Abstracts from the 100th Canadian Dermatology Association (CDA) Annual Conference in Halifax,Nova Scotia,June 18-21,2025

Values and Preferences of Patients on the Management of Hidradenitis Suppurativa: A Systematic Review

Daniel G. Rayner¹, Isabella Silang², Leonardo Ologundudu³, Shelly-Anne Li⁴, Ilya Mukovozov^5,6

¹Schulich School of Medicine and Dentistry, Western University, London, ON, ²Faculty of Science, McMaster University, Hamilton, ON, ³Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, ⁴Department of Family & Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ⁵Department of Medicine, Division of Dermatology, Women’s College Hospital, Toronto, ON, ⁶Toronto Dermatology Centre, Toronto, ON

Introduction: Hidradenitis suppurativa (HS) is a chronic inflammatory condition characterized by painful and recurrent nodules, abscesses, and scars. Existing guidelines for HS have only informally considered patient perspectives in their development. Explicitly understanding values and preferences of HS patients can improve the trustworthiness of guidelines and inform optimal clinical management. A systematic review was conducted to summarize the values and preferences of patients towards the management of HS.

Methods, Results: A search of MEDLINE, Embase, CINAHL, and PsycINFO to September 1st, 2024, was performed for qualitative or quantitative studies addressing patients’ values and preferences on the management of HS. Paired reviewers independently screened citations and extracted data. A critical meta-narrative synthesis was conducted with systematic profiles to transform quantitative data into qualitative data. Iterative thematic synthesis was conducted to generate analytical themes and the GRADE–CERQual approach was used to rate the confidence in the evidence. Overall, this analysis included 43 studies (median of mean age: 38.0 years; median 87% female) reporting on 10,532 patients. Twenty-seven studies (63%) were quantitative and 16 were qualitative (37%). Seven analytical themes were identified: (i) preference for effective treatments in pain and odour management (high confidence); (ii) preference for less invasive treatments with few side effects (moderate confidence); (iii) concern regarding the financial burden of HS management (low confidence); (iv) preference for care from providers aware and knowledgeable of the burden of HS (high confidence); (v) preference for consideration of women’s health in HS management (very low confidence); (vi) preference for integration of mental health in HS management (very low confidence); and (vii) concern regarding the impact of HS flares and treatments on visual appearance (low confidence).

Conclusions: This study identified 7 key themes related to patient values and preferences which may inform optimal management, clinical guidelines, and future research in HS.

Learning Objectives

Takeaway Message

Patients with hidradenitis suppurativa prefer less invasive treatments, those with fewer side effects, and those that are effective in pain and odour management. Future research is needed to better understand patient values and preferences towards women’s health and mental health in the context of hidradenitis suppurativa management.

Predictors of Drug Survival of Biologics in Hidradenitis Suppurativa: A Systematic Review and Meta-Analysis

Daniel G. Rayner¹, David Gou², Leonardo Ologundudu³, Touraj Khosravi-Hafshejani^4,5, Jan P. Dutz^5,6

¹Schulich School of Medicine and Dentistry, Western University, London, ON, ²Faculty of Health Sciences, McMaster University, Hamilton, ON, ³Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, ⁴Clinician Investigator Program, Faculty of Medicine, University of British Columbia, Vancouver, BC, ⁵Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, ⁶Senior Scientist, BC Children’s Hospital Research Institute, Vancouver, BC

Introduction: Patients with moderate-to-severe hidradenitis suppurativa (HS) often require medical management with biologics, including TNFα inhibitors (adalimumab, infliximab), IL-17A inhibitors (secukinumab, bimekizumab), and IL-12/23 inhibitors (ustekinumab). Despite their efficacy, these treatments have shown poor drug survival in patients with HS. We conducted a systematic review and meta-analysis to investigate the predictors of biologic drug survival in patients with HS.

Methods, Results: We searched MEDLINE, Embase, and CENTRAL up to January 1st, 2025, for studies reporting hazard ratios (HR) evaluating the predictors of drug survival of biologics in patients with HS. Paired reviewers independently screened citations and extracted data. Random-effects meta-analyses pooled effect estimates for each predictor. We applied the GRADE approach to assess the certainty of evidence. We used an absolute risk difference (ARD) of 5% to signify a meaningful association with biologic survival. We identified 9 studies reporting on 1,942 patients (median of mean age: 40.9 years; median 59% female). The most frequently investigated biologic was adalimumab (89%). Nine unique risk factors predicting 1-year biologic discontinuation were amenable to meta-analysis. Previous or current smoking (HR 1.72, 95%CI 1.26–2.35; ARD 18.0% more; high certainty) and female sex (HR 1.35, 95%CI 0.96–1.88; ARD 10.6%; moderate certainty) were associated with reduced biologic survival. Concomitant surgery (HR 0.51, 95%CI 0.37–0.71; ARD 23.9% fewer; high certainty) and being biologic naïve (HR 0.82, 95%CI 0.70–0.98; ARD 7.0% fewer; moderate certainty) were associated with increased biologic survival. Age, body mass index, duration of HS, and concomitant antibiotics were not meaningfully associated with biologic survival. The evidence was uncertain on the prognostic value of Hurley stage as a predictor of biologic survival.

Conclusions: Among patients with HS, smoking and female sex were associated with decreased biologic survival, and concomitant surgery and biologic naivety were associated with increased biologic survival.

Learning Objectives

Takeaway Message

Despite their efficacy, biologics show poor drug survival in patients with hidradenitis suppurativa. Smoking and female sex were associated with decreased biologic survival, and concomitant surgery and biologic naivety were associated with increased biologic survival.

Eating Disorders and Maladaptive Eating Behaviours in Hidradenitis Suppurativa: A Systematic Review

Grace Xiong¹, Shanti Mehta², Dea Metko¹, Eric P. McMullen³, Jennifer Couturier⁴, Chaocheng Liu⁵, Laurence Mainville³, Vincent Piguet^3,6

¹Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, ²Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ³Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, ⁴Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, ON, ⁵Department of Dermatology and Skin Science, University of British Columbia, Vancouver, ON, ⁶Division of Dermatology, Women’s College Hospital, Toronto, ON

Introduction: Hidradenitis suppurativa (HS) is a chronic, inflammatory skin condition that can have a devastating impact on quality of life. In addition to other psychological comorbidities, patients with HS often face body image issues and emotional distress that may increase the risk of maladaptive eating behaviors and disordered eating. This systematic review aims to explore the relationship between disordered eating and HS.

Methods, Results: We searched MEDLINE, Embase, Scopus, and Web of Science from inception to January 2024. Eligible articles were published in English and reported on disordered eating behaviors in HS patients. From 7 studies, a total of 572 HS patients were included in the review, with a weighted mean age of 38.9 years and female predominance (66.1%). The prevalence of DSM-5 eating disorders in this cohort was 8.9% (51/572), comprising cases of binge-eating disorder (45/51; 88.2%), anorexia nervosa (5/51; 9.8%), and bulimia nervosa (1/51; 2.0%). Disordered eating behaviours were present in 10% (57/572) of the cohort, including improper laxative, diet-pill, or diuretic use (30/57; 52.6%), food addiction (18/57; 31.6%) and emotional eating (9/57; 15.8%). The mean disease duration was 13 years, and 75.2% (188/250) of patients had moderate to severe disease. Obesity was prevalent, with 67.2% (209/311) of patients classified as obese (BMI > 30), and 22.2% (69/311) as overweight (BMI 25-30). Most patients were White (58%), followed by Black (21.7%), mixed-race, Asian, or unspecified populations.

Conclusions: This review highlights the association between disordered eating and HS. The physical and psychological complexities of HS require a sensitive approach to treatment, where screening for eating disorders and disordered eating behavior is conducted alongside weight-loss counselling. Example phrases to guide weight-loss conversations can be found in Figure 1. Further research to clarify the prevalence and characteristics of disordered eating in HS compared to the general population is needed.

Learning Objectives

Takeaway Message

Disordered eating is a significant and underrecognized issue in patients with hidradenitis suppurativa, potentially driven by a complex interplay of psychological, physiological, and treatment-related factors. Adopting a multidisciplinary, patient-centered approach that integrates screening for disordered eating is essential for improving outcomes in this population.

Key Data Elements for Hidradenitis Suppurativa: Consensus Recommendations for Clinical and Research Practices

Megan Park¹, Cathryn Sibbald², Christopher P. Keeling³, David Croitoru^4,5, Hélène Veillette⁶, Irene Lara-Corrales⁷, Irina Turchin^8,9,10, Marni Wiseman^11,12, Rebecca Levy², Se Mang Wong^13,14, Raed Alhusayen¹⁵

¹Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ²Division of Dermatology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, ³Division of Dermatology and Symmetry Dermatology, Department of Medicine, University of Alberta, Edmonton, AB, ⁴Division of Dermatology, Department of Medicine, Women’s College Hospital, Toronto, ON, ⁵Division of Dermatology, Department of Medicine, University Health Network, Toronto, ON, ⁶Division of Dermatology, Department of Medicine, Centre hospitalier universitaire de Québec-Université Laval, Québec, QC, ⁷Division of Dermatology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, ⁸Brunswick Dermatology Centre, Fredericton, NB, ⁹Department of Medicine, Dalhousie University, Halifax, NS, ¹⁰Probity Medical Research, Waterloo, ON, ¹¹Section of Dermatology, Department of Medicine, University of Manitoba, Winnipeg, MB, ¹²SKiNWISE DERMATOLOGY, Winnipeg, MB, ¹³Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, ¹⁴Mount St. Joseph Hospital, Vancouver, BC, ¹⁵Division of Dermatology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON

Introduction: Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disease affecting 0.1-4% of the global population. Despite major advancements in therapeutic strategies, no standardized system exists for data collection in clinical care and research. The study aims to establish expert consensus on core data items for use in clinical care and real-world research practices.

Methods, Results: An anonymous Delphi process gathered consensus from dermatologists with HS expertise on essential data items related to patient demographics and treatment effectiveness. The survey included 75 data items rated as “Should not be collected,” “Optional,” or “Mandatory.” Consensus was defined as over 70% agreement on “Optional” or “Mandatory.” Ten participants (75.0% response rate) completed the survey, reaching first-round consensus on all 75 items for inclusion in clinical and research databases. Data elements were divided into nine domains: (i) patient demographics; (ii) treatments; (iii) medications; (iv) procedures; (v) medical history; (vi) social history; (vii) physical exam; (viii) patient-reported outcomes; and (ix) response to therapy/disease activity. Twenty-two items were unanimously deemed “Mandatory,” including: gender; year of disease onset; current treatment(s) for HS; treatment outcomes; specific medications: IV ertapenem, metformin, adalimumab, secukinumab; procedures: wide local excision; medical history: diabetes, dyslipidemia, obesity, depression, Crohn’s disease, ulcerative colitis, or inflammatory bowel disease, psoriasis, and pilonidal sinus; social history: cigarette smoking, marijuana use; physical exam: affected sites, Hurley stage, lesion count; and patient-reported pain score. The greatest discrepancy pertained to the International Hidradenitis Suppurativa Severity Score System (IHS4), with 80% rating it “Optional.” Experts identified four additional critical items for data collection.

Conclusions: This study establishes expert consensus on core data items for routine collection in HS clinical care and real-world research settings. It is an important step toward harmonizing HS data infrastructure and promoting collaborative, comprehensive data collection to address gaps in clinical care and evidence-based research.

Learning Objectives

Takeaway Message

This study highlights the importance for a standardized data collection system in clinical care and real-world research settings for hidradenitis suppurativa. By successfully achieving expert consensus on core data items to be routinely collected, it offers recommendations to streamline data practices, support high-quality patient care, and facilitate the development of a future national registry for HS patients.

Surgical Deroofing for the Management of Hidradenitis Suppurativa: A Systematic Review and Meta-Analysis

Aliyah King¹, Jia Qi Adam Bai¹, Karishma Tailor¹, Marcus G. Tan^2,3, Reetesh Bose^2,3

¹Faculty of Medicine, University of Ottawa, Ottawa, ON, ²Division of Dermatology, University of Ottawa, Ottawa, ON, ³The Ottawa Hospital, Ottawa, ON

Introduction: Hidradenitis suppurativa (HS) is a chronic inflammatory dermatosis causing painful nodules, abscesses, and sinus tracts, primarily in intertriginous areas. This review examines outcomes of surgical deroofing, a minimally invasive procedure to remove sinus tracts and nodules.

Methods, Results: EMBASE, MEDLINE, and CENTRAL were searched from inception, through November 20^th, 2024.Study quality was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation scale. Meta-analyses used a random-effects model (P < 0.05) in RevMan 8.12.0. Of 178 studies, 17 comprising 677 HS patients treated with deroofing (mean age: 34.2 years, 59.7% female, 100% Hurley stage II-III) were included. Sharp deroofing was most common, with CO2 laser (14) and electrocautery (1) as alternatives. Common sites included the axilla (37.8%), inguinal (20.3%), and gluteal (14.0%) regions. Adjuncts included topical insulin and intense pulsed light combined with probe-based radiofrequency. Post-deroofing defects averaged 52.4 (7-67) cm². The mean healing time for sharp deroofing was 29.8 days (95% CI, 13.13-46.56; P = 0.0005), slightly longer than CO2 laser-assisted deroofing at 25.9 days. Sharp deroofing pain scores decreased from 3.28/10 (95% CI, 0.36-6.19; P = 0.03) on day one to 1.1/10 at one week and 0/10 at 3 months. On day 1, CO2 laser-assisted deroofing had a pain score of 1.7/10. Patient satisfaction was 8.95/10 (95% CI, 7.09-10.81; P < 0.00001) for sharp deroofing. Scar outcomes at 6 months were comparable between sharp and CO2-laser assisted deroofing (p= 0.11). Recurrence occurred in 22.7% (73/327) HS-sites at 8.6 months (range 1.2-6.2). Major adverse events (2; 0.3%) included one bleeding (requiring hospitalization) and one superinfection post-sharp deroofing.

Conclusions: This review supports surgical deroofing as an effective, well-tolerated treatment for Hurley stage II-III HS, with favorable outcomes in healing, pain, and satisfaction. Standardized protocols and long-term studies are needed to address data variability and compare alternative treatment options.

Learning Objectives

Takeaway Message

The current evidence supports surgical deroofing as a minimally invasive procedure removing sinus tract roofs and inflammatory nodules, as an effective treatment for Hurley stage II-III HS, offering favorable outcomes in healing, pain, and patient satisfaction. Standardized protocols and further research are essential to optimize its use and compare it with other treatment modalities.

Misdiagnosis in Hidradenitis Suppurativa: A Systematic Review

Shanti Mehta¹, Dea Metko², Eric P. McMullen³, Laurence Mainville^3,4, Shireen Dumont⁵, Narachai Julanon^3,6, Vincent Piguet^3,4

¹Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ²Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, ³Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, ⁴Division of Dermatology, Department of Medicine, Women’s College Hospital, Toronto, ON, ⁵Division of Dermatology and Venereology, Geneva University Hospitals, Geneva, Geneva, Switzerland, ⁶Division of Dermatology, Department of Medicine, Srinagarind Hospital, Khon Kean, Thailand

Introduction: Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition characterized by painful nodules, abscesses, and scarring, primarily in apocrine gland-bearing regions. Due to its variable clinical presentations and a broad differential diagnosis, HS is often misdiagnosed as infectious folliculitis, abscesses, acne, cutaneous Crohn’s disease, or malignancies. This systematic review consolidates the literature on misdiagnosed HS, aiming to identify the causes of diagnostic challenges and areas for improvement in clinical practice.

Methods, Results: We searched MEDLINE, Embase, Scopus, and Web of Science from inception to July 2024 for studies on misdiagnosed HS, following PRISMA guidelines. Nine peer-reviewed case reports were included, with a total of 15 patients (mean age 42.3 years; range 22–97). Of the patients, 66.6% were male, and lesions were primarily located in the axilla (85.7%) and inguinal region (28.6%). Biopsies were performed in 73.3% of cases. Initial treatments included antibiotics (72.3%), incision and drainage (45.5%), isotretinoin (18.2%), and steroids (18.2%). The final diagnoses included Langerhans cell histiocytosis (26.7%), scrofuloderma (13.3%), tuberculosis (13.3%), and other conditions such as metastatic adenocarcinoma and squamous cell carcinoma. The average delay in diagnosis was 66.9 months (range 0.46–264 months).

Conclusions: The most common misdiagnosis was infectious in nature, particularly scrofuloderma, highlighting the importance of considering infectious etiologies such as cutaneous tuberculosis and syphilis in the differential diagnosis. Biologic therapies for HS, such as TNF inhibitors, can reactivate tuberculosis, emphasizing the need for careful diagnostic workup. The significant delay in diagnosis, averaging 66.9 months, underscores the need for timely identification to prevent scarring, chronic pain, and mental health issues. Thorough investigations, including skin biopsy, are crucial when alternative diagnoses are suspected. The role of infectious etiologies, especially tuberculosis, should be emphasized in clinical practice to avoid misdiagnosis.

Learning Objectives

Takeaway Message

A Systematic Review of Dual Biologic or Small Molecule Therapy in Patients with Psoriasis and Comorbid Inflammatory Diseases

Shanti Mehta¹, Dea Metko², Eric P. McMullen³, Grace Xiong², Ronald Vender⁴

¹Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ²Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, ³Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, ⁴Associate Clinical Professor, McMaster University, Hamilton, ON

Introduction: Psoriasis is a chronic inflammatory skin disorder that often remains unresponsive to conventional therapies, including biologic monotherapy. This systematic review aims to evaluate the efficacy and safety of dual biologic or small molecule therapies in patients with psoriasis and comorbid inflammatory diseases.

Methods, Results: A search of Ovid’s Medline and Embase databases was conducted on April 3rd, 2024, following PRISMA guidelines, identifying 21 articles (17 case reports, 4 case series) that met inclusion criteria. A total of 38 patients (mean age: 50.5 years) were included, predominantly female (56.7%), with an average psoriasis duration of 15.3 years. Prior treatments included biologic monotherapy (67.6%), topical corticosteroids (58.8%), and systemic immunosuppressors (50%). The most common combination therapy was dupilumab and guselkumab (34.2%), with additional combinations including Janus kinase inhibitors paired with infliximab and ixekizumab. Dual therapy was often used for comorbid conditions such as atopic dermatitis (50%) and psoriatic arthritis (26.3%). Results showed high efficacy, with 85.7% of patients achieving therapeutic benefit and a mean change in Psoriasis Area and Severity Index (PASI) of 20.0 (p<0.01). Adverse reactions were rare, with 9.5% of patients reporting non-dermatological events and 7.1% reporting dermatological events.

Conclusions: This review highlights the potential of dual biologic or small molecule therapy for patients with refractory psoriasis and comorbid inflammatory diseases. The findings support previous literature on the efficacy of dupilumab and IL-23 inhibitors, which effectively target multiple inflammatory pathways. Despite the promising results, the small sample size and limited reporting of disease course and therapy indications suggest that larger studies are needed to confirm the effectiveness and safety of combined biologic or small molecule therapies in this patient population.

Learning Objectives

Takeaway Message

Cutaneous Manifestations of Dermatomyositis in Black Patients: A Review of Reported Cases

Edgar Akuffo-Addo¹, Samia Rahman², Kaitlyn Ramsay³, Vincent Piguet⁴, Marissa Joseph⁴

¹Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, ²Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, ³Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ⁴Division of Dermatology, Department of Medicine, Women’s College Hospital, Toronto, ON

Introduction: Dermatomyositis (DM) is an idiopathic inflammatory myopathy characterized by skeletal muscle inflammation and distinctive cutaneous eruptions. Black individuals have a higher prevalence of DM than White individuals, yet darker skin tones are underrepresented in DM educational materials. The clinical manifestations of DM in Black patients may differ from those observed in White patients as the clinical features vary considerably from patient to patient. The diverse clinical manifestations coupled with the underreporting of cutaneous manifestations of DM in darker phenotypes likely contribute to the delayed diagnosis and increased morbidity and mortality experienced by patients of color with DM. This review examines case reports of DM in Black patients and highlights the cutaneous manifestations in this population.

Methods, Results: We searched MEDLINE and Embase on October 5, 2024, using keywords related to dermatomyositis and Black patients. Case reports and case series published in English that reported the cutaneous features of DM in Black adult and juvenile cases were included. Our search and screening yielded 42 studies representing 100 patient cases. The mean age was 24.9 years. 68% of cases occurred in females. Notably, 10% of cases were initially misdiagnosed as infections, allergic reactions, erythema multiforme, malaria, or hypertrophic lichen planus. Seven patient deaths were reported. The most common cutaneous features of DM were Gottron papule (70%), heliotrope rash (45%) and nail fold changes (17%). Less commonly reported cutaneous findings included: v-neck erythema (16%), facial erythema (15%), shawl sign (13%), periorbital swelling (13%), mechanic’s hands (11%), poikiloderma (11%) and scalp findings (5%).

Conclusions: We observed a higher prevalence of dyschromia associated with Gottron papules and heliotrope rashes compared to previous reports. This suggests that dyschromia may be a more significant cutaneous manifestation of DM in Black patients. By increasing awareness, providers can improve the early diagnosis of DM in this population.

Learning Objectives

Takeaway Message

Awareness of the unique cutaneous features of DM in Black patients, particularly dyschromia, is essential for improving early diagnosis and reducing morbidity and mortality in this underserved population.

UVA-1 Phototherapy for Morphea and Sclerosing Skin Disorders: Insights from a Decade-Long Retrospective Analysis

William Liu, Sunil Kalia, Harvey Lui, Tashmeeta Ahad

University of British Columbia, Vancouver, BC

Introduction: Sclerosing skin disorders significantly affects physical and psychosocial wellbeing, often causing reduced quality of life. Treatment options include topical therapy, phototherapy and systemic agents. Ultraviolet A1 (UVA-1) phototherapy has fewer side effects compared to systemic therapies. However, efficacy data are limited.

Methods, Results: We conducted a retrospective review of patients that received UVA-1 treatment at the tertiary Phototherapy Clinic, Vancouver General Hospital, Canada. Diagnoses included: morphea (generalized, circumscribed, pansclerotic, linear), eosinophilic fasciitis, graft-vs-host disease, lichen-sclerosis, and systemic scleroderma. Charts from January 1, 2010 to November 1, 2024 were extracted for demographics, diagnosis, treatment dose, clinical outcome, modified Rodnan Skin Score (mRSS), adverse events, and previous/concurrent therapies. Improvement was classified as none (0%), mild (1-49%), moderate (50-74%), or marked (>75%). This was determined by physician description of lesions in patient charts.The study included 50 patients, 37 with morphea and 13 other conditions. An initial course resulted in an 80% response rate, 56% showing mild improvement, 20% marked, 20% none, 4% moderate. Among those with marked improvement, 90% (n=10) had generalized morphea. 18 patients had a second course with an 86% response rate with primarily (59%) mild improvement. Average mRSS decreased 9 points (n=5), surpassing the threshold for a clinically important difference. 5 patients discontinued their treatment course due to adverse effects. Over half of the patients (51%) had previous systemic/topical therapy with limited success.

