visible subungal mass. He had a history of previous crush injury to the toe sustained during a soccer match. The initial clinical differential diagnoses included glomus tumour, pyogenic granuloma, acquired digital fibrokeratoma and less likely verruca vulgaris. Curettage was attempted which revealed compact hyper-and parakeratosis along with degenerate inflammatory cells and old haemorrhage with no other specific features. PAS stain for fungal elements was negative. The consistency of the lesion did not feel wart-like nor did it demonstrate pinpoint bleeding. The patient then underwent local excision of the lesion with reflection of the nail bed, which revealed a firm tumour attached to the bony surface of the dorsal


ACD 47th Annual Scientific Meeting 2014 aspect of the distal phalanx. Histopathologic examination of the biopsy specimen revealed central fibroblastic proliferation, irregular cartilage and woven bone. There was no cellular atypia nor mitotic activity. No features of malignancy were seen. The differential diagnosis for cutaneous ossification in this location includes fibro-osseous pseudotumour (FOPT), bizarre parosteal osteochondromatous proliferation of bone (BPOP or so called Nora lesion) and subungual exostosis. We present and compare the distinguishing features of the various differential diagnoses and the challenges in reaching a final diagnosis. For such tumours, radiology is as vital as histopathology in making a diagnosis and excluding neoplasia. These sorts of lesions may present to the dermatologist, not always the foot surgeon!

Extramammary Paget’s disease: Surgical treatment with wide local excision R. Minocha1, C. Arianayagam2, P. Wong3,4 1 Department of Dermatology, Westmead Hospital, Westmead, New South Wales, Australia 2 Department of Plastic Surgery, Coffs Harbour Health Campus, Coffs Harbour, New South Wales, Australia 3 Mid North Coast Arthritis Clinic, Coffs Harbour, New South Wales, Australia 4 UNSW Rural Clinical School, Coffs Harbour, New South Wales, Australia Extramammary Paget’s disease (EMPD) is an uncommon cutaneous neoplasm, most commonly presenting in apocrine rich sites. High recurrence rates have been described, despite surgical management, due to conservative excisions in delicate tissue. This case series demonstrates the management of EMPD in four patients with wide local excision (WLE) using 1cm macroscopic clearance of margins. Two patients required second WLE to achieve clear histopathological margins and two patients required a third WLE. This report highlights the importance of adequate surgical clearance as the primary priority, with prompt re-excisions in the advent of positive histopathological margins. Reconstructive surgery of defects must be viewed as secondary priority to decrease the likelihood of local recurrence and tumour invasion. Cases 1 to 4 were followed up for 6 months, 5 years, 11 years and 13 years respectively. No cases developed local recurrence or invasive malignancy.

Multiple palmer epidermoid cysts in a patient with systemic lupus erythematosus R. Minocha1, P. Fernandez Penas1, J. Choi1, K. Tan2, S. Chou2 1 Department of Dermatology, Westmead Hospital, Westmead, New South Wales, Australia 2 Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, New South Wales, Australia Multiple epidermoid cysts in the palmoplantar region are a rare entity and are often clinically misdiagnosed as tophaceous gout or rheumatoid nodules. The pathogenic mechanism for the development on palms and soles is still poorly understood. There is now increasing evidence of the correlation between palmoplantar epidermoid cysts and

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infection with certain HPV subtypes. We present a 57 year old lady, diagnosed with Systemic Lupus Erythematosis since age 29, managed with immunosuppression, who presented with three epidermoid cysts on the volar aspect of her fingers. Immunostaining of the biopsy specimen with P16 demonstrated moderate positivity, whereas Ki67 stained positively in the basal layer only, consistent with a possible viral aetiology.

A case of diffuse melanosis cutis with positive BRAF mutation status and treatment with targeted therapies R. Minocha1, P. Uribe1, R. Kefford2, P. Fernandez Penas1 1 Department of Dermatology, Westmead Hospital, Westmead, New South Wales, Australia 2 Department of Medical Oncology, Westmead Hospital, Westmead, New South Wales, Australia Diffuse melanosis cutis (DMC) is a rare presentation of metastatic melanoma associated with a particularly guarded prognosis. The advent of target therapies has transformed the landscape of management in patients with metastatic melanoma, however it is yet to be determined whether this includes patients with a particularly poor prognosis such as those with DMC. We report a case of a 35 year old male with BRAFV600E metastatic melanoma treated with vemurafenib (as well as Ipilimumab and whole brain radiotherapy), who is alive, 25 months beyond the onset of his DMC. This is significantly longer than the reported mean survival of four months, further highlighting the promising survival advantage of targeted therapies when compared to conventional chemotherapeutic regimens.