Conclusions: UVA-1 is effective, tolerable, and beneficial for sclerosing skin disorders. Patients who respond to treatment often further improve from additional courses, showing high completion rates and few adverse effects. As a viable treatment for morphea and related sclerosing skin disorders, UVA-1 is a valuable option, even for refractory cases.

Learning Objectives

Takeaway Message

UVA-1 phototherapy is an effective and well-tolerated treatment option for morphea and other sclerosing skin disorders, demonstrating high response rates even in refractory patient populations. Currently UVA-1 is not widely accessible. However, given the benefits and minimal side effects compared with topical/systemic agents, further study is encouraged to optimize treatment regimens and support broader implementation. UVA-1 holds significant potential in managing challenging sclerosing skin conditions.

Effectiveness of Learning Interventions for Skin of Colour Dermatology in Medical Education: A Systematic Review

Meghna Varambally¹, Nawar Tarafdar¹, Jimmy Wang¹, Ronald Vender²

¹Schulich School of Medicine and Dentistry, Western University, London, ON, ²Division of Dermatology, Department of Medicine, McMaster University, Hamilton, ON

Introduction: Underrepresentation of skin of colour (SOC) in medical education can impair trainees’ confidence and ability to diagnose and manage dermatologic conditions. This may delay diagnoses and foster mistrust in health care systems among marginalized populations. This systematic review includes updates in the literature and evaluates learning interventions aimed at improving accuracy and confidence of medical students and residents in addressing skin conditions in patients with SOC.

Methods, Results: A systematic literature search was performed using OVID MEDLINE, EMBASE, Web of Science, and CINAHL databases. Nineteen studies (n=1702) met predefined inclusion criteria after screening, and study quality was assessed following EPPI centre guidelines. The studies included ten studies targeting medical students, six focusing on residents, and three including both groups. Among participants, 32.7% identified as racial and ethnic minority individuals, and 58.6% identified as female. Generally, studies defined SOC as Fitzpatrick skin types IV-VI. Six studies revised dermatology curricula by adding SOC images and culturally-focused content, while one assessed a conference-based training intervention. Four studies used single-session lectures, four employed interactive approaches (e.g., workshops, games, flipped classrooms), and four adopted self-directed modules. Seven interventions were technology-enhanced. Of nine studies measuring objective knowledge outcomes, 56% showed improvements in pre- and post-intervention scores. Moreover, 80% of ten studies assessing self-evaluated confidence reported an improvement. However, trainees cited the need for more diverse skin tone representation in visual materials to support their learning.

Conclusions: Pooled analyses demonstrate that targeted learning interventions can improve both knowledge acquisition and self-confidence in diagnosing and managing dermatologic diseases in SOC. Nonetheless, heterogeneity in effectiveness measures, incomplete data, and limited long-term follow-up indicate the need for future studies that incorporate objective metrics and sustained learning evaluation. Enhanced representation in educational materials is vital for promoting equitable dermatologic care and fostering trust in health care systems among diverse populations.

Learning Objectives

Takeaway Message

Targeted learning interventions may be effective in improving trainees’ knowledge and confidence when diagnosing and managing dermatological conditions in skin of colour (SOC). Still, there is a clear need for additional studies that evaluate long-term skill retention, emphasize the use of objective performance measures, and feature expanded representation of diverse skin tones in visual resources. Such efforts will ensure more equitable and comprehensive dermatology education, ultimately improving patient outcomes.

Identifying Gaps in Sun-Safety Understanding and Behaviours Among Canadian Elementary Students Stratified by Race: Updated Findings from an Ongoing Survey

Aliyah King¹, Russell Leong¹, Reetesh Bose^2,3

¹Faculty of Medicine, University of Ottawa, Ottawa, ON, ²Division of Dermatology, University of Ottawa, Ottawa, ON, ³The Ottawa Hospital, Ottawa, ON

Introduction: Teaching youth about sun-safety and encouraging sun-protective behaviors may play a pivotal role in skin cancer prevention as well as other benefits such as photodamage, rhytids, and acquired pigmentary disorders like melasma. School-based interventions have demonstrated success in enhancing sun-safety knowledge; however, few studies have explored the baseline perceptions of sun-safety among elementary school children before they receive formal education on the topic. Therefore, this ongoing survey-based study aims to assess the initial sun-safety perceptions of elementary students prior to a sun-safety educational session.

Methods, Results: Online surveys were administered to elementary students before being given sun-safety presentations between May 2023-April 2024. Among 260 respondents (mean age 12; 51.2% female), the race/ethnic distribution included White 140 (53.9%), Asian 36 (13.9%), Mixed race 20 (7.7%), Black 18 (6.9%), Hispanic (n = 5), Arab (n = 5), and Indigenous (n = 5) students. Survey results revealed an overall positive attitude toward sun protection and a negative perception of tanning. Asian respondents reported feeling greater pressure to tan, whereas a higher proportion of Black respondents were either unaware of their sunscreen’s Sun Protection Factor (SPF) value or did not use sunscreen at all. White respondents exhibited the highest incidence of experiencing more than two sunburns and erythema following sun exposure. Knowledge gaps included misconceptions regarding the importance of sunscreen reapplication and the significance of difference SPF values.

Conclusions: Overall, the results indicate that while elementary students generally understood the importance of sun safety, gaps in knowledge regarding sunscreen reapplication, SPF value differences, and the benefits of sun protection beyond skin cancer prevention highlight areas for improvement in educational programs. Limitations include reliance on self-reported data, small sample size, and lack of follow-up. Future research should analyze racial/ethnic differences to refine sun-safety programs and address diverse attitudes and practices effectively.

Learning Objectives

Takeaway Message

Understanding baseline photoprotection perceptions, across race/ethnicity, provides a foundation to guide more specific approaches to photoprotection education, which may need to include outcomes other than skin cancer prevention. While elementary students generally understood the importance of sun safety, gaps in knowledge regarding sunscreen reapplication, SPF value differences, and the benefits of sun protection beyond skin cancer prevention highlight areas for improvement in educational programs. Addressing these gaps and tailoring sun-safety education to students from diverse racial and ethnic backgrounds may enhance long-term effectiveness in promoting sun-protective behaviours.

Granulomatous Giant Centrifugal Miliaria Profunda in an Infant: A Clue to MAPK Pathway Dysregulation and Genetic Diagnosis

Adam C. Yu¹, Fatmah AlZahrani²

¹Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, ²Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC

Introduction: Granulomatous giant centrifugal miliaria profunda (GGCMP) is a rare skin condition caused by sweat gland obstruction, with limited documentation in the literature. We present a case report of GGCMP in a 4-month-old boy with cardiofaciocutaneous syndrome (CFCS), highlighting its diagnostic and pathophysiological implications.

Methods, Results: A 4-month-old boy presented with annular, edematous pink to translucent plaques on the forearms, knees, buttocks, and inguinal creases. His medical history was notable for dysmorphic facial features, hypocalcemia, neonatal seizures, white matter injury, pulmonary hypertension, and failure to thrive. Skin examination revealed diffuse hyperkeratotic papules on the face, extremities, and trunk. Additional early-life symptoms included excessive sweating and difficulty to soothe.

Initial biopsy suggested a histiocytic process, but a repeat biopsy demonstrated granulomatous inflammation centered on eccrine ducts, consistent with the granulomatous variant of giant centrifugal miliaria profunda. At 15 months old, genetic testing confirmed a pathogenic MAP2K1 variant (c.389A>G; p.Tyr130Cys), consistent with the diagnosis of CFCS.

Conclusions: Cutaneous manifestations are common in mutations along the Ras/MAPK pathway, yet this is the first report linking miliaria disorders to CFCS. Dysregulation of the Ras/MAPK pathway likely contributes to epidermal dysfunction, hyperkeratosis, overheating, and sweat duct occlusion, particularly under stress, as observed in this patient. This case highlights the diagnostic challenges and unique morphology of this rare condition, emphasizing the importance of recognizing skin findings in infants with suspected RASopathies to enable timely intervention and management. Special attention should be given to potential overheating and its sequelae, particularly during the newborn period.

Learning Objectives

Takeaway Message

This case highlights the first reported association between granulomatous giant centrifugal miliaria profunda and CFCS. Early recognition and intervention are essential for accurate diagnosis and effective management, while further research is necessary to better understand its pathophysiology and treatment.

Characterizing Tofacitinib Response in Pediatric Alopecia Areata: A Retrospective Review

Michal Moshkovich¹, Cinthiya Sugumar¹, Cathryn Sibbald^2,3

¹Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ²Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, ³Division of Dermatology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON

Introduction: Alopecia areata (AA) is an immune-mediated condition causing non-scarring hair loss, significantly impacting 2% of the global population with a higher prevalence in children than adults. Despite recent advancements, the unpredictable disease course and limited efficacy of treatments highlight the need for longitudinal studies on therapeutic outcomes. Tofacitinib is a janus kinase inhibitor indicated for juvenile idiopathic arthritis that has been successfully used for treatment of AA.

Methods, Results: Our retrospective analysis included 16 pediatric patients treated with tofacitinib at a pediatric dermatology clinic. Tofacitinib 5 mg twice daily was initiated in 87.5% of patients, with the rest receiving 5 mg once daily. Patients’ mean age was 10.3 years (SD ±4.7), with 56.3% females enrolled and 62.5% patients of Asian ethnicity. The median disease duration was 48 months (IQR: 36–60), and 50% of children had alopecia universalis diagnosis with eyebrow and eyelash involvement. Prior treatments included methotrexate in 25% of patients, systemic steroids in 37.5%, and topical steroids in 68.75%. After a mean follow-up of 14.7 months (SD ±7.97), the median Severity of Alopecia Tool (SALT) score decreased from 78.8 (IQR: 57.5–100) at baseline to 46.0 (IQR: 2.0–90.0), reflecting a 32.8% improvement in disease severity. Additionally, full eyebrow and eyelash regrowth was achieved in 6 and 7 out of 8 patients with initial alopecia universalis respectively. Tofacitinib was well tolerated in all patients with no abnormalities requiring intervention in regular bloodwork.

Conclusions: These findings support a role for tofacitinib as a promising treatment option for pediatric AA with a favorable short-term side effect profile, offering meaningful improvements in hair regrowth outcomes in a diverse patient population. The variability in patient response highlights a need for further research into individualized treatment strategies, including the impact of demographic and clinical characteristics on treatment response.

Learning Objectives

Takeaway Message

Tofacitinib demonstrates promising efficacy in pediatric patients with alopecia areata, showing significant hair regrowth outcomes and potential eyebrow and eyelash restoration. However, variability in individual responses emphasizes the need for further research into predictive factors and optimized, individualized treatment strategies. Establishing robust patient registries and conducting longitudinal studies are critical steps to improving care for children with AA and addressing its broader psychological and clinical impacts.

This Face is Not a PHACES

Kimberlie Paul Boulanger¹, Jérôme Coulombe^1,2

¹Université de Montréal, Montréal, QC, ²Centre Hospitalier Universitaire Sainte-Justine, Montréal, QC

Introduction: Tufted angioma (TA) is a rare, benign vascular tumor that may present at birth or during childhood. It exists on a spectrum of vascular lesions, with kaposiform hemangioendothelioma (KHE) being the more aggressive end of the spectrum. Diagnosing tufted angioma can be challenging, even for experienced clinicians.

Methods, Results: A 3-month-old infant was referred to dermatology for evaluation of a segmental facial infantile hemangioma (IH). Given the lesion’s size, appearance, and location, a diagnosis of PHACES syndrome was entertained. A skin biopsy was performed on the left shoulder blade where the vascular lesion was atypically firmer. Empirical treatment with oral propranolol (2 mg/kg/day) was initiated while awaiting further diagnostic results. Initial PHACES work-up (EKG, ultrasound, ophthalmology consultation) were unremarkable. Brain MRI revealed a hypoplastic P1 segment of the right posterior cerebral artery on the contralateral side to the segmental hemangioma.

After over 6 weeks of propranolol treatment with no clinical improvement and no paraclinical findings suggestive of PHACES, along with the biopsy results showing a vessels organized in cannonball patterns (GLUT1 negative, and WT positive), the diagnosis was revised to tufted angioma.

Segmental congenital TA is a rare presentation that can easily be confounded with infantile hemangioma. Getting the right diagnosis is of utmost importance to plan for the right management that include PHACES work-up and propranolol treatment for segmental IH, and prevention/treatment of Kasabach-Merritt phenomenon that can develop in TA.

Conclusions: This case underscores the diagnostic challenges posed by vascular anomalies, particularly in pediatric patients. Early identification and careful clinical and pathological assessment are crucial for appropriate management.

Learning Objectives

Takeaway Message

Vascular anomalies continue to present significant diagnostic challenges, highlighting the importance of clinico-radiologic and histopathological correlation, as well as the added value of a multidisciplinary approach.

Impact of Digital Wound Care: A Pilot Study at Giishkaandago’Ikwe Health Services

Ryan S.Q. Geng¹, Heba Tallah Mohammed², Deirdre Drombolis³, Samantha Bestavros¹, Samiha Mohsen¹, Kaitlyn Ramsay¹, Sheila C. Wang^4,2, Robert D.J. Fraser²

¹University of Toronto, Toronto, ON, ²Swift Medical, Toronto, ON, ³Giishkaandago’ikwe Health Services, Fort Frances, ON, ⁴Women’s College Hsopital, Toronto, ON

Introduction: Chronic wounds impose high physical, psychosocial burden on patients and costs on healthcare systems. Artificial intelligence (AI)-based systems have been developed with capabilities including measuring wound dimensions to provide objective wound tracking and support wound care decision-making. However, their real-world impact on clinical outcomes and operational efficiency remains unexplored. This study aims to evaluate an AI-based digital wound care system’s impact on clinical and operational outcomes for Giishkaandago’Ikwe Health Services.

Methods, Results: The AI-based digital wound care system was adopted by Giishkaandago’Ikwe Health Services between February 2022 to December 2023, servicing 10 Southern Treaty Three Anishinaabe communities. Performance metrics from February 2023 to December 2023 were analyzed in comparison to February 2022 to December 2022. All chronic wound types were included, with the most common wound types assessed during the study period including pressure injuries (25.9%, 72/278), surgical wounds (25.5%, 71/278) and diabetic ulcers (24.1%, 67/278).

A total of 202 patients (41% male, 59% female) comprising 3,194 wound evaluations were analyzed. Clinical outcomes included a 12.8% reduction in visits per wound, translating into ~$91,000 in cost savings. Additionally, there was a 2.9% reduction in wounds acquired during management and a 20% reduction in median healing time. Operationally, there was a 9.7% increase in evaluations completed within 24 hours. Furthermore, registered practical nurse (RPN) utilization increased by 9%, corresponding with a 9% decrease in registered nurse (RN) utilization.

Conclusions: The AI-based digital wound care system substantially improved clinical and operational outcomes for Giishkaandago’Ikwe Health Services and the communities it serves, potentially by improving wound progression monitoring and documentation efficiency. Future studies are on-going to assess long-term impacts and cost-effectiveness in diverse healthcare environments.

Learning Objectives

Takeaway Message

AI-based digital wound care systems have the potential to substantially improve clinical and operational outcomes by improving wound progression monitoring and documentation efficiency. However, further studies are needed to assess long-term impacts and cost-effectiveness in diverse healthcare environments.

The Use of Artificial Intelligence-Based Wound Assessment in Measuring Wound Tissue Area and Composition in the Clinical Setting

Samantha Bestavros¹, Kaitlyn Ramsay¹, Heba Tallah Mohammed², Katerina Bavaro³, Ryan S.Q. Geng¹, Samiha Mohsen¹, Samia Rahman⁴, Robert D.J. Fraser², Sheila C. Wang²

¹Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ²Swift Medical, Toronto, ON, ³The Michener Institute of Education, Toronto, ON, ⁴Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB

Introduction: Traditional methods of wound assessment rely heavily on clinical judgement and physical measurements. This introduces high variability in assessment standards, which can lead to inconsistent treatment approaches and suboptimal clinical outcomes, particularly for treatment-resistant wounds. The use of artificial intelligence (AI) is a potential tool to help clinicians assess wounds more efficiently and objectively. An AI-powered smartphone application algorithm was developed using 17,000 wound images labelled by expert reviewers and trained against a dataset of 465,000 wound images to optimize tissue classification. This study aims to evaluate the usability and clinical utility of this application by assessing its ability to provide an objective, data-driven assessment of wound area and percentage granulation, eschar, slough, and epithelialization in the clinical setting.

Methods, Results: Patients presenting to a wound care clinic underwent assessment with the AI application, which photographed their wound and analyzed wound area and percentage of granulation, eschar, slough, and epithelialization (Figure 1). A total of 38 wound photographs were taken, with a male predominance of 57.1% and an average patient age of 66.8 years old (range: 27-96 years). Various wound types were included. The mean wound area was 8.3cm² (range: 0.3-58.8cm²). 92.1% of patients had granulation, 7.9% had eschar, 36.8% had slough, and 0% had epithelialization. Clinicians reported that the AI enhanced wound assessment through rapid and detailed measurement, which helped inform treatment decisions adjunctively to clinical judgement.

Conclusions: The use of AI to measure wound area and tissue composition may improve ease of wound assessment, thus potentially leading to more streamlined patient care. The data and clinical feedback from this study, along with future studies, will be incorporated into the tool to enhance the application’s in-clinic intuitive operation and guide the AI’s learning, development, and refinement. This will ultimately aid in enhancing its applicability in the clinical setting.

Learning Objectives

Takeaway Message

The use of artificial intelligence has the potential to enhance wound assessment by providing objective measurements of wound area, as well as percentage of granulation, eschar, slough, and epithelialization. This approach can support clinical decision-making and contribute to more streamlined, effective patient care.

Evaluation of Artificial Intelligence Chatbots in Addressing Most Searched Queries on Psoriasis

Maxine Joly-Chevrier¹, Ahmad Alamari², Veselko Bakula², Yasmine Lachance¹, Elvis Martinez-Jaramillo³, Farhad Pourpanah³, Elham Rahme⁴, Maria Cutumisu⁵, Mathieu Powell², Elena Netchiporouk²

¹Faculty of Medicine, Université de Montréal, Montréal, QC, ²Division of Dermatology, Department of Medicine, McGill University and the McGill University Health Centre, Montreal, QC, ³Division of Experimental Medicine, McGill University Health Centre, Montreal, QC, ⁴Department of Medicine, Division of Clinical Epidemiology, McGill University, Montreal, QC, ⁵Faculty of Education, McGill University, Montreal, QC

Introduction: Large language model (LLM) chatbots have demonstrated the ability to generate empathic and high-quality responses compared to physicians. Hence, they could become valuable tools in clinical practice for patient medical education. This study evaluated the information quality and accuracy of four AI chatbots in addressing frequently queried questions about psoriasis.

Methods, Results: The top 25 psoriasis-related search queries from Google Trends (January 2021–January 2023) were analyzed, covering subtypes like psoriatic arthritis, scalp psoriasis, and others. The queries were entered into four chatbots (ChatGPT 3.5, Perplexity, Chatsonic, and Bing AI). Responses were graded independently by dermatologists using the modified DISCERN score and misinformation scale. Medical students evaluated understandability and actionability with the PEMAT tool. Statistical analyses (Chi-square, Kruskal-Wallis, and Dunn’s test) assessed quality differences, interrater reliability (Cohen’s kappa) and sensitivity to skin of color (SOC) content.

Of 100 responses, the median DISCERN score was 4 [1, 5], indicating good information quality with significant differences among chatbots. The inter-rater agreement across all chatbots was strong. Moderate and major misinformation content deviations occurred in 8% and 1% of responses, respectively. All chatbots, except ChatGPT, included references. Misinformation was overall minimal (Likert scale median: 1.0 [1, 4]) but varied significantly among chatbots. Patient understandability assessed through the PEMAT score was 80% [36, 91], with Perplexity performing the worst (p < 0.001). SOC-related content was limited, with only Perplexity AI (2/15) and Bing AI (5/15) addressing it. Responses predominantly focused on white skin.

Conclusions: While chatbots generally provided adequate information with minimal misinformation and good understandability, some incorrect treatment guidance was given, which may negatively impact patient care and safety. Gaps in novel therapeutics, treatment options, alternative therapies, and disease etiology were reported. Continuous updates in chatbot training are necessary to ensure accurate and inclusive medical information.

Learning Objectives

Takeaway Message

Although chatbots show promise in drafting educational content, their knowledge base often lacks updated information on novel therapeutics, largely because they are trained on older datasets. Misinformation was reported in treatment options, alternative and home care therapies, and disease etiology. This highlights the need for continuous updates and improvements in training data to ensure the accuracy and relevance of medical information. Medical representation bias towards white skin tones remains a pressing issue that needs to be addressed during chatbot dataset selection, training and fine-tuning processes. Longitudinal studies assessing the evolving performance of LLM chatbots are needed.

Exploring the Applications of Artificial Intelligence in Contact Dermatitis

Megan S. Lowe¹, Sonja Molin²

¹School of Medicine, Queen’s University, Kingston, ON, ²Department of Dermatology, Venereology and Allergy, Charité – Universitätsmedizin Berlin, Berlin, Germany

Introduction: Artificial intelligence (AI) is increasingly being investigated for its applications in dermatology, offering innovative solutions for diagnosing and managing skin conditions. Despite significant advancements, there is a notable lack of research specifically focused on the application of AI in contact dermatitis (CD). This review aims to critically assess the current utilization and effectiveness of AI technologies in the diagnosis and management of CD. It seeks to discuss AI-driven approaches compared to traditional methods in terms of accuracy, efficiency, and clinical outcomes.

Methods, Results: A comprehensive literature search from 2014 to 2024 was conducted across PubMed, EMBASE, Web of Science, and ScienceDirect databases. The search utilized key terms such as "artificial intelligence," "AI," "machine learning," "augmented intelligence," "neural network," and "deep learning" in combination with "contact dermatitis." The search was limited to studies that included original data, with no restrictions on language.

The initial search yielded 352 unique studies after duplicates were removed. Following full-text assessment, 19 articles were included in the review. Six studies focused on preventing CD by using AI to assess skin sensitization and predict the allergenicity of chemicals. Eight studies explored enhancingthe diagnostic process and classifying CD by automating and streamlining diagnosis. Two studies applied random forest models to identify biomarkers and gene signatures that differentiate types of CD. Three studies evaluated AI’s ability to recommend treatment and management plans.

Conclusions: AI demonstrates diverse applications in CD prevention, diagnosis, and treatment, with varying levels of effectiveness. Integrating AI into clinical practice holds significant promise, particularly for enhancing diagnostic accuracy and optimizing treatment. Notably, a significant gap in literature exists on AI and CD research, necessitating further investigation. This is crucial in Canada, where AI has the potential to mitigate healthcare disparities by expanding access to teledermatology services in remote and underserved regions.

Learning Objectives

Takeaway Message

AI has the potential to significantly improve the diagnosis and management of Contact Dermatitis (CD) in various ways, including prevention, diagnosis, and treatment. However, there is a significant gap in research on AI in CD, particularly in Canada where it could significantly improve healthcare access in remote regions.

Extended vs. Screening Series for Contact Allergy: A Retrospective Chart Review

Kylie E. Peake¹, Harman Toor², Gillian de Gannes²

¹University of British Columbia, Prince George, BC, ²University of British Columbia, Vancouver, BC

Introduction: The American Contact Dermatitis Core Allergen Series (ACDS80) is utilized as a screening series for patients being tested for contact allergy (CA). Patients may also undergo patch testing to extended series as indicated based on clinical context. The purpose of this study is to identify the current common allergens for patients in our centre from the ACDS80 screening series as well as extended series.

Methods, Results: Retrospective chart review from October 2022 to 2024 of all patients who attended the Contact Dermatitis Clinic at our centre and underwent patch testing to either the ACDS80, extended series, personal products, or a combination of these. 569 patients were included, 427 (75%) were female and the mean age was 47. 382 patients tested to the ACDS80 had a positive patch test result to at least one allergen (74.8%) and 185 patients tested to the extended series had at least one positive test result (50.7%). The most common allergen identified in the ACDS80 series was nickel sulfate (13.0%) and the most common allergen in the extended series was gold sodium thiosulfate (11.7%). Of the patients tested to extended series, the cosmetic series was the most common to be positive (41.6%).

Conclusions: In our centre, over 30% of patients had at least 1 positive patch test reaction on an extended series, which would have been missed if only the ACDS screening series was tested.

Learning Objectives

Takeaway Message

Extended series patch testing in addition to the ACDS80 screening series remains important in patients with contact allergy to appropriately identify the culprit allergen.

Postoperative Opioid Prescription Fill Rates and Consumption in Skin Cancer Patients: A Systematic Review

Aliyah King^1,2, Jia Qi Adam Bai^1,2, Carolyn Nessim^2,3

¹Faculty of Medicine, University of Ottawa, Ottawa, ON, ²The Ottawa Hospital Research Institute, Ottawa, ON, ³Department of General Surgery, Division of Surgical Oncology, The Ottawa Hospital, Ottawa, ON

Introduction: Opioids are widely used for post-skin cancer surgery pain management. As opioid prescription rates rise, the leftover supply of opioids raises concerns of misuse. While dermatologists are among the leading prescribers of opioids for post-surgical pain management, the extent of opioid over-prescription following skin cancer surgery remains unknown. We conducted a systematic review to investigate postoperative opioid prescription fill rates and consumption in skin cancer patients.

Methods, Results: MEDLINE, EMBASE, and CENTRAL were searched from inception until October 13th, 2023. Original studies reporting the opioid prescription fill rates and consumption of patients following skin cancer surgery were included. Six studies encompassing 577 patients receiving an opioid prescription were included. Among 423 patients reporting opioid prescription filling rates, 297 (70%) filled their prescriptions. Of those who reported on opioid consumption (232), 47% indicated consumption, with 10% consuming all opioids. A total of 148 (84%) of patients with reported leftover opioids (177) had leftovers, and 26 (53%) planned to keep them.

Conclusions: On average, patients were prescribed 12 opioids (range: 3-40), filled 7 (range: 1-20), and had 4 left over. The 5-pill discrepancy underscores the gap between prescription and usage, urging practice refinement. Concerns arise from potential opioid reservoirs and patient intentions to keep leftovers. Limitations of this review include the lack of high-quality data and comparison across specialities, beyond Mohs surgeons. As all included studies were completed in North America, generalizability is also limited. Overall, this study highlights the need for education on proper opioid disposal and support previous findings of prescribing no more than 5 pills post-skin cancer surgery, promoting non-narcotic alternatives, and refining prescription practices to mitigate opioid misuse risks.

Learning Objectives

Takeaway Message

Extracorporeal Photopheresis in Fibrosing Skin Disorders: A Systematic Review

Sydney A. Yee¹, Wisoo Shin¹, Bryan Ma¹, Jason J. Lee², P. Régine Mydlarski¹

¹Division of Dermatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, ²Division of Rheumatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB

Introduction: Systemic sclerosis (SSc), morphea, and eosinophilic fasciitis (EF) are fibrosing skin disorders associated with significant morbidity and mortality. Yet, effective treatment options remain limited. Extracorporeal photopheresis (ECP), an established therapy for graft-versus-host disease and cutaneous T-cell lymphoma, has emerged as a potential treatment for these disorders. Despite its excellent safety profile, ECP uptake remains low, and data from randomized controlled trials (RCTs) have been inconsistent. Therefore, we conducted a systematic review to evaluate the role of ECP in managing fibrosing skin disorders.

Methods, Results: A systematic review of MEDLINE and Embase was conducted to identify studies on ECP in SSc, morphea, and EF from inception to January 2024. The primary outcomes were modified Rodnan skin scores (mRSS) and Health Assessment Questionnaire (HAQ) scores. Additional author-reported outcomes were extracted, and the Cochrane risk of bias tool was used to assess study quality.

Of 301 studies, 24 met the inclusion criteria (258 patients). The most common protocol involved 0.6 mg/kg of 8-methoxypsoralen administered two consecutive days every 2–4 weeks. Most patients were previously or concurrently treated with immunosuppressive therapies. Due to variability in outcomes, a meta-analysis was not feasible.

Three RCTs on SSc showed mixed results, with one showing benefit and two reporting no significant improvement. Observational studies in SSc (n=14) similarly yielded conflicting findings. Conversely, studies on morphea (n=4) and EF (n=3) reported improved skin outcomes. ECP was well tolerated across all studies, with minimal adverse effects.

Conclusions: ECP shows promise in treating the cutaneous manifestations of fibrosing disorders. However, significant variability in outcome measures limits the generalizability of findings. Further high-quality research is required to understand better which patients may benefit from this treatment modality.

Learning Objectives

Takeaway Message

ECP shows potential as a treatment for cutaneous fibrosing disorders. However, inconsistencies in study results and outcome measures underscore the need for robust research to clarify its effectiveness and safety profile.

Impact of Narrow Margins on Melanoma Prognosis: An Independent Risk Factor for Local Recurrence and Mortality

Kayadri Ratnarajah¹, Mandy Malick², Saraa Yazidi³, Anya Bussière Filion⁴, Jade Bernatchez⁵, Justin Gervais⁵, Imane Labzagui⁵, Hannah Nguyen⁵, Elio Kechichian⁶, Carolina Fernandes⁶

¹Division of Dermatology, McGill University Health Centre, Montreal, QC, ²Division of Medicine, Université de Sherbrooke, Sherbrooke, QC, ³Division of Dermatology, Université Laval, Québec, QC, ⁴Université de Sherbrooke, Sherbrooke, QC, ⁵Faculty of Medicine, Université de Sherbrooke, Sherbrooke, QC, ⁶Division of Dermatology, Université de Sherbrooke, Sherbrooke, QC

Introduction: Cutaneous melanoma is an aggressive skin cancer with a high potential for dissemination. Surgical excision with adequate margins is the standard approach to minimize local recurrence and improve survival. Although clinical margin guidelines based on melanoma thickness are well-established, there is a lack of standardized recommendations or prognostic analysis for managing narrow histopathological margins. This gap may lead to variable surgical outcomes and unclear prognostic implications. This study examines the impact of narrow histological margins on melanoma recurrence and mortality, aiming to identify a threshold for margin inadequacy.

Methods, Results: A retrospective cohort study was conducted from June 2013 to March 2022, including patients with confirmed melanoma who underwent wide excision. Margin adequacy was assessed by comparing clinical and histological margins, adjusted for tissue shrinkage. Patients were classified into "adequate" or "inadequate" margin groups. Primary outcomes included local recurrence, locoregional recurrence, distant metastasis, and melanoma-specific mortality. Data were analyzed using Student’s t-test, chi-square, and multivariate analysis.

Among 415 cases of melanoma, 243 had adequate margins, while 172 had inadequate margins. Narrow histological margins were found in 41.4% of cases, predominantly in the head and neck (34.9%). Narrow margins were significantly associated with higher rates of local recurrence (7% vs. 2.9%, p=0.049) and melanoma-related mortality (7.6% vs. 2.5%, p=0.015). Adequate margins reduced melanoma-related mortality by 67% (RR 0.33, 95% CI 0.13-0.84, p=0.021). Locoregional recurrence was more frequent in the narrow margin group, though not statistically significant (p=0.051). A margin adequacy coefficient of 0.65 was identified as a threshold, above which the risk of recurrence increased by 54%.

Conclusions: Narrow histological margins, particularly in head and neck melanoma excisions, are linked to higher local recurrence and melanoma-related mortality. Re-excision may benefit patients with inadequate margins, although further large-scale studies are needed to define clear guidelines for margin adequacy and re-excision strategies.

Learning Objectives

Takeaway Message

Nearly half of histological margins do not meet the clinically recommended standards, significantly increasing the risk of local recurrence and melanoma-specific mortality. Achieving adequate histological margins through re-excision may improve patient outcomes, underscoring the need for prospective studies to refine melanoma management protocols.

Cutaneous Bacillary Angiomatosis in the Setting of Immunosuppression: A Rare Case in a Heart Transplant Recipient

Chloe E. Devoy, P. Régine Mydlarski, Fatemeh Jafarian

Cumming School of Medicine, University of Calgary, Calgary, AB

Introduction: Bacillary angiomatosis (BA) is a rare, opportunistic infection caused by Bartonella henselae or Bartonella quintana. In the skin, neovascular proliferation results in erythematous and violaceous papules and nodules that can become crusted or ulcerated. First observed in patients with human immunodeficiency virus, BA has since been reported in solid organ transplant recipients (SOTR) due to the administration of immunosuppressive agents and the opportunistic nature of Bartonella. While there are many reports of BA in SOTR, only two cases are documented in cardiac transplant recipients.

Methods, Results: Herein, we report a case of BA in a 67-year-old male post-orthotopic cardiac transplant on mycophenolate mofetil and tacrolimus. He presented with multiple erythematous papules scattered on the chest, back, and extremities. Biopsies revealed lobular capillary proliferation in the superficial dermis and positive Warthin-Starry staining. Nucleic acid amplification by PCR identified Bartonella quintana. After completing a 3-month course of doxycycline 100 mg twice daily, the patient had complete resolution of his skin findings.

Conclusions: While Bartonella henselae is a common cause of BA, all reported cases in heart transplant recipients have been caused by Bartonella quintana. This form of BA is often associated with body lice when people lack access to adequate hygiene. As the recipient had no clear risk factors for BA, the donor likely transmitted the infection. Bartonella quintana infection has rarely been transmitted via solid organ transplantation; however, in 2023, a cluster of six recipients from eleven seropositive Albertan unhoused deceased donors developed bartonellosis. If untreated, BA can affect the liver, spleen, gastrointestinal tract, and heart, resulting in significant morbidity and mortality. The rise in solid organ transplants, combined with the expanding repertoire of immunosuppressive therapies, has significantly improved patient survival. However, it has also created a favourable environment for opportunistic infections, including BA, to emerge as a growing concern.

Learning Objectives

Takeaway Message

Cutaneous bacillary angiomatosis is an emerging concern in solid organ transplant recipients. This case report describes one of the first presentations of cutaneous BA in a heart transplant recipient. Further research is needed to better understand donor transmission, symptoms, and the risks associated with this condition in the context of organ transplantation.

Disease Severity and Pruritus Treatment Outcomes in Prurigo Nodularis: A Systematic Review of Randomized-Controlled Trials

Ryan S.Q. Geng¹, Siddhartha Sood¹, Jihad Waked², Rayyan Mahmood³, Khalad Maliyar¹, Muskaan Sachdeva¹, Abrahim Abduelmula¹, Jensen Yeung^1,4,5,6, Asfandyar Mufti^1,4

¹University of Toronto, Toronto, ON, ²Western University, London, ON, ³University of Illinois, Chicago, IL, ⁴Sunnybrook Health Sciences Centre, Toronto, ON, ⁵Women’s College Hospital, Toronto, ON, ⁶Probity Medical Research, Waterloo, ON

Introduction: Prurigo nodularis (PN) is a chronic immune-mediated dermatosis characterized by intensely pruritic indurated nodules. Clinical trials have investigated several therapies for PN, with the literature describing the efficacy of trialed agents. This systematic review of randomized controlled trials investigates evidence regarding treatments for PN disease severity and pruritus.

Methods, Results: Following PRISMA guidelines, MEDLINE, Embase and Cochrane Central databases were searched using specific keywords. Articles were independently screened by 2 reviewers, resulting in 10 articles, encompassing 1984 patients. Investigator Global Assessment (IGA) and Worst Itch Numeric Rating Scale (WI-NRS) were used as as validated treatment metrics. Treatments included nemolizumab (49.7%, 560/1127), serlopitant (31.1%, 351/1127), dupilumab (13.6%, 153/1127), nalbuphine (3.5%, 40/1127) and vixarelimab (2.0%, 23/1127).

The greatest reduction in WI-NRS compared to control was achieved by nemolizumab 30-60 mg every 4 weeks (Q4W) (-58.6%; placebo -18.6%; n=229; duration 16-weeks), nemolizumab 0.5 mg/kg Q4W (-61.9%; placebo -25.7%; n=70; duration 12-weeks) and dupilumab 300 mg every 2 weeks (Q2W) (-48.9%; placebo -22.2%; n=151; duration 24-weeks). The greatest proportion of patients achieving >4 points reduction in WI-NRS compared to control was achieved by dupilumab 300 mg Q2W (60.0%; placebo 18.4%; n=151; duration 24-weeks), nemolizumab 30-60 mg Q4W (57.2%; placebo 18.2%; n=789; duration 16-weeks), and nemolizumab 30-60 mg Q4W (41.1%; placebo 7.0%; n=560; duration 4-weeks).

The greatest proportion of patients achieving IGA score of 0/1 compared to control was achieved by nemolizumab 0.5 mg/kg Q4W (67.6%; placebo 14.3%; n=70; duration 12-weeks), dupilumab 300 mg Q2W (48.0%; placebo 18.4%; n=151; duration 24-weeks) and nemolizumab 30-60 mg Q4W (31.9%; placebo 9.1%; n=560; duration 16-weeks).

Conclusions: Nemolizumab and dupilumab were the most effective at reducing itch and PN disease severity assessed by WI-NRS and IGA scores.

Learning Objectives

Takeaway Message

Nemolizumab and dupilumab were the most effective at reducing itch and PN disease severity assessed by WI-NRS and IGA scores.

JAK-1 Inhibitors in the Management of Atopic Dermatitis in Older Adults: A Descriptive Cohort Study

Jiayue Zheng¹, Karla Robles-Velasco^2,3, Sonia Sharma², Rodrigo Gay Ducati^2,4, Veronica Ferris Pasquini², Hermenio Lima²

¹Department of Medicine, McMaster University, Faculty of Health Sciences, Hamilton, ON, ²LEADER Research Inc., Hamilton, ON, ³Universidad Espiritu Santo, Samborondon, Ecuador, ⁴University of Vale do Taquari - Univates, Lajeado, Brazil

Introduction: Atopic dermatitis (AD) is a chronic inflammatory skin condition that affects older adults, a group increasingly recognized for distinct disease characteristics and comorbidities. Janus kinase inhibitors (JAK-1 inhibitors), such as upadacitinib and abrocitinib, have emerged as effective treatments for moderate-to-severe AD. However, data on their safety and efficacy in older adults remain limited due to underrepresentation in clinical trials.

Methods, Results: A retrospective cross-sectional study that examined patients aged 65 years or older treated at Pitanga Clinic in Hamilton, Ontario with a documented diagnosis of AD. Data were extracted from electronic medical records and included demographics, disease characteristics, and treatment specifics. Disease control was assessed using the Atopic Dermatitis Control Tool (ADCT), while adverse events were analyzed. Statistical comparisons between baseline and follow-up ADCT scores were conducted using the Wilcoxon Signed-Rank Test. The study included 31 patients (mean age 72.6 years, 65% female). Thirteen patients (42%) received abrocitinib, and 18 (58%) were treated with upadacitinib. The mean reduction in DCT scores was -84.4%, with a slightly greater improvement observed in abrocitinib users (-87.7%, p < 0.001). Mild adverse events were reported in 21 patients (68%), while 26% experienced no adverse effects. Two patients discontinued treatment due to adverse events.

Conclusions: Although causality cannot be established, this study supports the efficacy and safety of JAK-1 inhibitors in older individuals with AD. These findings highlight the potential of JAK-1 inhibitors in this population while underscoring the need for personalized treatment approaches and further research in larger cohorts.

Learning Objectives

Takeaway Message

Although causality cannot be established, this study supports the efficacy and safety of JAK-1 inhibitors in older individuals with AD, providing groundwork for larger-scale investigations that may more accurately delineate the risk-benefit profile of these drugs.

Outcomes of Therapeutic Strategies in Merkel Cell Carcinoma Among Pediatric and Young Adult Patients (Ages 0–45)

Andy D. Lee¹, Jinny Choi¹, Joshua Yi¹, Kristen A.R. Yee², Joseph M. Lam³, Chaocheng Liu⁴

¹Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ²Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, ³Division of Dermatology, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC, ⁴Department of Dermatology and Skin Science, Faculty of Medicine, University of British Columbia, Vancouver, BC

Introduction: Merkel cell carcinoma (MCC) is a rare, aggressive neuroendocrine skin cancer typically affecting older adults, with a median diagnosis age of 75 years. Cases among pediatric and young adult patients (aged 0–45 years) are uncommon and not well characterized. In particular, immunosuppression and cumulative ultraviolet exposure have been implicated in MCC pathogenesis, though these factors may vary in younger patients. Despite advancements in diagnostic techniques, younger patients often experience delays in identification, potentially contributing to more advanced disease at presentation. This systematic review aimed to evaluate treatment outcomes and identify factors influencing disease course in this younger group.

Methods, Results: A systematic search of multiple databases was performed through October 31, 2024, focusing on MCC in patients aged 0–45 years. Sixteen articles were identified, representing 27 patients across different regions. The mean age was 19.3 years, with a relatively even distribution between men and women. Among those with staging data, 50% were stage I, 21.4% were stage II, and 28.6% were stage III. Treatment approaches varied, including monotherapy (surgery or chemotherapy) and combination therapy (surgery plus radiotherapy, with or without chemotherapy). Complete resolution was achieved in 42.9% of surgery-only cases and 100% of surgery plus radiotherapy cases. Higher recurrence was noted with monotherapy. Adverse events were rare but included severe dry eye. Two deaths were reported: one in a patient receiving combination therapy and one in an untreated patient.

Conclusions: Pediatric and young adult MCC can present with notable aggressiveness and elevated recurrence rates. However, surgery combined with radiotherapy yielded better outcomes and reduced recurrence compared with monotherapy. Early consideration of MCC in younger patients may facilitate prompt biopsy, diagnosis, and tailored treatment. Larger, multicenter studies are warranted to refine treatment protocols, develop age-specific guidelines, and improve prognosis for this distinct population.

Learning Objectives

Takeaway Message

Combined surgical and radiotherapeutic approaches can significantly improve outcomes and reduce recurrence in younger MCC patients.

Advancing Equitable Wound Care: AI-Powered Predictive Algorithm for Diverse Populations

Sheila C. Wang^1,2, Lucas Goldstone³, Heba T. Mohammed³, Rishahb Gupta³, Sharjeel Mustafa⁴, Robert D.J. Fraser^5,3, Matthew Wynn⁶, Justin Allport³

¹University of Toronto, Toronto, ON, ²Women’s College Hospital, Toronto, ON, ³Swift Medical, Toronto, ON, ⁴University of Windsor, Windsor, ON, ⁵Western University, London, ON, ⁶Liverpool John Moores University, Liverpool, UK

Introduction: Chronic wound assessment and treatment often suffer from subjective evaluations, leading to potential biases and inconsistencies in care. This study presents a novel AI-powered prognostic tool that aims to provide objective, unbiased wound assessments across diverse patient populations. By leveraging advanced deep learning techniques and the largest, most diverse dataset of wound images published to date, this tool addresses critical issues of inclusivity, diversity, and equity in wound care.

Methods, Results: The AI model was developed using 465,187 wound images from patients of various ethnicities, ages, and wound types. The dataset was carefully curated to ensure representation across different skin tones using the Fitzpatrick scale. The model incorporates wound area, tissue composition, and other relevant factors to generate a quantitative prognosis for wound healing.

In a retrospective analysis of 173,816 wounds from 85,599 patients across 2,448 healthcare facilities, the AI tool demonstrated superior performance compared to standard assessment methods. It achieved a balanced accuracy of 65% by week 3 in predicting delayed wound healing, outperforming conventional methods which reached this level only by week 4. Notably, the tool showed consistent performance across all skin tones and wound types, addressing potential biases in visual assessment.

Conclusions: This novel AI-powered prognostic tool represents a significant advancement in equitable wound care. By providing objective, consistent assessments regardless of patient demographics, it has the potential to standardize wound care practices and improve outcomes for all patient populations. Future prospective studies are needed to validate its clinical impact and potential for reducing healthcare disparities in wound management.

Learning Objectives

Takeaway Message

This novel AI-powered prognostic model represents a significant advancement in equitable wound care by providing more accurate and earlier predictions of delayed wound healing across diverse patient populations.

Key takeaways include:

This novel approach combines advanced AI technology with clinical expertise to promote more equitable and effective wound care, potentially improving outcomes for all patients and reducing healthcare disparities in wound management.