A multi-mechanism skin brightening regimen delivers pigment evening benefits in an ethnically diverse population B.L. Edison, B.A. Green, L. Buckley, I. Brouda, P.N. Konish, Y. Lee, R.L. Weinkauf NeoStrata Company, Inc., Princeton, New Jersey, USA Introduction: A new brightening skincare regimen was developed to improve the complexion of facial skin by targeting multiple steps and pathways that affect pigmentation. The regimen consists of a facial cleanser, serum, and lotion, which contain N-acetylglucosamine plus a variety of other benefit ingredients to collectively exfoliate pigmented areas, reduce tyrosinase activity and melanin production, and deliver an overall pigment evening effect. Method: The clinical study on skin brightening was a 16 week study. Regime was twice a day use of the cleanser, serum and lotion on the entire face. Visits were conducted at 0, 4, 8 and 16 weeks. Evaluations are based on objective (visual grading, chromameter measurements and clinical photographs) and subjective (self-assessment questionnaires) measures. Results: Visual Grading & Clinical Photographs showed: • Lighter and more even skin colour • Brighter overall skin tone • Reduced overall sallowness


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• Lighter and less apparent brown spots • Effects were observed in all ethnic groups Chromameter Measurements showed: • Both normally pigmented areas and brown spots became brighter and less sallow • Normally pigmented areas brightened faster than brown spots • Brown spots improved in sallowness faster and to a greater degree than normally pigmented areas Self-Assessment Questionnaires: • Confirmed that subjects noticed brighter skin tone, more even pigmentation, and less apparent brown spots A periungal verrucous Bowen’s disease mimicking viral wart S.S.Y. Ng, C.C. Ang Department of Dermatology, Changi General Hospital, Singapore A 37 year old chinese man presents with a 3 year history of a persistent periungal lesion. It was gradually increasing in size and would occassionally bleed after trauma. On examination, it was a pigmented verrucous plaque of about 5x7mm. He had not seeked any treatment prior to this. The preliminary diagnosis was that of a viral wart. However, a shave biopsy confirmed squamous cell carcinoma in-situ. Bowen’s disease can present atypically as a verrucous plaque, especially if associated with the human papilloma virus, but usually in the genital region. Its presence at the periungal region is less well recognised and may remain undiagnosed if not for a biospy.1,2Although, Bowen’s disease may also respond to cryotherapy, as with a viral wart, it is still paramount not to miss this diagnosis as a squamous carcinoma in-situ would warant closer surveillance. References 1.

Riddel C, Rashid R, Thomas V. Ungual and periungual human papillomavirus–associated squamous cell carcinoma: A review. J. Am. Acad. Dermatol. 2011; 64: 1147–53. 2. Kreuter A, Gambichler T, Pfister H et al. Diversity of human papillomavirus types in periungual squamous cell carcinoma. Br. J. Dermatol. 2009; 161: 1262–9.

Case series of BHA and allergic contact dermatitis R. Nguyen, N. Tam, A. Palmer Skin and Cancer Foundation Victoria, Melbourne, Victoria, Australia This is a case series of 3 patients with cheilitis and circumoral dermatitis 8 months, 12 months and 9 years respectively. They were patch test positive to BHA (2tertbutyl-dimethoxy-diphenyl butyl hydroxyanisole) which was relevant in their clinical history. Of the 5386 patients tested for BHA from 1st January 1993 to 5th August 2013, there were 56 cases, of which only 3 were relevant. BHA is found in many products including lip balms, lip waxes and is used as a food preservative so it was felt to be

relevant in these three cases. Upon avoidance of BHA, 2 patients noted improvement in their symptoms. The other patient (symptoms of 9 years) was non-contactable for followup. It was an interesting subset of patients of which allergic contact dermatitis to BHA was thought to be a contributory factor to their ongoing lip dermatitis.

Secukinumab ‘fixed-interval’ versus ‘retreatment-as-needed’ regimen for moderate-to-severe plaque psoriasis: Results from the Study Comparing secukinumab Use in Long-term Psoriasis maintenance therapy: fixed regimen versus re-Treatment Upon start of Relapse (SCULPTURE) Novartis Pharmaceuticals U. Mrowietz1, C. Leonardi2, G. Girolomoni3, D. Toth4, A. Morita5, S. Balki6, J. Szepietowski7, P. Regnault8, H.J. Thurston9, S. Helou10, C. Papavassilis10 1 Department of Dermatology, University of Kiel, Kiel, Germany 2 Dermatology, Central Dermatology, St Louis, USA 3 Clinica Dermatologica, University of Verona, Borgo Trento, Italy 4 Dermatology, Windsor Hospital, Windsor, Canada 5 Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan 6 Dermatology, Shree Hospital & Critical Care, Nagpur, India 7 Department of Dermatology, Venereology and Allergology, University of Medicine, Wroclaw, Poland 8 Global Clinical Development, Novartis Pharma AG, Basel, Switzerland 9 Integrated Information Sciences, IHC Franchise, Novartis Pharma AG, Basel, Switzerland 10 Development Franchise Integrated Hospital Care, Novartis Pharma AG, Basel, Switzerland Background: SCULPTURE compared the maintenance of efficacy over time using a ‘fixed-interval’ regimen (FI) compared to a ‘retreatment-as-needed’ regimen (RAN) of secukinumab, an anti-IL-17A mAb in subjects with moderate-to-severe psoriasis. Methods: 966 subjects were randomized to receive s.c. secukinumab 150 mg or 300 mg. At Week 12, subjects were classified as PASI-75 responders, partial responders (≥50% but

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