Understanding the Phenotypic Switch Between Psoriasis and Atopic Dermatitis

Kerry Yang¹, Sonia Czyz¹, Christopher G. Bunick², Fatemeh Jafarian^1,3

¹University of Calgary, Calgary, AB, ²Yale University, New Haven, CT, ³McGill University, Montreal, QC

Introduction: Atopic dermatitis (AD) and psoriasis (PsO) are common immune-mediated skin conditions with overlapping pathophysiological features, which is exemplified by a phenotypic switch from one to the other after the initiation of immunomodulatory therapy.

Methods, Results: This study uses a pharmacovigilance-based disproportionality analysis on the FDA Adverse Events Reporting System to investigate this phenomenon. When looking at dupilumab for the treatment of AD, eczema, or dermatitis, a signal emerges for psoriasiform dermatitis (Reporting Odds Ratio [95% Confidence Interval] =3.23 [1.69,1.35]) as an adverse event (AE), but not psoriasis (3.23 [1.69,1.35]). For biologics used in the treatment of PsO, psoriasiform dermatitis emerged as a signal for TNF-α inhibitors=1.51 [1.69,1.35], IL-17 inhibitors=3.89 [4.58,3.30], and IL-12/23 inhibitor=1.79 [2.41,1.33]. When looking at dupilumab for the treatment of AD, eczema, or dermatitis, a signal emerges for psoriasiform dermatitis (Reporting Odds Ratio [95% Confidence Interval]=3.23 [4.39, 2.37]) as an adverse event (AE), but not psoriasis (0.56 [0.61,0.52]). Limiting the indication to PsO strengthened signals for psoriasiform dermatitis (TNF-α =3.01 [4.26,2.13] and IL-17 inhibitors=11.46 [14.34,9.16]), and allowed new ones to emerge for psoriasiform dermatitis (IL-23 inhibitors=2.49 [4.80,1.29] and apremilast=2.04 [3.71,1.13]), eczema (IL-17 inhibitors=1.84 [2.06,1.64]), and dermatitis (IL-17 inhibitors=1.95 [2.29,1.66]), but not AD. This suggests that paradoxical reactions create an intermediary physiologic and immunologic presentation between psoriasis and AD. For the interleukin biologics, the signal strength of IL-17 inhibitors is significantly stronger than IL-23 and IL-12/23 inhibitors, suggesting Th17 and Th22 cells are involved in the switch. A phenotypic switching effect did not occur for another Th2 and Th22-mediated condition, asthma, suggesting that phenotypic switching is not a generalized effect. AE signals for Th2-mediated allergic conditions emerged for all biologic classes as well, suggesting the paradoxical reaction could potentially involve increased Th2 activity.

Conclusions: Taken together, our study proposes a comprehensive model for the phenotypic switch between atopic dermatitis and psoriasis. This study is the first of its kind, and it has major implications for dermatologic prescribing practices.

Learning Objectives

Takeaway Message

A phenotypic switching effect occurs between atopic dermatitis and psoriasis that likely involves Th1, Th2, Th17, and Th22 cell pathways.

Investigating Cell of Origin of Merkel Cell Carcinoma, a Historic Misnomer

Richie Jeremian¹, Sriraam Sivachandran¹, Melissa Galati², Brandon Ramchatesingh¹, Hibo Rijal³, May Chergui¹, Margaret Redpath¹, Samy Abou Setah¹, Ivan V. Litvinov¹

¹McGill University, Montreal, QC, ²Univeristy of Toronto, Toronto, ON, ³Queens University, Kingston, ON

Introduction: Merkel cell carcinoma (MCC) is a highly aggressive skin cancer with the poorest prognosis, posited to be derived from Merkel cells. Emerging evidence, however, suggests other potential origins for MCC including hematological lineages. Given the high fatality of MCCs and that many arise in the immune suppressed population, often precluding the use of immunotherapy, it is important to determine the cell of origin for these cancers to elucidate targetable pathways to enable novel treatment approaches.

Methods, Results: We utilized targeted and multi-omics approaches to explore expression patterns at both the protein and RNA level of MCCs. Western blotting, immunofluorescence, and immunohistochemistry were performed for two patient-derived MCC samples, one MCC cell line, and 92 FFPE samples, respectively, for numerous B-cell markers.

MCC patient-derived and cell line samples heterogeneously expressed B-cell and neuroendocrine markers including PAX5, TdT, IgA, CD19, CK20, and chromogranin A. Further, transcriptome analysis demonstrated differentially expressed genes based on sex and MCPyV status. MCPyV+ tumors demonstrated significant upregulation of genes involved in immune cell function and downregulation of processes related to neuronal activity. Finally, WGCNA highlighted enrichment for pathways involved in immune function including B-cell differentiation. Cell type enrichment analysis highlighted enrichment for multipotent stem cells, several immune cell types, and keratinocytes.

Conclusions: Our findings together with previous results indicate that MCCs are not derived from Merkel cells and instead from multiple or divergent cell types, including those of B-cell lineage. Further, MCC cell of origin may depend on patient and tumor specific characteristics including sex and cell type/differentiation state of a cell infected by the MCPyV. Our work highlights the need for a more personalized approach to diagnosis/characterization and treatment of MCCs given the variability of potentially targetable pathways.

Learning Objectives

Takeaway Message

This multi-platform study demonstrates that many MCCs express B-cell markers such as CD20, BCL-2, PAX5, TdT, IgA, and CD19. Further, RNA sequencing data and analyses support the enrichment of numerous immune-related pathways and cell types in MCC including those of B-cell lineage but also multipotent progenitors and keratinocytes. Finally, the differential expression of genes between MCPyV positive and negative cancers as well as tumors from male vs. female patients emphasizes the need for a personalized medical approach to MCC as expression of pathways differs between these groups, likely with implications for therapeutic targets.

Our combined results support multiple potential cells of origin for MCC outside of Merkel cells. Our work, in particular, supports a possible B-cell lineage origin, but further highlights the diversity of expression patterns and cell types enriched in MCC, particularly those that differ among subgroups. Given the fatality of these tumors, it is necessary to elucidate new treatments targeting novel drivers of carcinogenesis pathways based on the true cell of origin for MCC.

Understanding Attitudes Related to Sun Exposure and the Impact of Sunscreen Paradox on the Risk of Melanoma in Atlantic Canada

Jonathan LeBeau¹, Sauliha Alli², Sandra Pelaez³, Ivan V. Litvinov¹

¹McGill University, Montreal, QC, ²University of Toronto, Toronto, ON, ³Université de Montréal, Montréal, QC

Introduction: Cutaneous melanoma (CM) is an aggressive skin cancer with rising incidence globally, including in Canada. The Atlantic provinces, particularly Nova Scotia (NS) and Prince Edward Island (PEI), have higher CM rates, while Newfoundland and Labrador (NL) has lower rates. Sun exposure behaviors, shaped by social norms and environmental conditions, significantly impact CM risk. The "sunscreen paradox," where increased sunscreen use does not lower sunburn rates, underscores the need to explore regional differences in sun protection behaviors.

Methods, Results: This study employed a consensual qualitative research design with 22 focus groups across NS, PEI, New Brunswick (NB), and NL, involving 95 participants. Thematic analysis using MAXQDA software, guided by the social-ecological model, examined sun protection behaviors, attitudes, and social norms, particularly contrasting high-incidence (NS, PEI) and low-incidence (NL) regions.

Participants in NS and PEI showed high awareness of sun protection, with over 80% regularly using sunscreen and checking the UV index. However, these regions also reported higher sunburn rates, illustrating the "sunscreen paradox." Many participants believed sunscreen alone provided full protection, leading to prolonged sun exposure during peak UV hours. In contrast, NL participants, influenced by cooler climates and cultural norms, engaged less in sun-seeking behaviors and prioritized shade and protective clothing over sunscreen. Social norms in high-incidence areas favored tanned skin, pressuring individuals—especially youth—to sunbathe despite awareness of CM risks. Barriers to effective sun protection included the inconvenience of sunscreen reapplication and discomfort with protective clothing.

Conclusions: Despite widespread sunscreen use in high-incidence regions, misconceptions about its effectiveness contribute to increased sunburn risk. Public health campaigns should address the sunscreen paradox by promoting comprehensive sun protection strategies—such as wearing protective clothing, seeking shade, and limiting sun exposure during peak UV hours—to reduce CM risk in Atlantic Canada.

Learning Objectives

Takeaway Message

Cutaneous melanoma (CM) rates are rising in Canada, with notably higher incidence in Nova Scotia (NS) and Prince Edward Island (PEI) compared to Newfoundland and Labrador (NL). This study explored how sociocultural and environmental factors influence sun exposure and protection behaviors across these regions. Despite high awareness and frequent sunscreen use in NS and PEI, participants reported higher sunburn rates, illustrating the "sunscreen paradox"—the misconception that sunscreen alone offers full protection, leading to prolonged sun exposure. Social norms valuing tanned skin, especially among younger individuals, further encouraged risky behaviors. In contrast, NL’s cooler climate and cultural attitudes resulted in less sun-seeking behavior, with greater reliance on shade and protective clothing. Barriers to effective sun protection included the inconvenience of reapplying sunscreen and discomfort with wearing hats or long sleeves. These findings highlight the need for public health campaigns to address misconceptions about sunscreen and promote comprehensive sun safety strategies.

Efficacy and Safety of Treatments for Bowen’s Disease: A Systematic Review and Network Meta-Analysis

Daniel G. Rayner¹, Leonardo Ologundudu², Cheng En Xi³, Valencia D. Thomas ⁴, Marcus G. Tan^4,5

¹Schulich School of Medicine and Dentistry, Western University, London, ON, ²Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, ³Faculty of Medicine, University of Ottawa, Ottawa, ON, ⁴Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, ⁵Division of Dermatology, Faculty of Medicine, University of Ottawa, Ottawa, ON

Introduction: Bowen’s disease (BD) is a malignant disorder of keratinocytes which remain confined to the epidermis. Although numerous treatments exist for BD, there is a paucity of comparative evidence. We conducted a systematic review and network meta-analysis (NMA) to compare the efficacy and safety of treatments for BD.

Methods, Results: MEDLINE, Embase, CENTRAL, CDSR, CNKI, and VIP were searched from inception to January 3rd, 2025, for randomized controlled trials (RCT) and observational studies comparing treatments for BD. Paired reviewers screened citations and extracted data. Random effects NMAs pooled risk ratios (RR), and GRADE was used to assess the certainty of evidence. We included 28 RCTs (1,411 patients; median age: 70.9 years; median 51% female) and 28 observational studies (3,949 patients; median age: 70.5 years; median 56% female). No RCTs evaluated Mohs surgery. Treatment protocols for photodynamic therapy (PDT) and topical 5-fluorouracil were heterogeneous across studies. The NMAs yielded low and very low certainty evidence. Compared to placebo, excision (RR 6.31), PDT (RR 5.81), cryotherapy (RR 5.41), curettage (RR 4.92), topical 5-fluorouracil (RR 4.78), and imiquimod (RR 2.62) were more likely to achieve complete clearance (Figure 1A). Clearance rates for PDT were higher when combined with dermabrasion (RR 8.36), ablative lasers (RR 8.14), and cryotherapy (RR 6.45). Compared to placebo, the risk of BD recurrence (median follow-up [range]: 365 [182–540] days) was significantly lower with excision (RR 0.04), PDT with ablative lasers (RR 0.07), and PDT alone (RR 0.28); the evidence was uncertain for cryotherapy, curettage, or 5-fluorouracil (Figure 1B). The evidence was uncertain for the outcomes of serious adverse events and treatment discontinuations due to adverse events, and the heterogeneous observational data.

Conclusions: We identified low certainty evidence that excision and PDT have the highest rates of clearance and lowest risks of recurrence among the single-modality treatments for BD.

Learning Objectives

Takeaway Message

Compared to placebo, low certainty evidence demonstrated that excision and photodynamic therapy had highest rates of clearance and lowest risks of recurrence among the single-modality treatments for Bowen’s disease. Many treatments had very low certainty evidence, highlighting the need for additional randomized trials comparing treatments for Bowen’s disease.

Treatment Strategies for Skin Picking Disorder: Efficacy of Pharmacological and Non-Pharmacological Approaches—A Systematic Review and Evidence Mapping

Andy D. Lee¹, Chloe E. Devoy², Ryan S.Q. Geng³, Mehul Nimpal⁴, Kristen A.R. Yee⁴, Kevin Wang¹, Liz Dennett⁴, Katharine Hibbard^4,5, Tarek Turk^4,6, Sebastian Straube^4,7, Marlene Dytoc^4,6

¹Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ²Cumming School of Medicine, University of Calgary, Calgary, AB, ³Temerty Faculty of Medicine, Toronto, ON, ⁴Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, ⁵Division of Psychiatry, University of Alberta, Edmonton, AB, ⁶Division of Dermatology, University of Alberta, Edmonton, AB, ⁷Division of Preventive Medicine, Edmonton, AB

Introduction: Skin picking disorder (SPD) is recognized as a psychiatric condition characterized by repetitive picking behaviors that lead to significant tissue damage and distress. With no standard regulatory-approved treatments, clinicians often rely on pharmacological and non-pharmacological interventions gleaned from limited evidence. There is growing interest in identifying which therapies achieve the greatest symptom reduction while remaining both safe and accessible. A systematic review was undertaken to examine the efficacy of the main interventions used for SPD, including pharmacotherapy, behavioral and cognitive strategies, and neurostimulation approaches.

Methods, Results: Eligible randomized controlled trials were identified through systematic searches of multiple electronic databases. A total of 25 studies involving 3,407 participants were included, with outcomes frequently assessed using validated scales such as the Skin Picking Scale and the Yale-Brown Obsessive Compulsive Scale. Behavioral modification techniques were most common (41.8%), followed by cognitive and behavioral therapies (25.5%), self-help tools (18.4%), pharmacological treatments (13.5%), and neurostimulation (0.5%). Pharmacological agents, particularly selective serotonin reuptake inhibitors and N-acetylcysteine, demonstrated an overall 49.1% improvement, with fluoxetine showing the highest efficacy (98.3%) in selected patients. Behavioral and cognitive therapies averaged a 39.8% symptom reduction, with habit reversal training yielding particularly notable benefits, while self-help strategies produced a 30.0% reduction.

Conclusions: Although the etiology of SPD remains multifactorial, these findings underscore the potential of combining pharmacological and behavioral interventions to address this often underrecognized disorder. Serotonergic dysfunction appears to be central, explaining the robust response to selective serotonin reuptake inhibitors. Evidence also supports cognitive and behavioral approaches, including habit reversal training, as effective treatment options. Larger, high-quality trials that use standardized outcome measures are needed to confirm these benefits, reduce heterogeneity, and guide clinical practice.

Learning Objectives

Takeaway Message

SSRIs and behavioral therapies show promise for SPD, but further high-quality research is needed to optimize management.

The Clinical Outcomes, Safety Profiles, and Treatment Patterns of Electron Beam Therapy for Basal Cell Carcinoma

Andy D. Lee¹, Nicholas Lum¹, Amrit Thandi¹, Kristen A.R. Yee², Darshana Seeburruth¹, Megan Park¹, Sherry Chen¹, Nina T. Yeung³, Cathryn Sibbald⁴, Chaocheng Liu⁵

¹Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ²Faculty of Medicine & Dentistry, University of Alberta, Edmonton, ON, ³Faculty of Medicine & Dentistry, University of Albert, Edmonton, AB, ⁴Division of Pediatric Dermatology, The Hospital for Sick Children, University of Toronto, Toronto, ON, ⁵Department of Dermatology and Skin Science, Faculty of Medicine, University of British Columbia, Vancouver, BC

Introduction: Basal cell carcinoma (BCC) is the most common cutaneous malignancy, and its incidence continues to rise steadily worldwide. While surgical excision remains a mainstay of treatment, radiotherapy (RT) may be preferable for older individuals or patients with comorbidities, or when lesions occur in areas where surgery could compromise function or cosmesis. Electron beam therapy (EBT) delivers high doses to superficial tissues with limited deeper penetration, potentially offering favorable outcomes and reduced morbidity.

Methods, Results: A systematic search (October 17, 2024) of MEDLINE, Embase, APA PsycInfo, and Scopus followed PRISMA guidelines. The search combined “basal cell carcinoma” and “electron beam therapy” with synonyms for “electron irradiation” and “electron radiotherapy.” Eleven eligible studies reported fractionation schedules, total doses, response rates, toxicity, and cosmetic results for 535 BCC lesions. Patients’ mean age ranged from the mid-60s to early-80s. Most lesions involved the head, neck, trunk, or extremities. EBT fractionation varied from a single dose to 31 fractions. Total doses ranged from ~2,000 cGy to >6,000 cGy with beam energies of 4–10 MeV. Early-stage tumors showed complete response rates above 85%. Mild adverse events included transient erythema or subtle skin changes, with rare severe complications. Necrosis was reported predominantly in large or advanced lesions receiving higher total doses. Cosmetic outcomes were excellent or good in over 80% of cases, with recurrences below 10% in early-stage disease, often noted beyond six months. Combination approaches did not significantly alter outcomes.

Conclusions: EBT is a highly effective modality for early-stage BCC, achieving high cure rates and favorable cosmetic results with limited toxicity. Although advanced or deeply invasive lesions may warrant alternate therapy, EBT remains a valuable option for anatomically challenging or cosmetically sensitive areas. Prospective investigations should focus on standardizing fractionation schedules, optimizing dosing for advanced disease, and systematically assessing long-term cosmesis and outcomes.

Learning Objectives

Takeaway Message

Electron beam therapy offers high cure rates with favorable cosmetic outcomes for basal cell carcinoma, especially for early-stage disease and patients who are not surgical candidates.

Under the Arctic Sun: A Cross-Sectional Survey Study Assessing Melanoma Risk and Sun Protection Behaviours Across Indigenous Communities in Nunavik

Amina Moustaqim-Barrette¹, Alexandra S.V. Kelly², Chenrui Xie¹, Arusa Shah³, Angie Moshutz¹, Phedra Fadel¹, Agustina Hasbani¹, Said Dababneh³, Sammy Pootoo⁴, Mary Sala⁵, Putulik Ilisituk⁵, Annie Kumarluk⁵, Serena Weetaltuk⁶, Parsa Kitishimik⁵, Ricky Moorhouse⁷, Maata Inukpuk⁵, Francois Lagace¹, Sandra Pelaez¹, Ivan V. Litvinov¹

¹McGill University, Montreal, QC, ²University of Ottawa, Ottawa, ON, ³Université de Montréal, Montréal, QC, ⁴Salluit Northern Village, Salluit, QC, ⁵Nunavik Regional Board of Health and Social Services, Nunavik, QC, ⁶Municipality of Kuujjuaraapik, Kuujjuaraapik, QC, ⁷Kativik Regional Government, Kativik, QC

Introduction: Inuit communities in northern Canada are uniquely impacted by ultraviolet (UV) exposure due to cultural, geographic and climate change factors, yet their sun protection behaviors and melanoma risk perceptions remain poorly understood. This study aimed to assess sun protection and skin cancer awareness among Inuit of Nunavik, and compare findings to other Canadian populations.

Methods, Results: A cross-sectional survey was conducted in four Nunavik communities during summer 2024. Participants aged ≥16 who self-identified as Inuit and who completed the Sun Exposure and Behaviour Inventory (SEBI) were included. Demographic data and variables related to UV exposure, sun protection habits, and melanoma awareness were analyzed using descriptive statistics. Age- and gender-adjusted odds ratios were calculated using logistic regression. Results were compared with previously collected SEBI cohorts from Manitoba and Atlantic Canada.

Among 541 Inuit participants (mean age 39.9 years; 63.4% female), 56.3% reported moderate to very high lifetime sun exposure. We identified significant disparities across demographic groups. Men were less likely to use sunscreen (OR 0.50, 95% CI 0.30–0.81) compared to women, though significantly more likely to report high occupational UV exposure (OR 2.62, CI 1.74–3.96). Individuals with high educational attainment (high school or above) had 109% increased odds of wearing sunscreen compared to those who had not finished high school (OR 2.09, CI 1.31–3.37). Compared to our Manitoba cohort (n=3347) and Atlantic Canada cohort (n= 7861), occupational sun exposure was significantly higher among Inuit (OR 2.54, CI 2.00-3.22), while odds of sunscreen use, shade seeking, and hat use were significantly lower (OR 0.07, 0.15, 0.38 respectively).

Conclusions: Inuit in Nunavik demonstrated reduced sun protection behaviors and melanoma awareness compared to the general Canadian population. Findings underscore the need for culturally tailored community engagement to improve sun safety and skin cancer prevention in northern Canadian Indigenous communities.

Learning Objectives

Takeaway Message

Our study evaluated skin cancer risk factors and sun safety knowledge and practices among Inuit in Nunavik, Canada, and contextualises data on this remote Canadian region by providing direct comparisons of the outcome variables of interest with non-Indigenous Canadian cohorts. To our knowledge, this is the among the first cross-sectional studies to investigate sun protection and melanoma knowledge in Inuit populations of Nunavik, and the first study to provide direct comparisons using the same validated questionnaire on sun protection habits and skin cancer risk perceptions between Inuit and non-Indigenous populations of Canada.

In general, we found that Inuit men, younger individuals, and those with less education were less likely to adhere to sun protection practices and worry about concerning skin lesion changes as compared to women, older individuals, and those with higher education, respectively. Importantly, our study also highlights significantly lower rates of sun protection behaviors and significantly higher occupational UV exposure among the Inuit compared to our other Canadian cohorts. These findings may suggest limited access to or prioritization of sun protection resources in Nunavik. Further, lower levels of concern regarding mole changes may indicate reduced awareness of melanoma and non-melanoma skin cancer risk factors. The distinct patterns of UV exposure and sun protection behaviors observed in Nunavik likely reflect cultural, environmental, and socioeconomic influences, as well as barriers to accessing healthcare and educational resources. Our findings suggest a need to develop culturally relevant, community-driven strategies to address these gaps.

Topical Roflumilast as a Novel Treatment for Porokeratosis

Rachel S. Simpson¹, Danee Lafontaine², Linda Xing³, Marisa Ponzo⁴, Fiona Lovegrove^1,2

¹Schulich School of Medicine and Dentistry, Western University, London, ON, ²Lovegrove Dermatology, London, ON, ³Rejuvenation Dermatology, Oakville, ON, ⁴North York Dermatology Clinic, Toronto, ON

Introduction: Porokeratosis is a relatively common genodermatosis marked by mutations in the mevalonate pathway. It comprises a group of clinical conditions characterized by annular erythematous papules and/or plaques with a hyperkeratotic rim. Disseminated Superficial Actinic Porokeratosis (DSAP) is the most common clinical subtype, with multiple lesions seen on the extremities in sun-exposed skin. Porokeratosis of Mibelli (PM) is usually a solitary lesion and is the second most common subtype. Porokeratosis has been associated with an increased risk of squamous cell carcinoma. Current treatments include cryotherapy and topical therapy (retinoids, 5-fluorouracil, imiquimod and lovastatin with cholesterol); however, the efficacy of these treatments is limited and side-effects can be significant. Topical roflumilast, a selective phosphodiesterase-4 (PDE4) inhibitor approved for plaque psoriasis, may provide a new treatment option for Porokeratosis by disrupting the autoinflammatory cascade through the mevalonate pathway and restoring normal keratinocyte function.

Methods, Results: Eight patients across three independent centers received 0.3% topical roflumilast cream once daily for the treatment of Porokeratosis. Four patients had a diagnosis of PM and four a diagnosis of DSAP. After a mean of 9 weeks (range: 3-13) on topical roflumilast, 87% of patients achieved a partial resolution and 13% achieved a complete resolution of Porokeratosis. There were no reported adverse events, and no patients discontinued topical roflumilast.

Conclusions: Porokeratosis is a common genodermatosis with a risk of advancement to malignancy. Many patients have porokeratosis which is uncontrolled by or refractory to currently available treatments. We report the findings of eight patients across three centers who achieved either a partial or complete resolution of PM and DSAP following topical roflumilast, highlighting its potential novel role in porokeratosis management. Studies investigating larger-scale use are warranted.

Learning Objectives

Takeaway Message

Topical roflumilast may be a safe, well-tolerated and effective novel treatment for porokeratosis subtypes, including PM and DSAP.

Please note Dr. Linda Xing and Dr. Marisa Ponzo contributed equally to this work.

Development of a Transfer Learning-Based, Multimodal Neural Network for Identifying Malignant Dermatological Lesions from Smartphone Images

Heather J. Zhao¹, Jiawen Deng¹, Eddie Guo²

¹University of Toronto, Toronto, ON, ²University of Calgary, Calgary, AB

Introduction: Early skin cancer detection in primary care settings is crucial for prognosis, however primary care physicians often lack relevant training. Machine learning (ML) tools offer a potential solution by enabling systematic triaging of suspicious lesions using images. This study aims to develop a novel neural network for the binary classification of skin lesions into malignant and benign categories using smartphone images and clinical data via a multimodal and transfer learning-based approach.

Methods, Results: We used the PAD-UFES-20 dataset, which included 2298 sets of lesion images. Three neural network models were developed: a clinical data network, an image-based network based on a pre-trained DenseNet-121, and a multimodal network combining clinical and image data. Models were tuned using Bayesian Optimization HyperBand (BOHB) across 5-fold cross-validation. Model performance was evaluated using AUC-ROC, average precision, Brier score, calibration curve metrics, Matthew’s correlation coefficient, sensitivity, and specificity. Model explainability was explored using permutation importance and Grad-CAM heatmaps.

During cross-validation, the multimodal network outperformed the other models with an average AUC-ROC of 0.91 (95% confidence interval [CI] 0.88 to 0.93) and Brier score of 0.15 (95% CI 0.11-0.19). The multimodal network also outperformed the other models during internal validation, with an AUC-ROC of 0.91 and Brier score of 0.12. However, the classification performance of the multimodal model is similar to the image-based model at high-sensitivity thresholds. Important features used for clinical data-based classification included bleeding, elevated lesions, patient age, and recent lesion growth. Grad-CAM revealed that the image-based network focused on the lesioned area to make classification decisions in most example cases.

Conclusions: A transfer learning-based, multimodal neural network can effectively identify malignant skin lesions. To ensure the generalizability and applicability of our model, further external validation with more diverse and extensive datasets is needed.

Learning Objectives

Takeaway Message

A transfer learning-based multimodal neural network, combining smartphone images and clinical data, demonstrates high accuracy in classifying skin lesions as malignant or benign, with a potential to aid early skin cancer detection in primary care settings.

Vulvar Crohn Disease: A Case Report

Jason Kreutz¹, Colton Jensen², Marlene Dytoc²

¹Division of Dermatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, ²Division of Dermatology, Faculty of Medicine, University of Alberta, Edmonton, AB

Introduction: Vulvar Crohn disease (VCD) is a rare extraintestinal manifestation of Crohn disease (CD) with fewer than 200 documented cases. VCD is often misdiagnosed and can take years to identify. While most VCD patients have concomitant active gastrointestinal manifestations of CD, up to 25% of patients present with vulvar lesions before gastrointestinal CD is diagnosed. Management options for VCD may include topical corticosteroids, calcineurin inhibitors, metronidazole, systemic corticosteroids, sulfasalazine, azathioprine, TNFα inhibitors, IL-12/23 inhibitors, and surgical treatment. However, the optimal treatment of VCD remains contested.

Methods, Results: A 47-year-old female with a history of inverse psoriasis and hidradenitis suppurativa presented with a 2-year history of painful, pruritic linear vulvar fissures. There was no history of inflammatory bowel disease and colonoscopy revealed no intestinal CD findings. Vulvar punch biopsy demonstrated dense lymphoplasmacytic infiltrate with multifocal small noncaseating granulomas, consistent with CD. We continued her adalimumab and prescribed metronidazole 500mg BID. With minimal improvement after 2 months, the patient consented to triamcinolone acetonide 5mg/mL injections (ILTAC) preceded by the application of lidocaine 5% gel. After 6 weeks, her fissures, pain, and pruritus improved. Her fissures had completely resolved at the most recent follow-up with adalimumab 40mg, metronidazole 500mg, and ILTAC injections.

Conclusions: VCD should be included in the differential for patients presenting with vulvar ulcers, regardless of the presence of gastrointestinal CD or symptoms. Timely diagnosis may improve treatment outcomes. We therefore propose that endoscopy is unnecessary to initially diagnose VCD, although it is still required to rule out intestinal CD. Reports on ILTAC as a treatment modality for VCD are limited in the literature and remain absent from proposed treatment algorithms. Given the considerable improvement our patient experienced with ILTAC injections, it should be considered as a first-line treatment for VCD and for patients who fail other treatment options.

Learning Objectives

Takeaway Message

Vulvar Crohn disease is a rare condition in which timely diagnosis is important for effective treatment. Intralesional triamcinolone acetonide injections may offer significant symptom relief and should be considered as a first-line treatment or for patients who fail other therapies.

Genital Porokeratosis: A Case Report and Review of Pathogenesis and Genitogluteal Subtypes of Porokeratosis

Camille Hamm¹, Jennifer Lipson²

¹University of Ottawa, Ottawa, ON, ²Department of Dermatology, The Ottawa Hospital, Ottawa, ON

Introduction: Porokeratosis is a condition characterized by abnormal epidermal keratinization with a unique morphology of papules or plaques surrounded by a thread-like border of scale corresponding to the cornoid lamella on histology. Many established subtypes have been described, however genitogluteal porokeratosis is a rare entity.

Methods, Results: We report the case of a 58-year-old male with pruritic keratotic reddish lesions affecting the genital region for the last 4 years. He experienced no improvement after treatment of a presumed recurrent intertrigo/inguinal candidiasis. On examination, he was found to have multiple dull-red warty papules on the mons pubis, penis, scrotum, pubis, groin and thighs, some displaying thin rims of scale at the periphery. A biopsy revealed mounds of parakeratosis typical with cornoid lamellae. Given the clinical presentation and histopathology, he was diagnosed with the rare entity of genital porokeratosis. He has since experienced significant improvement with pathogenesis-targeted treatment of compounded topical 2% lovastatin/2% cholesterol.

Conclusions: Isolated genitogluteal porokeratosis is a rare entity most diagnosed in men. Three other subtypes of genitogluteal porokeratosis have been mentioned in the literature including Mibelli porokeratosis in the genital region, psychotropic porokeratosis and penoscrotal porokeratosis. Our patient’s presentation was most in keeping with Mibelli porokeratosis in the genital region. Further discoveries in the gene mutations and pathways involved in porokeratosis have assisted in pathogenesis- and mechanism-directed approaches such as the use of compounded lovastatin and cholesterol topical agents. Although no malignant change has been reported in genitogluteal porokeratosis it remains a theoretical concern thus regular follow-up is recommended. This case highlights features of this rare and diagnostically challenging subtype of porokeratosis.

Learning Objectives

Takeaway Message

Although no cases of malignant transformation in genital porokeratosis have been reported, regular follow-up is still recommended for skin surveillance. Genital porokeratosis should be considered in the differential diagnosis of keratotic plaques and papules isolated to the genitogluteal region as misdiagnosis can lead to inappropriate treatment and inadequate follow-up.

Assessing Chatbot Responses on Treatment Management for Atopic Dermatitis Compared to Clinical Guidelines and Recommendations

Maxine Joly-Chevrier¹, Ahmad Alamari², Laura Xu², Safin Aly¹, Veselko Bakula², Yasmine Lachance¹, Katya Peri³, Farhad Pourpanah⁴, Mathieu Powell², Elena Netchiporouk²

¹Faculty of Medicine, Université de Montréal, Montréal, QC, ²Division of Dermatology, Department of Medicine, McGill University and the McGill University Health Centre, Montreal, QC, ³Faculty of Medicine, McGill University, Montreal, QC, ⁴Division of Experimental Medicine, McGill University Health Centre, Montreal, QC

Introduction: Atopic dermatitis (AD) is a chronic inflammatory skin disease requiring effective patient education for optimal treatment adherence. Large language model (LLM) chatbots offer potential for improving patient understanding, but their performance in addressing AD-related questions and adherence to dermatology guidelines remains unclear.

Methods, Results: Using Google Trends (2021–2023), the most common AD treatment queries were identified and input into four chatbots: ChatGPT 3.5 (OpenAI), Perplexity (Perplexity.AI), Chatsonic (Writesonic), and Bing AI (Microsoft). Responses were evaluated by physicians for information quality (modified DISCERN score) and accuracy (Likert misinformation scale). Patient understandability was assessed using the Patient Education Materials Assessment Tool (PEMAT) by two medical students. Skin of color (SOC) inclusivity in responses was documented. Chatbot treatment recommendations were compared with the AAD 2024 and 2014 guidelines.

Among 66 prompts, chatbot responses demonstrated good information quality (median DISCERN: 4.0 [3.0, 4.5]) and minimal misinformation (median Likert: 1.0 [1.0, 1.0]). Patient understandability was moderate (PEMAT: 58.3% [50.0, 71.5]). Only Perplexity addressed SOC (24.0%, 6/25 responses). Agreement with AAD guidelines was found in 39/66 responses, with variable adherence across chatbots: ChatGPT (10/15), Perplexity (12/17), Chatsonic (8/19), Bing AI (9/15).

While chatbots correctly addressed many guideline-supported recommendations, some responses included advice unsupported by the AAD guidelines in treatment management, alternative and home care therapies. For instance, recommending oral antihistamines to any patient, specific cosmetic brands, specialized clothing fabrics, specific dietary changes, medicated shampoos, or encouraging self-desensitization techniques.

Conclusions: Despite generally good quality information, chatbots showed moderate understandability on a patient perspective and occasional misalignment with current AAD guidelines. The lack of SOC-sensitive responses highlights a need for greater inclusivity and equity in chatbot conception and training.

Learning Objectives

Takeaway Message

Chatbots provided generally good quality information. However, moderate understanding from a patient perspective was reported with occasional misalignment of current AAD guidelines. Ongoing updates are crucial to improve the medical reliability of treatment recommendations, and patients should remain aware of potential flaws in chatbot-generated medical advice.

Efficacy and Safety of Dual Biologic Therapy in Patients with Inflammatory Skin Diseases: A Systematic Review

Eric P. McMullen¹, David Croitoru^1,2,3,4, Cathryn Sibbald^1,5, Ronald Vender^6,7,8, Shanti Mehta², Dea Metko⁶, Grace Xiong⁶, Parsa Abdi⁹, Abu Bakar Butt¹⁰, Usman Kahloon¹¹, Vincent Piguet^1,4

¹Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, ²Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ³Division of Dermatology, University Health Network, Toronto Western Hospital, Toronto, ON, ⁴Division of Dermatology, Department of Medicine, Women’s College Hospital, Toronto, ON, ⁵Division of Dermatology, Department of Paediatrics, Toronto, ON, ⁶Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, ⁷Division of Dermatology, Department of Medicine, McMaster University, Hamilton, ON, ⁸Dermatrials Research Inc. & Venderm Consulting Inc., Hamilton, ON, ⁹Faculty of Medicine, Memorial University of Newfoundland, St. John’s, NL, ¹⁰School of Health, University of Waterloo, Waterloo, ON, ¹¹School of Epidemiology and Public Health, Faculty of Medicine, Ottawa, ON

Introduction: Dual biologic therapy, involving concurrent administration of two biologic agents, has been increasingly explored as a potential therapeutic avenue for refractory cases and comorbid inflammatory conditions. Herein, we synthesize and critically appraise the literature on dual biologic therapy in inflammatory skin diseases.

Methods, Results: We searched MEDLINE, Embase, CENTRAL, Web of Science, and Scopus from inception to March 2024 for studies reporting safety and efficacy of dual biologic therapy in inflammatory skin diseases. We identified 40 studies reporting on 106 patients (Table 1). The most frequently studied biologic combination was omalizumab and rituximab, primarily for refractory bullous pemphigoid (25.7%), followed by omalizumab and secukinumab for refractory CSU and psoriasis (16.5%). On average, patients had previously failed 1.3 topical therapies, 2.4 non-biologic systemics, and 2.1 biologic monotherapies prior to initiating dual biologic therapy. All patients initially responded to dual biologic therapy. The most commonly treated inflammatory skin conditions were CSU (35.8%), bullous pemphigoid (28.3%), psoriasis (23.6%), and atopic dermatitis (9.4%). Thirty-two patients (30.2%) began dual biologic therapy due to inadequate response to biologic monotherapy. Other patients had comorbid inflammatory conditions requiring dual biologics, including skin disease (35.8%) and non-dermatologic disease (34.0%). Most patients (78.3%) reported no adverse events during dual biologic therapy, with an average follow-up duration of 14.7 months (range: 1–62). Among adverse events, 10.4% involved non-life-threatening infections, such as herpes zoster and fungal or bacterial skin infections. Four patients experienced a loss of response and one patient with bacterial sepsis died. Infections were reported in nine patients and associated with ustekinumab or TNF-inhibitors (66.7%, n=6/9, each).

Conclusions: We highlight the initial clinical response and relative safety of dual biologic therapy in inflammatory skin diseases. Despite these promising findings, current evidence is limited by small sample sizes and potential publication bias. Future well-built studies are needed.

Learning Objectives

Takeaway Message

We highlight the initial clinical response and relative safety of dual biologic therapy in inflammatory skin diseases. Despite these promising findings, current evidence is limited by small sample sizes and potential publication bias. Future well-built studies are needed.

Combination of Carbon Dioxide (CO2) Laser and Triamcinolone Acetonide for Keloid and Hypertrophic Scar Treatment: A Systematic Review

Miranda K. Branyiczky¹, Dea Metko¹, Jeffrey T.S. Hsu^2,3, Monica K. Li^4,5

¹Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, ²Oak Dermatology, Itasca, IL, ³Department of Dermatology, University of Illinois, Chicago, IL, ⁴Department of Dermatology & Skin Science, University of British Columbia, Vancouver, BC, ⁵Vancouver Skin MD, Vancouver, BC

Introduction: Keloids and hypertrophic scars (HTS) are pathological wound healing sequelae that can cause pain, pruritus, and cosmetic concerns, significantly impacting quality of life. Intralesional (IL) corticosteroid therapy, such as triamcinolone acetonide (TAC), is a first-line treatment, however rarely achieves complete resolution, with high recurrence rates. Carbon dioxide (CO2) lasers, by creating microablative columns of injury, not only stimulate collagen remodeling but may also enhance drug delivery. This review examines the efficacy and safety of CO2 laser-assisted TAC (CO2-TAC) for keloids and HTS.

Methods, Results: A systematic search of Embase and MEDLINE until November 2024 identified 156 records, with 17 studies, including 480 patients, meeting inclusion criteria. Patients were aged 2–72 years and scars persisted for 6 months to 30 years, primarily located on the head/neck (37.7%), trunk (36.6%), and extremities (26.3%). Combination therapy involved an average of 5 sessions, with TAC (10–40 mg/mL) delivered intralesionally (64.0%) or topically (36.3%) post-laser.

Treatment outcomes included improved appearance (42.1%), texture (51.4%), pigmentation (31.7%), and size reduction (52.4%). One RCT showed significantly greater volume reduction with CO2-TAC compared to IL-TAC alone (86.5% vs. 59.1%, p=0.016). TAC administration route may influence outcomes, with topical application potentially reducing steroid-related AEs through even distribution. Adverse effects (AE) occurred in 33.1% of cases, including recurrence (4.6%), pigmentation changes (3.8%), and telangiectasias (1.9%), lower than reported AE rates for TAC monotherapy.

Conclusions: CO2-TAC is a promising combination therapy for keloids and HTS, offering more rapid and robust responses, with fewer AEs compared to either monotherapy. The combination leverages the anti-inflammatory and collagen-modulating effects of TAC with the wound-healing stimulation provided by CO2 lasers. Future RCTs are needed to optimize treatment protocols and compare CO2-TAC with other treatment modalities.

Learning Objectives

Takeaway Message

Carbon dioxide laser-assisted triamcinolone acetonide delivery (CO2-TAC) is a highly effective treatment for keloids and hypertrophic scars, offering superior outcomes with fewer adverse effects compared to each monotherapy. By combining the wound-healing stimulation of CO2 lasers with the anti-inflammatory effects of TAC, this therapy has demonstrated improvements in scar appearance, texture, and size, making it a valuable option for managing keloids and hypertrophic scars and improving quality of life.

Erosive Lichen Planus Treated with Tofacitinib: A Case Series of 23 Patients

Vera Y. Miao^1,2, Miranda K. Branyiczky³, Rebecca B. Saunderson^1,2, Gayle Fischer^1,2

¹Department of Dermatology, Royal North Shore Hospital, St Leonards, Sydney, Australia, ²Northern Clinical School, University of Sydney, Sydney, Australia, ³Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON

Introduction: Erosive lichen planus (ELP) is a chronic inflammatory dermatosis affecting mucosal sites, including the vulvovaginal area (EVLP). EVLP can cause persistent symptoms, scarring, reduced quality of life (QoL), and impaired sexual function. Up to 40% of EVLP cases are refractory to topical steroids, requiring systemic immunosuppressive agents, with variable efficacy and significant side effects. Emerging evidence implicates the Janus kinase (JAK)-signal transducer and activator of transcription pathway in ELP pathogenesis, with tofacitinib, a JAK1/3 inhibitor, showing promise in case reports.

Methods, Results: A retrospective observational study of 23 adult women with EVLP, treated with oral tofacitinib 5mg twice daily, was conducted at a vulvovaginal subspecialty clinic. Patients were followed for a mean duration of 5.7 years. Disease severity was assessed using a 5-point Physician Global Assessment (PGA) and patient-reported Vulvar Quality of Life Index (VQLI).

The mean age at diagnosis was 48.4 years, with an average disease duration of 9.1 years. PGA improvement was achieved in 65.2% of patients, 13.0% by two categories and 52.2% by one category. Symptomatic improvement occurred after a mean duration of 3.7 months. All patients with concurrent oral/oesophageal ELP achieved complete resolution within 6.3 months. Mean VQLI score improvement was 11.6 points. Domain-specific improvements included "symptoms" (94.1%), "feelings" (82.3%), and "activities" (64.7%). Those with dyspareunia (57.1%) were able to resume sexual intercourse pain-free. Mild adverse effects, including elevated lipids, gastrointestinal upset, and herpes zoster, occurred in 47.8% of patients. One patient developed breast cancer during follow-up.

Conclusions: Tofacitinib demonstrated efficacy in refractory ELP, particularly for oral and esophageal disease, with significant QoL improvements. EVLP showed greater treatment resistance, potentially reflecting higher disease severity. Adverse effects were manageable, and patient satisfaction was high. These findings align with prior reports, however larger, controlled trials are warranted to confirm tofacitinib’s role in ELP management.

Learning Objectives

Takeaway Message

This study highlights the potential of tofacitinib as an effective systemic therapy for refractory ELP, especially with oral and esophageal involvement. While vulvovaginal ELP (EVLP) demonstrated greater treatment resistance, tofacitinib provided notable symptomatic relief and quality-of-life improvements in most patients. Adverse effects were generally mild and manageable, and patients expressed high satisfaction with treatment outcomes. These findings align with existing case reports and suggest tofacitinib as a promising option for refractory ELP, underscoring the need for larger, controlled trials to further validate its efficacy and safety profile.

Clinical Characteristics and Treatment Outcomes of Reported Cases of Non-Cutaneous Melanomas: A Systematic Review

Edgar Akuffo-Addo¹, Sinthiha Krishnan², Ennie Olajide², Eunice Aluko², Lea Saroufim³, Ezekiel Garuba², Nana Efia Acquah², Katya Peri³, Angel Osei⁴, Robin Olaonipekun⁵, Ebenezer Oladogba¹, Ilya Mukovozov^6,7

¹Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, ²Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ³Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, ⁴Faculty of Art and Science, University of Toronto, Toronto, ON, ⁵Royal College of Surgeons in Ireland, Dublin, Ireland, ⁶Toronto Dermatology Centre, Toronto, ON, ⁷Division of Dermatology, Department of Medicine, Women’s College Hospital, Toronto, ON

Introduction: Melanomas, malignant melanocytic tumors, commonly arise on the skin but occasionally in uvea or mucosal surfaces. Due to their concealed locations and nonspecific symptoms, these melanomas are often diagnosed at advanced stages. This systematic review consolidates findings on the clinical features and treatment outcomes of non-cutaneous melanoma.

Methods, Results: Following PRISMA guidelines and a search on MEDLINE and Embase databases using predefined search terms, studies describing uveal or mucosal melanomas, interventions, and outcomes like recurrence or mortality were included.

Ultimately, 71 studies comprising 88 cases were included. The cohort included 44 males and 44 females, with a mean age of 58.9 years. Ethnicity data indicated 44% White, 16% Asian, 2% Black, and 38% unreported. Ocular melanomas were the most common, 64% of cases, particularly in the conjunctiva (34%) and iris (19%). Oral cavity melanomas accounted for 13%, primarily involving the gingiva (6%) and palate (5%). Genitourinary melanomas (15%) predominantly affected the vulva (11%), while anorectal melanomas (6%) involved the anal canal (5%). Only one case of nasal melanoma was reported. Clinical presentations varied by site. Ocular melanomas commonly presented with vision changes or pigmented masses. Oral melanomas appeared as pigmented patches or painful lesions. Genitourinary melanomas presented with pruritus, bleeding, or pain, and anorectal melanomas with rectal bleeding or bowel changes.

AJCC staging revealed 22%–50% of cases, depending on the anatomical site were Stage IV at diagnosis, reflecting advanced disease. Surgery was the primary treatment, particularly for ocular and oral melanomas. Combined therapies, including radiation or systemic treatments, were used for advanced cases. Recurrence rates were highest for genitourinary melanomas, with associated distant metastases and mortality.

Conclusions: Non-cutaneous melanomas are rare, aggressive, and associated with poor outcomes. Larger studies are needed to better understand their epidemiology and treatment outcomes.

Learning Objectives

Takeaway Message

Non-cutaneous melanomas are rare and aggressive, necessitating early detection and tailored therapeutic strategies to improve outcomes.

Laser-Based Treatments for Lichen Planus Pigmentosus and Erythema Dyschromicum Perstans in Skin of Colour: A Systematic Review

Nawar Tarafdar¹, Harry Chaocheng Liu²

¹Schulich School of Medicine and Dentistry, Western University, London, ON, ²Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC

Introduction: Lichen planus pigmentosus (LPP) and erythema dyschromicum perstans (EDP) are dermal pigmentary disorders primarily affecting patients with darker skin tones. These conditions pose treatment challenges because of the risk of post-inflammatory hyperpigmentation (PIH) and the limited guidance on safe, effective laser parameters.

Methods, Results: Medline, Embase, and CINAHL were searched to December 10, 2024 to identify studies reporting treatment outcomes of laser therapy for LPP or EDP. Two reviewers screened references and assessed methodological quality using the Oxford Centre for Evidence-Based Medicine guidelines. Fourteen articles (n=56 patients; 82.1% female) met inclusion criteria. Q-switched (QS) Nd:YAG (1064 nm) was most frequently used (n=40), delivered at a mean fluence of 3.1 J/cm² with 5.65 mm spot size over six sessions, achieving partial-to-complete improvement in 90% of patients. Fractional Erbium (1550 nm) therapy, employed in nine EDP patients (mean five sessions, fluence 15 mJ/microbeam, ~16% coverage, eight passes), yielded limited benefit. One LPP patient received combined QS Nd:YAG (1.0–1.5 J/cm²) plus fractional Erbium (15–20 mJ/cm²) and achieved complete clearance. Picosecond Nd:YAG was associated with 75–90% pigment clearance in all treated patients (n=2, 1064 nm mode, 200 mJ, average spot size 6 mm), while fractional ablative CO₂ (10,600 nm; mean pulse energy 5.8 mJ, 5-6 sessions) led to partial-to-complete clearance in two LPP patients. Topical therapies such as tacrolimus, hydroquinone, and corticosteroids were frequently used adjunctively or prior to laser sessions to enhance treatment response and minimize PIH. Adverse events were minimal with primarily transient hyperpigmentation, though one case of koebnerized vitiligo occurred with a QS Nd:YAG fluence increase.

Conclusions: Multiple laser modalities can achieve pigment clearance in LPP and EDP when used with tailored parameter selection and appropriate adjunctive topical therapies. Larger, long-term studies are required to define optimal laser settings, combination treatment protocols, and their clinical efficacy.

Learning Objectives

Takeaway Message

Although published data are limited by small sample sizes and variable study designs, available evidence suggests that conservative, individualized use of Q-switched (QS) Nd:YAG, picosecond Nd:YAG, fractional lasers, and adjunctive topicals can yield meaningful pigment clearance in LPP and EDP. Tailored parameter selection, multimodal treatment approaches, and vigilance for post-laser hyperpigmentation in skin of colour remains critical.

Retrospective Review of Canadian Pediatric HS Patients at a Multidisciplinary Clinic

Serena Dienes¹, Arya Rahmani², Irene Lara-Corrales³, Rebecca Levy³, Raed Alhusayen^4,5, Amy Barnett, David Croitoru^4,6,7, Ralph George⁸, Jill Hamilton⁹, Kirsti Johnson¹⁰, Marissa Joseph^3,4,7, Latoya Palmer¹¹, Reza Mirza¹², Nimrita Sangha¹³, Carmen Liy Wong¹⁴

¹Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ²School of Medicine, Queen’s University, Kingston, ON, ³Division of Dermatology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, ⁴Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, ⁵Sunnybrook Research Institute, Toronto, ON, ⁶Division of Dermatology, Toronto Western Hospital, Toronto, ON, ⁷Division of Dermatology, Women’s College Hospital, Toronto, ON, ⁸Department of Surgery, University of Toronto, Toronto, ON, ⁹Division of Endocrinology, The Hospital for Sick Children, Toronto, ON, ¹⁰Department of Nursing, The Hospital for Sick Children, Toronto, ON, ¹¹Hidradenitis and Me Support Group, Toronto, ON, ¹²Division of Rheumatology, Department of Medicine, McMaster University, Hamilton, ON, ¹³Department of Social Work, The Hospital for Sick Children, Toronto, ON, ¹⁴Department of Pediatrics, Division of Dermatology and Rheumatology, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON

Introduction: Hidradenitis suppurativa (HS) is a common and highly comorbid condition that is understudied in pediatric populations, despite roughly 30% of patients experiencing symptoms before the age of 18. Furthermore, Canadians are inadequately represented in HS research, limiting our evaluation of care in real-world settings and patient experiences in Canada.

Methods, Results: We developed the infrastructure for a Canada-wide HS registry and piloted it at a single-centre pediatric HS clinic. Patients required an established HS diagnosis and a trial of antibiotics to be seen. They were assessed by a multidisciplinary team, underwent comprehensive comorbidity screening, and completed validated quality of life (QOL) and mental health questionnaires. We performed an REB-approved retrospective review of patients seen to date, using data collection forms (DCF) developed for the registry. Consent was waived for retrospective DCF piloting. Data was stored on a secure REDCap database.

In total, 39 patients were included. Mean age was 15.6±1.9 years, 53.8% were female, and most (60.5%) were Hurley stage II. Mean age of symptom onset and time to diagnosis were 10.9±3.4 years and 2.1±2.0 years, respectively. Mean BMI was 31.6±9.0 kg/m². Common comorbidities included obesity (57.9%), acne (30.7%), and trisomy 21 (23.1%). 20.5% had a family history of HS, with 62.5% of these being a 1^st degree relative. Remaining characteristics and treatment recommendations are presented in Table 1. 21.6% and 22.2% reported depression and anxiety scores of moderate or greater severity, respectively. 56.8% reported moderate-to-severe QOL impact. Bullying was reported in 17.6% of patients.

Conclusions: Our preliminary analysis reveals distinct demographic characteristics in Canadian pediatric HS. Notable findings include Asian-predominant ethnicity, near-equal gender distribution, and higher prevalence of trisomy 21 and developmental delay. Continued prospective data collection with these DCFs will enhance our understanding of the Canadian pediatric HS landscape.

Learning Objectives

Takeaway Message

Canadian pediatric HS patients show unique demographic patterns and comorbidity profiles, with a high psychosocial burden, highlighting the importance of comprehensive multidisciplinary care.

A Case Report of Successful Treatment of Keratoderma Secondary to Severe Plantar Psoriasiform Dermatitis with Roflumilast Cream

Victoria Young¹, Khalad Maliyar², Jessica Asgarpour²

¹Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ²Division of Dermatology, University of Toronto, Toronto, ON

Introduction: We present a case study of Psoriasiform dermatitis (PSD), an inflammatory dermatosis that exhibits clinical and histological features of psoriasis and dermatitis, involving both TH1 and TH2 immune pathways. Severe cases complicated by keratoderma are challenging to treat, particularly when systemic therapies are contraindicated due to comorbidities. Roflumilast 0.3% cream, a topical phosphodiesterase-4 inhibitor, has demonstrated efficacy in psoriasis and dermatitis but has not been studied for PSD with keratoderma.

Methods, Results: A 57-year-old male presented with prolonged history of extensive hyperkeratotic plantar plaques and excoriated eczematous plaques covering approximately 50% of his body surface area. His medical history included dyslipidemia, alcohol use disorder, and non-alcoholic fatty liver disease, precluding the use of systemic treatments such as Methotrexate and Acitretin due to hepatotoxicity risk. Initial treatments, including topical corticosteroids, oral antihistamines and narrowband UVB phototherapy, were ineffective and ultimately disease was refractory. Histopathological analysis confirmed spongiotic psoriasiform dermatitis. Given the refractory nature of the condition and the patient’s contraindications to systemic therapy, the patient was enrolled for Dupilumab and while awaiting approval was prescribed Roflumilast 0.3% cream off-label for once-daily application. He was initially non-compliant, however with four months of rigorous use, at a ten-month follow-up the patient showed a 90% reduction in plantar keratoderma and clearance of body eruption. He reported no adverse effects, and clearance was maintained with use of Roflumilast. Dupilumab application was cancelled.

Conclusions: This case highlights the successful off-label use of Roflumilast cream for PSD complicated by severe keratoderma. By modulating both TH1 and TH2 pathways, Roflumilast was effective in penetrating thick keratoderma plaques and reducing inflammation while avoiding systemic risks. Its favorable safety profile, tolerability, and cost-effectiveness compared to biologics suggest its potential as a viable treatment option for PSD. Further studies are warranted to evaluate Roflumilast’s efficacy in inflammatory dermatoses and role in managing refractory cases.

Learning Objectives

Takeaway Message

This case demonstrates the effective off-label treatment of Psoriasiform Dermatitis (PSD) exacerbated by severe keratoderma with topical phosphodiesterase-4 inhibitor Roflumilast 0.3% cream. Treatment for PSD, an inflammatory dermatosis that has characteristics of psoriasis and dermatitis, can be difficult, especially when systemic medications are contraindicated due to comorbidities.

In this case, Roflumilast cream significantly improved a stubborn case of widespread eczematous eruptions and substantial hyperkeratotic plantar plaques. The patient saw a 90% decrease in plantar keratoderma at a 10 month follow up following four months of regular use; without any negative side effects. This outcome underscores the efficacy of Roflumilast cream in penetrating thick keratoderma plaques, altering TH1 and TH2 pathways, and reducing inflammation without the risks of systemic therapy. The importance of patient compliance in attaining treatment effectiveness and preserving disease management is further highlighted by this case.

Further research is necessary to validate Roflumilast’s effectiveness in treating PSD and other inflammatory dermatoses, especially for individuals with complicated presentations or those who are not candidates for systemic therapy. The potential of novel topical medicines to increase therapy options for difficult dermatological disorders is demonstrated by this case.

Idiopathic Pyostomatitis-Pyodermatitis Vegetans with Nasal Obstruction: A Case Report

Talia M. Katz¹, Arnon M. Katz²

¹University of Toronto, Toronto, ON, ²Dixon Dermatology Centre, Newmarket, ON

Introduction: Pyostomatitis-pyodermatitis vegetans is a rare mucocutaneous dermatosis of unknown etiology. It is characterized by erythematous pustules that coalesce into exudative, vegetative plaques on the oral mucosa and/or skin. Diagnosis is primarily clinical but is supported by histopathological findings. Pyostomatitis-pyodermatitis vegetans is often associated with underlying conditions such as inflammatory bowel disease, liver dysfunction, and others.

Methods, Results: We present the case of a 48-year-old male with erythematous, eroded plaques involving the nares and upper lip. Histopathological evaluation revealed a dense mixed inflammatory infiltrate with pronounced peripheral eosinophilia. Notably, the patient had no history of inflammatory bowel disease or other systemic conditions. Systemic corticosteroids were helpful in clearing mucocutaneous lesions, although this effect was only sustained at high doses.

Conclusions: Pyostomatitis-pyodermatitis vegetans is a rarely reported condition in the medical literature, and its nosology remains debated. Some authors regard it as a mucosal variant of pyoderma gangrenosum, which shares an association with inflammatory bowel disease. However, as illustrated in this case, pyostomatitis-pyodermatitis vegetans may occur without identifiable systemic comorbidities, and skin lesions can precede the development of inflammatory bowel disease. Because of the rarity of this dermatosis, there are no evidence-based treatment algorithms. Systemic corticosteroids are generally considered effective first-line therapy, but relapse during tapering or withdrawal of medication is likely. As demonstrated here, patients may require long-term suppressive therapy and steroid-sparing agents should be preferred. Further studies are needed to clarify the pathogenesis and optimal management strategies for pyostomatitis-pyodermatitis vegetans.

Learning Objectives

Takeaway Message

Pyostomatitis-pyodermatitis vegetans is a rare mucocutaneous dermatosis that may occur independently of systemic conditions like inflammatory bowel disease. Effective management often requires systemic corticosteroids, but long-term remission may necessitate steroid-sparing agents to prevent relapse and reduce adverse effects.

Comorbidities of Rosacea: A Systematic Review and Meta-Analysis of Case Control Studies

Ryan S.Q. Geng¹, Samiha Mohsen¹, Jihad Waked², Kaitlyn Ramsay¹, Cathryn Sibbald³

¹University of Toronto, Toronto, ON, ²Western University, London, ON, ³The Hospital for Sick Children, Toronto, ON

Introduction: Rosacea is a highly prevalent chronic inflammatory skin disease. However, the association between rosacea and its comorbidities have not been comprehensively analyzed. This systematic review and meta-analysis was conducted to provide a comprehensive overview of comorbidities associated with rosacea and assess the potential for an underlying systemic inflammatory component of disease.

Methods, Results: Following PRISMA guidelines, Medline and Embase were searched from inception to October 2024. Original case-control studies reporting on comorbidities of rosacea in comparison to healthy controls were included after duplicate screening of titles, abstracts and full-text. Data was extracted and quality assessed independently by 2 reviewers. Restricted maximum likelihood with random-effects model was used for meta-analysis. The main outcome was odds ratios of comorbidities reported in rosacea patients compared to healthy controls.

Of the 282 articles initially identified, 30 were included, comprising a sample size of 31.8 million. Of particular note was the association of rosacea with cutaneous malignancies, including actinic keratoses (OR 4.53; CI 2.97-6.96), melanoma (OR 1.68; CI 0.39-7.39) and non-melanoma skin cancer (OR 1.45; CI 0.81-2.59). Rosacea was also associated with several autoimmune diseases including systemic sclerosis (OR 8.50; CI 1.97-36.97), Grave’s disease (OR 5.42; CI 3.42-8.67) and Crohn’s disease (OR 3.78; CI 1.86-7.69), and other systemic diseases including cardiovascular (OR 1.48; CI 1.06-2.08) and metabolic disease (OR 2.89; CI 2.01-4.14). The highest psychiatric associations were reported for anxiety (OR 3.97; CI 0.86-18.36) and depression (OR 2.83; CI 1.02-7.85).

Conclusions: This systematic review and meta-analysis provides a comprehensive overview of comorbidities associated with rosacea, suggesting that the current view of rosacea being primarily a cutaneous cosmetic concern is too limited in scope and supports rosacea as a disease with an underlying systemic inflammatory component with negative impacts in both mental and physical health domains.

Learning Objectives

Takeaway Message

Rosacea is highly associated with cutaneous malignancies, autoimmune diseases, metabolic and cardiovascular disease. Rosacea should no longer be viewed as primarily a cutaneous cosmetic concern, as there may be an underlying systemic inflammatory component with negative impacts in both mental and physical health domains.

Renal Safety of Biologic and Systemic Therapies for Psoriasis: A Systematic Review

Ryan S.Q. Geng¹, Siddhartha Sood¹, Jihad Waked², Nabil Merchant³, Jensen Yeung^1,4,5,6, Asfandyar Mufti^1,4

¹University of Toronto, Toronto, ON, ²Western University, London, ON, ³Royal College of Surgeons in Ireland, Dublin, Ireland, ⁴Sunnybrook Health Sciences Centre, Toronto, ON, ⁵Women’s College Hospital, Toronto, ON, ⁶Probity Medical Research, Waterloo, ON

Introduction: Psoriasis is a chronic inflammatory disease, with current American Academy of Dermatology–National Psoriasis Foundation guidelines recognizing chronic kidney disease (CKD) as a common comorbidity. Despite increasing use of biologics and non-biologic systemic therapies for moderate-to-severe psoriasis, data remains limited regarding the renal safety of these therapies. This systematic review investigates evidence regarding the impact of biologics and conventional systemic therapies on estimated glomerular filtration rate (eGFR).

Methods, Results: Following PRISMA guidelines, MEDLINE and Embase databases were searched using specific keywords. Changes in eGFR were pooled for each treatment, weighted by sample size. Articles were independently screened by 2 reviewers, resulting in 20 articles, encompassing 1,914 patients and 2,108 treatments. CKD was present in 73.1% (1399/1914) patients and normal renal function in 26.9% (515/1914). Data was analyzed with descriptive statistics and unpaired t-tests, with significance level of p<0.05.

Impact of biologics on renal function was reported in 42.0% (886/2108) of cases, with a mean -1.8% change in eGFR over a mean treatment duration of 579.7 days (-1.1%/year). The greatest decreases in eGFR were reported with ustekinumab (-2.1%, n=271; mean duration: 671.8 days), adalimumab (-2.1%, n=163; mean duration: 587.1 days), and golimumab (-3.0%, n=105; mean duration: 730.0 days).

Impact of conventional systemics on renal function was reported in 58.0% (1222/2108) of cases, with an overall mean -5.6% change in eGFR over a mean treatment duration of 625.9 days (-3.3%/year). The greatest decreases in eGFR were reported with cyclosporine (-8.4%, n=577; mean duration: 558.1 days), acitretin (-2.0%, n=256; mean duration: 730.0 days), and methotrexate (-1.6%, n=389; mean duration: 657.9 days).

Conclusions: Biologic therapy in psoriasis patients exhibited 3-fold lower declines in eGFR compared to conventional systemic therapies (-1.1%/year vs -3.3%/year, p<0.0001), approximating the -1%/year eGFR decline observed in the general population beginning in the third decade of life.

Learning Objectives

Takeaway Message

Biologic therapy demonstrates enhanced renal safety in psoriasis patients compared to conventional systemic therapies, approximating the -1%/year eGFR decline observed in the general population beginning in the third decade of life.

Comorbidities of Prurigo Nodularis: A Systematic Review

Ryan S.Q. Geng¹, Siddhartha Sood¹, Jihad Waked², Martin Heung³, Khalad Maliyar¹, Muskaan Sachdeva¹, Abrahim Abduelmula¹, Jensen Yeung^1,4,5,6, Asfandyar Mufti^1,4

¹University of Toronto, Toronto, ON, ²Western University, London, ON, ³McMaster University, Hamilton, ON, ⁴Sunnybrook Health Sciences Centre, Toronto, ON, ⁵Women’s College Hospital, Toronto, ON, ⁶Probity Medical Research, Waterloo, ON

Introduction: Prurigo nodularis (PN) is a chronic immune-mediated skin disease characterized by intensely pruritic indurated nodules. Despite the importance of comorbidities on treatment selection, treatment response and influencing disease burden and mortality, comprehensive data on comorbidities in PN is lacking.

Methods, Results: Following PRISMA guidelines, MEDLINE and Embase databases were searched with specific keywords. Articles were independently screened by 2 reviewers, resulting in 15 case-control studies, consisting of a sample size of 83.6 million. For articles reporting the same comorbidity within the same population and time frame, only the article with the largest sample size was included to prevent duplication. Odds ratios (OR) and 95% confidence intervals (CI) were calculated.

The comorbidities with the highest ORs by category were: malignancy (ovarian cancer [OR 18.4; CI 4.6-73.8; n=4,950,139]), infectious (HIV [OR 18.5; CI 17.2-19.9; n=81,499,136]), psychiatric (neurotic excoriation [OR 74.3; CI 23.5-234.5; n=23,690]), cardiovascular (phlebitis [OR 15.9; CI 10.7-23.4; n=4,950,139]), dermatologic (atopic dermatitis [OR 16.7; CI 16.2-17.3; n=7,173,726]), rheumatologic (vasculitis [OR 13.1; CI 9.5-18.1; n=4,950,139]), neurologic (ulnar nerve entrapment [OR 13.3; CI 13.3-34.7; n=4,950,139]), endocrine (osteoarthritis [OR 10.4; CI 9.0-12.1; n=4,674,593]), gastrointestinal/hepatobiliary (inflammatory bowel disease [OR 4.0; CI 3.6-4.4; n=6,680,596]), metabolic (type II diabetes mellitus [OR 3.2; CI 3.1-3.3; n=7,378,476]), ophthalmic (allergic conjunctivitis [OR 2.5; CI 1.8-3.4; n=17,955]), respiratory (chronic obstructive pulmonary disease [OR 3.3; CI 3.1-3.4; n=7,145,218]), hematologic (amyloidosis [OR 23.9; CI 13.5-42.4; n=4,950,139]), otorhinolaryngology (allergic rhinitis [OR 1.2; CI 1.1-1.3; n=2,023,958]) and renal (chronic kidney disease [OR 4.5; CI 4.3-4.8; n=7,425,582]).

Conclusions: PN was highly comorbid with similarly Th2-driven dermatoses but many associated systemic inflammatory conditions were primarily Th1-driven. Given the high association of PN with HIV, screening should be considered when risk factors are present, and appropriate management considerations should be made in the context of therapy choice and prevention of secondary infectious sequelae associated with excoriations.

Learning Objectives

Takeaway Message

Prurigo nodularis was highly comorbid with similarly Th2-driven dermatoses (e.g. atopic dermatitis), but many associated systemic inflammatory conditions were primarily Th1-driven (e.g. inflammatory bowel disease, vasculitis, rheumatoid arthritis). HIV screening in prurigo nodularis patients with risk factors may be warranted.

Phototherapy for Cutaneous Mastocytosis: A Systematic Review

Aliyah King¹, Steven J. Glassman^2,3

¹Faculty of Medicine, University of Ottawa, Ottawa, ON, ²Division of Dermatology, University of Ottawa, Ottawa, ON, ³The Ottawa Hospital, Ottawa, ON

Introduction: Mastocytosis, a rare disorder of abnormal mast cell accumulation, manifests in cutaneous-limited (90%) or systemic forms. Phototherapy has been explored for cutaneous mastocytosis (CM), and this review evaluates its effectiveness for the treatment of mastocytosis-related lesions and pruritus.

Methods, Results: EMBASE, MEDLINE, and CENTRAL were searched through September 19th, 2024. Incomplete and non-English studies were excluded. Study quality was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation scale. Of 329 studies, 35 studies involving 199 CM patients were included. Phototherapy included oral psoralen plus ultraviolet-A (oPUVA; n=81; mean age 39.9), bath PUVA (n=10; mean age 42.2), topical PUVA (n=2; mean age 26.3), UVA-1 (n=64; mean age 32.4); narrow-band ultraviolet-B (NB-UVB; n=26; mean age 38.9), and other (n=24; mean age 30.4). oPUVA and UVA-1 had the most data, with oPUVA showing greater lesion improvement (+37.7%) despite a higher relapse rate (+43.3%). Pruritus improvement was similar, although oPUVA had higher relapse (+48%). When stratifying for adult patients with urticaria pigmentosa, similar results were found although pruritis improved greater with UVA-1. NB-UVB saw improvement in 10 (83.3%) patients with no relapse over 6 years. Eight patients with diffuse CM improved with no relapse over 6 years. Patients with telangiectasia macularis eruptive perstans saw improvement across phototherapy modalities, although one failed NB-UVB therapy. Among pediatric patients, oral PUVA (n=8) and NB-UVB (n=1) resulted in lesion and pruritus improvement with no relapse over 6 years. One pediatric diffuse CM patient relapsed at 20 months following topical PUVA. No major adverse events occurred except one basal cell carcinoma with an uncertain link to PUVA.

Conclusions: oPUVA appears most effective for lesions, although with higher relapse. Pruritus improvement was similar across treatments. The findings are limited by the small sample size and low-quality data. Further studies could clarify the role of phototherapy in CM.

Learning Objectives

Takeaway Message

Phototherapy, particularly oPUVA and UVA-1, have the potential to improve CM-related lesions and pruritus, though oPUVA appears to have higher relapse rates. Small sample sizes and limited data quality highlight the need for further studies to clarify the role of phototherapy in managing cutaneous mastocytosis.

Punch Excision Therapy for the Treatment of Keloids: A Systematic Review

Jia Qi Adam Bai¹, Chaocheng Liu²

¹University of Ottawa, Ottawa, ON, ²University of British Columbia, Vancouver, BC

Introduction: Keloids are thick and raised scars resulting from an abnormal fibrous-proliferative collagen response marked with elevated IL-6 and TGF-beta. Punch excision therapy is a simple, quick, and accessible treatment option for keloid management, but its efficacy and safety remain unclear. As a result, this systematic review aims to evaluate the efficacy of punch excision therapy as a novel treatment modality for keloids.

Methods, Results: MEDLINE, EMBASE, CENTRAL, and Scopus electronic databases were searched in June 2024 with two reviewers conducting screening, full-text review, and data extraction. Articles that examined punch excision therapy in patients with keloids were identified and included. Six studies (from 2012-2024) out of 229 screened studies including two randomized controlled trials, one cohort study, and three cases series were analyzed, assessing the efficacy of punch excision therapy as mono- or combination-therapy. Three studies reporting Vancouver Scar Scale (VSS) scores found a mean reduction of 70.1 (+/- 9.3)%. Moreover, one case series study (n=30) reported a 69.6% decrease in Patient and Observer Scar Assessment Scale (POSAS) 2.0 scores after punch excision therapy combined with triamcinolone acetonide injection. Keloid pliability and vascularity was found in a cohort study (n=16) to have decreased by 78.2% and 44.8%, respectively. Additionally, one randomized controlled trial (n=58) reported a reduction in keloid volume by 66.9% after punch excision therapy. Lastly, one case series (n=30) found reduction in pain (73.9%), itchiness (73.5%), color (56.2%), stiffness (68.0%), thickness (73.9%), and irregularity (71.1%) associated with the keloid. All six included studies reported substantial improvement in keloid characteristics after punch excision therapy.

Conclusions: Punch excision therapy shows promising efficacy for keloid improvement, being cost-effective and accessible. However, further comparative studies with standardized treatment protocols, measurement tools, and long-term follow-up are needed to fully understand its benefits and role in the comprehensive management of keloids.

Learning Objectives

Takeaway Message

Punch excision therapy is a revolutionary approach in keloid management, offering simplicity, accessibility, and cost-effectiveness. This systematic review synthesizes data from six studies demonstrating significant improvements in keloid characteristics after punch excision therapy, such as reduced volume, vascularity, and pliability. Notably, the treatment achieves optimal results when combined with intralesional steroid injections, harnessing anti-inflammatory effects to address the hyperactive fibroblasts essential to keloid formation.

Reductions in Vancouver Scar Scale and Patient and Observer Scar Assessment Scale 2.0 scores, along with diminished keloid-associated pain, stiffness, and aesthetic irregularities, highlight the efficacy of punch excision therapy. Importantly, adverse events were minimal, reinforcing its safety profile. While punch excision therapy minimizes scar tension by removing keloid cores, the use of intralesional steroids enhance therapeutic outcomes by targeting deep tissue collagen synthesis, significantly reducing recurrence rates.

This review highlights the need for long-term, comparative studies with standardized metrics to better refine this treatment’s role in comprehensive keloid care. Punch excision therapy, especially in combination with intralesional steroids, holds potential to redefine clinical practice, addressing the unmet needs of patients burdened by this challenging condition.

Association of Inpatient Prescribing of Sedating Antihistamines with Delirium in Older Adults: A Cross-Sectional Study

Alanna C. Bridgman¹, Mohammad A. Imrit², Surain B. Roberts^2,3, Mina Tadrous^4,5, Nathan M. Stall^1,6,7, Michael Fralick^1,6, Jennifer Watt^1,2,8,3, Amol A. Verma^1,2,8,3, Fahad Razak^1,2,8,3, Aaron M. Drucker^1,4,7

¹Department of Medicine, University of Toronto, Toronto, ON, ²Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, ³Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, ⁴Department of Medicine, Women’s College Hospital, Toronto, ON, ⁵Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, ⁶Division of General Internal Medicine and Geriatrics, Sinai Health, Toronto, ON, ⁷Research and Innovation Institute, Women’s College Hospital, Toronto, ON, ⁸Unity Health, Toronto, ON

Introduction: Sedating antihistamines are often inappropriately prescribed in the inpatient setting for non-specific itch or cutaneous drug eruptions. It is unclear whether sedating antihistamines cause clinically important delirium among older adult inpatients. Our objective was to estimate the association between physician prescribing of sedating antihistamines and delirium among older general medicine inpatients.

Methods, Results: This was a cross-sectional study using the GEMINI database of inpatient hospital admissions in patients aged 65 years and older between April 1, 2015, and March 31, 2022, across 17 hospitals in Ontario, Canada. We categorized inpatient attending physicians into quartiles of sedating antihistamine prescribing within each hospital site from low- to high-prescribers based on the proportion of their admissions with an antihistamine prescription. The primary outcome was inpatient delirium identified using a validated machine learning tool applied to inpatient medical records. We estimated the association between attending physicians’ sedating antihistamine prescribing rate and individual inpatients’ risk of delirium using multivariable mixed-effects logistic regression. Among 328,140 inpatient admissions to 755 physicians, 11,507 (3.5%) admissions included a sedating antihistamine prescription. Physicians in the lowest quartile prescribed a sedating antihistamine during 2.1% of admissions and physicians in the highest quartile prescribed sedating antihistamines during 5.4% of admissions. Delirium occurred in 32.3% of admissions to the lowest-prescribing quartile of physicians and 36.6% of the highest-prescribing quartile of physicians. Compared to patients admitted to physicians in the lowest quartile of sedating antihistamine prescribing, patients admitted to physicians in the highest quartile had 41% increased odds of delirium (aOR 1.41, 95% CI 1.28 - 1.56). In adjusted analyses, every 1% absolute increase in sedating antihistamine prescribing was associated with 8% increased odds of delirium (aOR 1.08, 95% CI 1.05 – 1.10).

Conclusions: Older adults admitted to physicians who prescribe sedating antihistamines more commonly were more likely to experience delirium in hospital.

Learning Objectives

Assess inpatient antihistamine prescribing as a risk factor for delirium in older adults admitted to general medical wards.

Takeaway Message

Older adults admitted to general medical wards are more likely to experience delirium if their attending physician more commonly prescribes sedating antihistamines; these medications should be used cautiously.

Use of Oral Antibiotics for Diabetic Foot Osteomyelitis: A Systematic Review

Siddhartha Sood¹, Ryan S.Q. Geng¹, Jihad Waked², Asfandyar Mufti^1,3, Aswen Sriranganathan⁴, Ronald G. Sibbald¹

¹University of Toronto, Toronto, ON, ²Western University, London, ON, ³Sunnybrook Health Sciences Center, Toronto, ON, ⁴University of Ottawa, Ottawa, ON

Introduction: The optimal treatment modality for diabetic foot osteomyelitis (DFO) remains unclear. The current guidelines from Diabetes Canada recommend the use of oral antibiotics and/or intravenous antibiotics with no preferred agent or route of administration. This report aimed to evaluate the current evidence surrounding oral antibiotic therapy for DFO.

Methods, Results: Following PRISMA guidelines, Embase and MEDLINE databases were searched for original articles written in English that reported efficacy and safety data on oral antibiotic use for this indication. Twenty-six unique studies were included encompassing 972 patients treated with oral antibiotics. The mean age was 64.6 years (range: 30-90 years).

When used as monotherapy, the complete resolution and partial resolution rate for oral antibiotic therapy were 75.2% (539/717) and 3.2% (23/717), respectively. When used as a step-down therapy after intravenous antibiotics, the complete and partial resolution rate for oral antibiotics were 56.5% (155/255) and 20.4% (52/255), respectively. No resolution of DFO resulting in refractory infection or amputation was observed in 155 (21.6%) cases of oral antibiotics monotherapy and 59 (23.1%) of step-down therapy. Recurrence rates for oral antibiotics monotherapy and step-down therapy were 5.4% (39/717) and 3.9% (10/255), respectively.

Conclusions: Oral antibiotic therapy demonstrates favorable outcomes in DFO comparable to intravenous treatment. Oral antibiotic therapy may be especially useful in low-resource settings where hospital beds are limited and in situations where patients require ambulation. Nonetheless, patients should be counselled on the vital importance of adherence and resource stewardship should be practiced by healthcare providers to avoid antibiotic resistance.

Learning Objectives

Takeaway Message

Oral antibiotic therapy demonstrates favorable outcomes in DFO comparable to intravenous treatment. Oral antibiotic therapy may be especially useful in low-resource settings where hospital beds are limited and in situations where patients require ambulation. Nonetheless, patients should be counselled on the vital importance of adherence and resource stewardship should be practiced by healthcare providers to avoid antibiotic resistance.

Efficacy of Oral Isotretinoin Combined with Topical Clascoterone Compared to Isotretinoin Monotherapy for Severe Acne Vulgaris: A Multi-Center Study

Grace Xiong¹, UYeong Choi¹, Dea Metko¹, Ajith Cy^2,3, Smith Pathayappura², Mohamed Bawazir², Mohannad Abu-Hilal²

¹Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, ²Division of Dermatology, McMaster University, Hamilton, ON, ³Alliance Clinical Trials and Probity Medical Research, Inc., Waterloo, ON

Introduction: Severe nodular acne often causes significant psychological distress and reduced quality of life. Topical clascoterone 1% cream, a novel anti-androgen with a favorable safety profile, may enhance the efficacy of oral isotretinoin, the current gold-standard therapy for severe nodular acne. This study aimed to compare the efficacy of oral isotretinoin monotherapy with isotretinoin in combination with topical clascoterone 1% cream twice daily.

Methods, Results: Since June 2023, patients with severe and/or nodular acne at several university-affiliated dermatology clinics were treated with oral isotretinoin, either alone or combined with clascoterone 1% cream applied to the face twice daily. In December 2024, records from these clinics were reviewed retrospectively. The analysis included patients aged 12 years and older with severe/nodular acne who received isotretinoin (0.5–0.8 mg/kg/day) with or without twice-daily clascoterone 1% cream for at least 24 weeks. Outcome measures were facial lesion count (FLC), Physician’s Global Assessment (PGA), and facial xerosis, all assessed at week 24. Eighty-two patients (44 monotherapy; 38 combination therapy) were included. The cohort was majorly female (57.3%) and had a mean age of 22 years. Both groups achieved significant FLC reductions at week 24 (p<0.001). Mean FLC count reduced from 29.1 to 4.4 in the monotherapy group and from 29.4 to 1.8 in the combination group. Significantly more patients in the combination group reached PGA 0/1 than in the isotretinoin monotherapy group (92.1% vs. 72.7%; p<0.05). Facial xerosis rates were lower in the combination group (84% vs. 91%), although this was not statistically significant.

Conclusions: Our study suggests that the addition of clascoterone 1% cream may enhance the efficacy of oral isotretinoin therapy without exacerbating adverse effects, offering a promising approach for managing severe/nodular acne. Further studies are needed to confirm these results and evaluate long-term effects.

Learning Objectives

Takeaway Message

Our study suggests that combination oral isotretinoin and topical clascoterone 1% cream has promising potential to enhance treatment efficacy for severe/nodular acne while reducing facial xerosis. This combination offers a practical approach to optimize therapeutic outcomes without introducing additional safety concerns, although further studies are needed to confirm its long-term effectiveness.

A Systematic Review of Cases of Clinical Mimickers of Cutaneous Melanoma in Skin of Colour

Shanti Mehta¹, Dea Metko², Eric P. McMullen³, Narachai Julanon^3,4, Kyobin Hwang¹, Edgar Akuffo-Addo³, Ronald Vender⁵

¹Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ²Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, ³Division of Dermatology, Department of Medicine, Toronto, ON, ⁴Division of Dermatology, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand, ⁵Division of Dermatology, Department of Medicine, McMaster University, Hamilton, ON

Introduction: Melanoma, the most lethal type of skin cancer, is more likely to be misdiagnosed in patients with skin of colour (SoC), contributing to delays in diagnosis, increased morbidity, and mortality. This systematic review investigates the misdiagnosis of melanoma in patients with SoC to identify gaps in care.

Methods, Results: We searched MEDLINE, Embase, Scopus, and Web of Science for English peer-reviewed studies on melanoma misdiagnosis in patients with SoC, defined as individuals from ethnoracial groups with darker skin tones. Misdiagnosis was defined as either an initial misdiagnosis of another condition or a final diagnosis differing from an initial melanoma diagnosis. Eleven studies (9 case reports, 2 case series) were included, with 12 patients (mean age 65.8 years), most of whom were female (66.7%) identified. Of the 10 patients diagnosed with melanoma, the most common location was the feet (80%), with onychomycosis being the most frequent initial misdiagnosis (40%). The final diagnoses included amelanotic melanoma (40%) and acral lentiginous melanoma (30%). The mean Breslow thickness at diagnosis was 4.03 mm, with a mean diagnostic delay of 13.1 months. Of those with follow-up, 66.7% had no recurrence, while 33.3% died.

Conclusions: Acral lentiginous melanoma was the most commonly misdiagnosed type in this cohort and is common in SoC. The significant diagnostic delay and advanced disease at diagnosis underscore the need for timely and accurate diagnosis. This highlights the need for greater clinical vigilance, particularly for lesions in atypical locations like the feet and nails. Misdiagnosis of melanoma in SoC is often due to underrecognition of its clinical features, including amelanotic and acral presentations, which are less familiar to clinicians. Clinician education on these presentations is crucial for improving outcomes. Additionally, implementing standardized diagnostic protocols could reduce delays and improve survival rates.

Learning Objectives

Takeaway Message

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis Disease: Insights from a Retrospective Chart Analysis

Julie Shatto, Pamela Mathura, Edsel Ing, Hajira Danial, Eunice Y. Chow

University of Alberta, Edmonton, AB

Introduction: Stevens-Johnson Syndrome and Toxic Epidermal necrolysis (SJS/TEN) are severe, life-threatening drug reactions that often result in long-term ocular and gynecological complications. While guidelines stress the importance of ophthalmologist and gynecologist involvement in managing these complications, care consistency, both during hospitalization and after discharge, varies. This study aims to identify care gaps and improve outcomes by characterizing SJS/TEN patients within a health zone, focusing on the prevalence of ocular and vulvovaginal involvement and access to specialist care.

Methods, Results: A longitudinal retrospective chart review of patients (N = 24) diagnosed with SJS/TEN disease in one health zone over four years (January 1, 2020 to Jan 31, 2024) was conducted. Descriptive statistics were used to (1) characterize patient demographics and ocular/vulvovaginal complications, (2) evaluate current practices and access to specialized care, and (3) assess post-discharge follow-up practices. Among the cohort, 54% had documented ocular involvement and 70% of female patients had reported vulvovaginal involvement. Of those with ocular involvement, 92% were seen by the ophthalmology service within a median of 1 day (range 0-2 days). Artificial tears, antibiotic drops, and steroid drops were the most common medical interventions for ocular SJS/TEN. Sixty-nine percent of these patients had follow-up ophthalmology care arranged upon discharge. For vulvovaginal complications, 43% of female patients were seen by gynecology with a median consult time of 3 days (range 1-4). Clobetasol ointment was the most frequent treatment, and follow-up was arranged for the 3 patients seen by gynecology.

Conclusions: Ocular and vulvovaginal complications of SJS/TEN are common. Specialist inpatient care and post-discharge followup for these patients was identified as inconsistent. We recommend the development and implementation of evidence-based care pathways and electronic medical record (EMR)-supported order sets to be utilized when a patient presents with SJS/TEN.

Learning Objectives

Takeaway Message

Ocular and vulvovaginal complications are common in patients with Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis (SJS/TEN), yet specialist care and follow-up for these complications are inconsistent. Standardizing and expediting care provision and consult pathways through EMR-supported order sets may reduce negative patient outcomes from ocular and vulvovaginal complications of SJS/TEN.

The Impact of Dupilumab on Sleep Disruptions in Patients with Prurigo Nodularis: A Systematic Review

Dea Metko¹, Shanti Mehta², Parsa Abdi³, Owen Lyons⁴, Vincent Piguet⁵

¹Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, ²Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ³Memorial University of Newfoundland, St. John’s, NL, ⁴Women’s College Hospital, Toronto, ON, ⁵Women’s College Hospital, Toronto, ON

Introduction: Prurigo nodularis (PN) is a chronic inflammatory skin condition characterized by intensely pruritic nodules that significantly impair quality of life. Non-restorative sleep, a debilitating consequence of persistent pruritus in PN, exacerbates the disease burden by affecting overall well-being and increasing the risk of comorbidities. Dupilumab, a monoclonal antibody targeting interleukin-4 (IL-4) and IL-13 signalling pathways, has demonstrated efficacy in improving symptoms of PN. This study systematically reviews the current evidence on dupilumab’s impact on sleep quality in patients with PN.

Methods, Results: A comprehensive literature search was conducted in MEDLINE and Embase on April 5, 2024, using keywords related to PN, dupilumab, and sleep. The search adhered to PRISMA guidelines and was registered in PROSPERO (CRD42024545873). Five studies were incorporated into the quantitative synthesis. The total cohort comprised 236 patients with a mean age of 51.8 years, 58.1% of whom were male. The mean disease duration was 6.43 years. The most common prior treatments included topical corticosteroids (80.9%) and antihistamines (48.8%). Dupilumab led to statistically significant improvements in quality of life and sleep disturbance, as indicated by pooled mean differences (MDs) for DLQI (14.74, 95% CI: 14.06–15.42, p<0.001, I²=93%), Itch Numerical Rating Scale (NRS) (5.60, 95% CI: 5.45–5.75, p<0.001, I²=99%), and Sleep Disturbance NRS (3.10, 95% CI: 2.77–3.43, p<0.001, I²=98%).

Conclusions: Dupilumab significantly improves sleep quality, reduces pruritus, and enhances overall quality of life in PN patients. Improving sleep in PN patients is essential to mitigating risks for associated comorbidities, such as cardiovascular disease, diabetes, and depression. Additionally, impaired sleep may exacerbate inflammation through increased C-reactive protein, IL-6, and TNFα levels, suggesting a cycle of pruritus and inflammation. Limitations include the small sample size and heterogeneity across studies.

Learning Objectives

Takeaway Message

Skin Manifestations of Adult-Onset Immunodeficiencies

Sandrine Ménard¹, Robert Gniadecki², Mohammed Osman²

¹Université de Montréal, Montréal, QC, ²University of Alberta, Edmonton, AB

Introduction: Immunodeficiencies represent a group of diseases characterized by dysregulated immune function. Although these conditions are frequently diagnosed in childhood, some forms manifest later in life, complicating diagnosis. Adult immunodeficiencies generally stem from genetic mutations which result in immune dysfunction: namely autoimmunity and increased infection risks. They commonly affect the skin, as it defends against many pathogens and is populated by resident immune cells. Typical presentations of immunodeficiencies include recurrent and refractory cutaneous infections, unexplained weight loss and inflammatory dermatoses. Often, they can be mistakenly attributed to hematological disorders or interpreted as adverse events related to therapeutic measures. However, a more thorough clinical examination may reveal that immunodeficiency itself may be responsible for the physiopathologic cascade. This review examines the spectrum of skin involvement in adult immunodeficiencies and highlights its importance in the clinical assessment and management of affected patients.

Methods, Results: A comprehensive review of adult immunodeficiencies was carried out, focusing on dermatological presentations and associated hematological conditions. The results reveal that several autoimmune pathologies can cause cutaneous symptoms, with some reaching over 50% of cases. Pathologies such as common variable immunodeficiency, selective IgA deficiency and idiopathic CD4+ lymphocytopenia can manifest as bacterial skin infections and resistant warts. Autoimmune manifestations such as vitiligo, lichen planus, atopic dermatitis and other skin infections are associated with Good’s syndrome, APECED, VEXAS and LRBA deficiency. These findings often coincide with systemic hematological complications, including lymphomas, thymomas and myelodysplastic syndromes. The attached table provides a summary of the associations between skin manifestations and corresponding hematological disorders.

Conclusions: Skin manifestations are important diagnostic indicators of immunodeficiency in adulthood. Early recognition of these signs is key to prompt detection and targeted intervention. Addressing gaps in our knowledge of these pathologies is essential to refining diagnostic approaches and tailoring management to the unique challenges of adult phenotypes.

Learning Objectives

Takeaway Message

Cutaneous manifestations are often diagnostic markers for adult immunodeficiencies. Their early recognition can significantly improve patient outcomes by facilitating diagnosis and appropriate management.

G2-PASE,G2-EASE,G2-VASE,G2-HECSE are Novel, Rapid, Reliable Measure of Plaque Psoriasis, Atopic Eczema, Vitiligo, Hand Eczema Severity for Clinical Practice Use

Wayne P. Gulliver¹, Susanne R. Gulliver²

¹Memorial University of Newfoundland, St. John’s, NL, ²Newlab Clinical Research Inc., St. John’s, NL

Introduction: The Psoriasis Area and Severity Index (PASI) is a composite measure of plaque psoriasis disease severity. It is, however, time consuming for every-day clinical use. The Gulliver-Gestalt-Psoriasis Area Severity Estimate (G2-PASE) measure was developed to approximate PASI scores using body surface area (BSA) and the Physician Global Assessment (PGA). Similar Tools were also developed for Atopic Eczema:G2-EASE,Vitiligo:G2-VASE and Hand Eczema:G2-HECSE. Objectives: To determine the reliability and validity of G2-PASE vs PASI, G2-EASE vs EASI,G2-Vase vs VASI,G2-HECSI VS HECSE.

Methods, Results: Canadian patients with a history of moderate to severe plaque psoriasis enrolled in the first cohort of the PSOLAR 1. Baseline disease severity data (PGA, BSA, and PASI) were leveraged to test the reliability and validity of the previously developed G2-PASE algorithm. The G2-PASE for each patient was calculated by applying baseline BSA and PGA values available from PSOLAR patient data at enrollment. The correlation and reliability of G2-PASE compared to the recorded PASI scores for each patient at enrolment were then assessed.

Of the 1896 Canadian patients in PSOLAR 1, 1803 had PASI data and were included in this analysis. The average baseline PASI score was 5.52 (SD 6.44, range 0.00-64.30), and the mean calculated G2-PASE score was 8.37 (SD 7.51, range 0.00-45.00). The Pearson’s correlation coefficient was 0.83 (p<0.0001), indicating very strong and significant correlation between PASI and G2-PASE scores. The standardized Cronbach coefficient alpha was 0.91. G2-EASE was calculated in a similar manner utilizing gestalt BSA and PGA, with a correlation coefficient of 0.95 (p value 0.000) for the first sample and 0.92 (p value 0.000) for the second sample. Cronbach’s α values of 0.97 and 0.95 indicated excellent reliability for G2-EASE. AUC values are determined to be 1 (p = 0.00). Similar Tools have been developed for Vitiligo and Hand Eczema.

Conclusions: This study validates G2-PASE and G2-EASE as a reliable measure of plaque psoriasis and atopic eczema.

On going validation for G2-VASE and G2-HECSE are ongoing.

Learning Objectives

Takeaway Message

Rapid, Reliable Pros can be developed and used in clinical practice

Navigating the Misdiagnosis of Pityriasis Rubra Pilaris and Successful Treatment with Guselkumab: A Case Report of Dual Biologic Therapy

Danika Bongfeldt, Sylvia Martinez-Cabriales

Northern Ontario School of Medicine University, Sudbury, ON

Introduction: Pityriasis Rubra Pilaris (PRP) is a rare and chronic dermatologic condition often misdiagnosed due to its clinical resemblance to psoriasis. It significantly impacts quality of life due to its clinical presentation and systemic discomfort. Conventional treatments, including retinoids, corticosteroids, and methotrexate, often yield suboptimal outcomes, particularly in refractory cases. Recently, biologic therapies have shown promise for PRP management. This case report describes the successful treatment of PRP with guselkumab.

Methods, Results: A 57-year-old male presented with an 8-year history of refractory papulosquamous disorder affecting 70% of his body surface area, which was initially diagnosed and treated as psoriasis. The patient had failed topical steroids, topical calcineurin inhibitors, sulfasalazine, and methotrexate. He had a past medical history of seronegative spondyloarthropathy, and asthma treated with dupilumab. On skin exam there were orange-red scaly plaques on the scalp, trunk, upper and lower extremities, buttocks, and genitals. Some of the plaques coalesced in areas to confluent, making PRP a presumptive diagnosis. Diagnosis was confirmed by 3 punch biopsies and treatment with guselkumab 100 mg every 4 weeks was started. Within 8 weeks of guselkumab initiation, complete skin clearance was achieved and maintained at 7-months follow-up.

Conclusions: This case highlights the potential of guselkumab as an effective treatment for refractory PRP, even in cases of extensive disease. It underscores the importance of accurate diagnosis through biopsy and dermoscopy and demonstrates the feasibility of concurrent biologic therapies for managing comorbid inflammatory conditions. Further research is needed to optimize biologic treatment strategies and enhance understanding of dual biologic use in complex dermatologic cases.

Learning Objectives

Takeaway Message

This case underscores the importance of accurate diagnosis in rare dermatologic conditions like PRP and highlights guselkumab’s potential as an effective treatment for refractory cases. It also demonstrates that dual biologic therapy can be successfully employed for managing separate comorbid inflammatory diseases, emphasizing the need for further research and individualized patient care.

Multidisciplinary Approach to a Hydrochlorothiazide Induced Lichenoid Drug Eruption: A Case Report

Danika Bongfeldt, Alanna Pullen, Sylvia Martinez-Cabriales

Northern Ontario School of Medicine University, Sudbury, ON

Introduction: Lichenoid drug eruptions are rare medication-induced dermatologic conditions that mimic lichen planus. They present as pruritic, violaceous, flat-topped papules, often in photo-distributed areas, and rarely include oral mucosal involvement. These eruptions are commonly associated with hydrochlorothiazide, statins, and anticoagulants. Diagnosis in elderly patients is complicated by polypharmacy and the delayed onset of symptoms, which can occur weeks to years after initiating the offending medication. This report describes the case of an elderly female with recurrent lichenoid eruptions and oral mucosa involvement caused by hydrochlorothiazide.

Methods, Results: An 85-year-old woman presented with a six-month history of pruritic skin lesions. One month after the lesions first appeared she developed transient painful oral lesions. A thorough review of her medical history revealed she had been newly taking hydrochlorothiazide for one year. On skin exam there were multiple violaceous, monomorphic papules on arms, wrists, buttocks, thighs, legs and dorsum of feet, which biopsy was compatible with a lichenoid drug eruption. The rash resolved within four months of discontinuing hydrochlorothiazide. One year later, she returned with a similar eruption involving the same areas, which appeared two days after initiating apixaban and 6 months after reinitiation of hydrochlorothiazide. Biopsy findings were compatible with a lichenoid drug reaction, and hydrochlorothiazide was considered the most likely causative agent. Discontinuation of hydrochlorothiazide and apixaban, along with supportive dermatologic treatment, led to resolution of the rash within 1 month.

Conclusions: This case underscores the diagnostic challenges in identifying drug-induced lichenoid eruptions in elderly patients with polypharmacy. The recurrence of symptoms due to inadvertent re-prescription highlights the importance of communication among healthcare providers, pharmacists, and the patient. This report adds to the growing body of evidence implicating hydrochlorothiazide and apixaban in photosensitive lichenoid eruptions and emphasizes the value of a multidisciplinary approach in preventing recurrence.

Learning Objectives

Takeaway Message

Lichenoid drug eruptions are a rare but significant adverse effect of medications like hydrochlorothiazide and apixaban. Accurate diagnosis requires a thorough review of medical and medication histories, especially in polypharmacy settings. Effective communication among the multidisciplinary care team is crucial to preventing recurrence and ensuring patient safety.

Perceptions and Barriers to Sunscreen Use Among Black Individuals: A Content Analysis of a Reddit Community

Victoria Young¹, Edgar Akuffo-Addo², Shahnawaz Towheed³, Samantha Bestavros¹, Jordan-Moses Williams⁴, Jeannie Boisvert⁵, Marissa Joseph^1,6,7

¹Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ²Department of Medicine Division of Dermatology, University of Toronto, Toronto, ON, ³Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, ⁴School of Nursing, University of Maryland, Baltimore, MD, ⁵Faculty of Arts and Science, University of Toronto, Toronto, ON, ⁶Division of Dermatology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, ⁷Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON

Introduction: Sunscreen use is associated with skin health benefits, such as skin cancer prevention and photoaging, yet adoption rates among Black populations remain disproportionately low. This study aimed to explore perceptions and usage of sunscreen within the Black community using discussions from the Reddit forum r/Blackskincare to inform strategies for promoting sunscreen adoption.

Methods, Results: A cross-sectional content analysis of posts and comments containing the keyword “sunscreen” was conducted on the subreddit r/Blackskincare using Python Reddit API Wrapper (PRAW). Thematic and sentiment analyses were applied to 88 posts and 1,430 comments. Neutral sentiments toward sunscreen use were predominant (79% of posts, 54% of comments). Hyperpigmentation (40%) and skin rejuvenation (17%) were the most discussed topics, with 83% of posts indicating current sunscreen use. Negative perceptions, when present, were largely due to cosmetic concerns like white cast (29%) and adverse reactions (43%), as well as misconceptions about sunscreen’s necessity for melanated skin.

Conclusions: This study highlights that negative attitudes toward sunscreen use are not pervasive in Black communities, suggesting significant opportunities for healthcare providers to promote adoption through targeted education. Barriers include misconceptions about melanin’s protective role, cosmetic concerns such as white cast, and limited access to products tailored to richly pigmented skin. Emphasizing sunscreen’s role in managing hyperpigmentation and skin rejuvenation, while addressing product-related concerns, can enhance uptake. Additionally, improving accessibility and affordability of sunscreens formulated for darker skin tones could support equitable sun protection practices. Further research is needed to explore barriers and facilitators to sunscreen use in this population to inform effective, culturally sensitive health promotion initiatives.

Learning Objectives

Takeaway Message

This study sheds light on Black individuals’s nuanced attitudes toward sunscreen use, suggesting that although usage rates are still lower than those of other groups, unfavourable opinions are not pervasive. Rather, neutral feelings predominate, offering a chance to boost sunscreen adoption with focused interventions.

Misconceptions regarding melanin’s UV protection function and cosmetic issues including white cast, oily texture, and skin irritation are among the main barriers identified. These results highlight the necessity for healthcare professionals to advise patients on how to choose sunscreens that specifically address these issues. In addition to techniques to reduce white residue, recommendations can include chemical sunscreens or tinted formulas that are better suited for skin with intense pigmentation.

The analysis also emphasizes how critical it is to address hyperpigmentation, which is a major factor in this population’s decision to wear sunscreen. Tailored messaging can increase adoption by presenting sunscreen as necessary for preventing and addressing hyperpigmentation, and minimizing photoaging.

Lastly, even though cost was not a significant consideration in this study, obstacles still exist due to the greater cost and restricted availability of sunscreens made for richly pigmented skin. To promote equitable sun protection practices, efforts must be made to provide access to reasonably priced and suitable goods.

Persistence of Post-Inflammatory Hyperpigmentation in Patients with Psoriasis: Influence of Disease Duration and Severity Before Biologic Treatment

Victoria Young¹, Dimitra E. Bednar², Maria Lucas³, Morvarid Hessami-Booshehri⁴

¹Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ²Division of Dermatology, University of Toronto, Toronto, ON, ³Scarborough Health Network General Hospital, Toronto, ON, ⁴Scarborough Health Network General Hospital Dermatology, Toronto, ON

Introduction: Psoriasis is a chronic inflammatory skin condition which commonly results in post-inflammatory hyperpigmentation (PIH), particularly in individuals with richer skin tones. The inflammatory cytokine profile of active psoriasis lesions increases melanin synthesis and dispersion, resulting in PIH. These post-inflammatory pigmentary changes can persist despite biologic treatments. This retrospective case series investigated the influence of disease duration and severity of psoriasis on PIH and analyzed for confounding variables including prototype and comorbidities. We hypothesized that longer and more severe psoriasis duration would contribute to persistent PIH in participants with richer skin tones.

Methods, Results: We conducted a retrospective analysis of 12 participants with psoriasis treated with biologics for at least two years’ duration using descriptive and multivariate analysis to adjust for confounders. Data collected included gender, comorbidities, Fitzpatrick skin types, type of biologic treatment, disease duration, and hyperpigmentation persistence.

The cohort included 11 males (91.7%) and 1 female (8.3%). Fitzpatrick skin types were distributed as follows: five patients (41.7%) with type III, five (41.7%) with type IV and two (16.6%) with type V. Guselkumab was the most commonly prescribed (n=6). Comorbidities included type 2 diabetes mellitus, hypercholesterolemia, hypertension, and psoriatic arthritis. The average disease duration was 12.75 years (±7.89). Despite complete resolution of all psoriatic lesions, PIH persisted with no improvement across all Fitzpatrick skin types independent of other factors.

Conclusions: Persistence of PIH despite resolution of psoriasis on biologics can occur irrespective of skin type or disease duration. Larger studies are needed to better understand these findings.

Learning Objectives

Takeaway Message

In the treatment of psoriasis, post-inflammatory hyperpigmentation (PIH) is still a persistent problem, especially for people with darker skin tones. This study shows that regardless of the length, severity, or Fitzpatrick skin type, PIH can continue in patients even after successful biologic therapy and full clearance of psoriatic lesions. To address this unmet need in dermatology, the results highlight the necessity of developing specific therapy options and gaining a deeper understanding of the underlying mechanisms of PIH. The quality of life for patients, especially those in skin-of-color groups, could be greatly improved by better treatment for PIH.

Targeting PRAME Directly or via EZH2 Inhibition Overcomes Retinoid Resistance and Represents a Novel Therapy for Keratinocyte Carcinoma

Brandon Ramchatesingh, Ivan V. Litvinov

McGill University, Montreal, QC

Introduction: Retinoids have demonstrated efficacy as preventative/treatment agents for keratinocyte carcinomas (KCs): basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC). However, retinoid resistance mechanisms limit the practical efficacy of these compounds. Preferentially Expressed Antigen in Melanoma (PRAME) is a transcriptional retinoid signaling co-repressor that is expressed in KCs. PRAME proposed to repress retinoid signaling by guiding enhancer of zeste homologue 2 (EZH2) to retinoic acid response elements (RARE) in gene promoters.

Methods, Results: We evaluated the effects of PRAME expression on KC pathogenesis and retinoid response using a combination of transcriptomics analyses, 2D and 3D cell culture models and tested efficacy of targeting PRAME and downstream EZH2 to restore sensitivity to retinoid therapies in KCs.

High PRAME expression in tumors negatively correlated with epidermal differentiation gene signatures. Similarly, PRAME overexpression (OE) downregulated epidermal differentiation gene signatures and impaired epidermal differentiation in 3D culture. PRAME OE attenuated retinoid-induced RARE activation, growth suppression and differentiation responses. Conversely, low-PRAME expressing tumors and KC cells where PRAME was downregulated demonstrated enrichment of epidermal differentiation gene signatures. PRAME downregulation restored retinoid-induced RARE activation, suppression of KC growth, keratinization in SCC and cell death signaling in BCC. Combining retinoid treatment with an EZH2 inhibitor augmented RARE activation and suppressed the growth of PRAME-expressing KC cells.

Conclusions: PRAME confers retinoid resistance in KC, which could be targeted directly or through EZH2 inhibition. This study proposes PRAME as a biomarker of aggressive disease/retinoid resistance and highlights its utility as a clinical target to restore retinoid sensitivity.

Learning Objectives

Takeaway Message

Skin cancers are more common than all human malignancies combined. Precursor lesions, actinic keratoses, are routinely treated with topical retinoids and these agents could potentially be used to prevent cutaneous Squamous Cell Carcinomas (cSCCs) and Basal Cell Carcinomas (BCCs). However, many cSCCs/BCCs develop resistance to retinoid therapy. This study demonstrates that ectopic expression of Preferentially Expressed Antigen in Melanoma (PRAME) is driving such resistance in BCC and cSCC skin tumors and can be overcome by repurposing EZH2 inhibitors (e.g., tazemetostat) or directly targeting PRAME. Expression of PRAME could also be used to diagnose poor prognosis/poorly differentiated SCCs early, therefore, enabling timely aggressive treatments for high-risk patients.

Imatinib-Induced Bullae and Skin Fragility

Nader Elbarch, Maha El Barch, Benoit Côté

Université de Montréal, Montréal, QC

Introduction: Imatinib mesylate is a tyrosine kinase inhibitor used in various neoplastic conditions including gastrointestinal stromal tumors (GIST). Cutaneous side effects are common and include maculopapular eruption, periorbital edema and hypopigmentation. Only a few cases of skin blistering have been reported. Loss of lamina lucida and type 4 collagen in the basement membrane has been suggested as a possible mechanism. We report a case of skin blistering under imatinib therapy, a potentially underreported adverse event.

Methods, Results: An 81-year-old man was referred to the dermatology clinic for recurrent painful blisters. His past medical history includes a metastatic small bowel GIST for which he was treated with high dose imatinib mesylate (800 mg daily) in the last 3 years. The patient reported an 8-month history of painful bullae on his dorsal hands, often occurring after minor trauma. He also complained of slightly pruritic vesicles on friction sites over his upper and lower extremities. There was no history of photosensitivity. Physical examination revealed multiple non-inflammatory hemorrhagic bullae measuring up to 2 cm on his dorsal hands, no mucosal involvement and no nail changes. A skin biopsy revealed a subepidermal blister with minimal inflammatory content and a sparse lymphocytic perivascular infiltration in the superficial dermis. Direct immunofluorescence was negative for immunoglobulin deposits. A diagnosis of imatinib-induced bullae was thus made. From an oncologic perspective, imatinib dosage could not be decreased. The patient was therefore provided with supportive treatment. Spontaneous improvement was noted in the following months.

Conclusions: We report a case of imatinib-induced skin fragility and blistering in a patient with metastatic GIST, histologically characterized by pauci-cellular subepidermal blisters and a negative direct immunofluorescence. The patient improved with avoidance of trauma and supportive care. Dermatologists must be aware of this uncommon cutaneous adverse reaction to avoid unnecessary discontinuation of a potentially life-saving medication.

Learning Objectives

Takeaway Message

Imatinib mesylate can rarely induce skin fragility and blistering and seems to present after 1-2 years of therapy. Diagnosis can be made after the exclusion of other bullous conditions, namely epidermolysis bullosa acquisita and porphyria. Management options include decreasing imatinib dosage. Supportive treatment and trauma avoidance can also lead to improvement, as seen in our patient.

Shiitake Mushroom Dermatitis Across Time: A Systematic Review

Alexa Moschella¹, Mark G. Kirchhof²

¹University of Ottawa, Ottawa, ON, ²The Ottawa Hospital, Ottawa, ON

Introduction: After the introduction of shiitake mushroom (SM) from East Asia to the Western world, there has been a notable increase in shiitake mushroom dermatitis (SMD), a rare dermatosis which occurs after SM ingestion. SMD presents as a striking, flagellate eruption resembling whip-lashes, and can be severely pruritic leading to insomnia. Due to non-specific histological and laboratory findings, an accurate diagnosis relies heavily on healthcare provider knowledge to obtain history about SM consumption. Thus, the objective of this review is to summarize relevant patient history details related to SMD and to examine the geographical distribution of SMD outside of Asia over time.

Methods, Results: A systematic search of the English-language primary literature was performed in MEDLINE, Embase, Scopus, and Pubmed in November 2024. After de-duplication, 191 studies were screened, with 66 studies included, representing 152 adults and 1 pediatric patient. Most cases occurred in males (n= 108, 78%; females: n=45, 29%; mean age: 45 years, SD= 15). Median time from SM consumption to symptom onset was 48 hours (IQR: 24). SMs were consumed raw (55%, n = 81), cooked (24%, n=35) or both (1%, n=2). Between 2000-2009, 100% (n= 6) of patient cases were from Europe. In 2010-2019, 57% (n= 32) were from Europe, 25% (n= 14) were from North America, 9% (n= 5) were from Oceania, and 5% (n= 3) were from South America. Since 2020, 84% (n= 74) of patient cases were from Europe, 10% (n= 9) from North America, and 1% (n= 1) from Oceania.

Conclusions: Reported cases of SMD continue to increase outside of Asia, especially in Europe, which may reflect increased reporting or incidence. These findings emphasize the importance of global clinical awareness to make an accurate diagnosis and initiate appropriate management.

Learning Objectives

Takeaway Message

Shiitake mushroom dermatitis (SMD) is a clinical diagnosis which requires healthcare provider awareness to prompt targeted inquiry about shiitake mushroom consumption. SMD is self-limiting, however, the dramatic, flagellate appearance of the rash can resemble other conditions which require more intensive management. These include connective tissue disorders such as Still’s disease and dermatomyositis, as well as infectious etiologies such as herpes zoster. Patients with SMD may present to a variety of settings including dermatology clinics, emergency departments, and primary care practices, emphasizing the importance of recognizing this condition across specialties. Therefore, we aim for attendees to develop a comprehensive understanding of the evolving geographical distribution of SMD, the key historical details to elicit from patients, and the influence of preparation practices on its manifestation. Targeted inquiry and prompt recognition can improve diagnostic accuracy, prevent unnecessary interventions, and reassure patients.

A Systematic Review of Drug-Induced Pityriasis Rosea

Chloe E. Devoy¹, Andy D. Lee², Ryan S.Q. Geng², Hibo Rijal³, Jing Y. Han¹, Bethany Wilken⁴, Jennifer Chen², Naila Bouadi⁵, Cathryn Sibbald⁶

¹Cumming School of Medicine, University of Calgary, Calgary, AB, ²Temerty School of Medicine, University of Toronto, Toronto, ON, ³School of Medicine, Queen’s University, Kingston, ON, ⁴Schulich School of Medicine and Dentistry, Western University, London, ON, ⁵Faculty of Medicine, Université Laval, Québec, QC, ⁶Division of Pediatric Dermatology, The Hospital for Sick Children, University of Toronto, Toronto, ON

Introduction: Pityriasis rosea (PR) is a self-limited papulosquamous exanthem usually characterized by an initial erythematous plaque (the herald patch), followed by secondary development of smaller papulosquamous lesions along cleavage lines in a “Christmas-tree” pattern. Although it is usually associated with infectious triggers, onset of drug-induced PR has been reported. However, summary evidence is lacking. As such, this systematic review aimed to summarize characteristics of drug-induced PR.

Methods, Results: Following PRISMA guidelines, a systematic review was conducted using MEDLINE and EMBASE. Study quality was assessed with the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence. A total of 93 studies reporting on 505 drug-induced PR patients were included. The most common triggering medications included vaccines (90.1%; mRNA COVID vaccines [n=366], viral vector COVID vaccines [n=24], inactivated COVID vaccines [n=54], non-COVID vaccines [n=11]) and biologic agents (1.6%; Etanercept [n=2], Omalizumab [n=2], Adalimumab [n=1], Dupilumab [n=1], Infliximab [n=1], Rituximab [n=1]). Latency period to onset of PR was less than 4 weeks in 85.8% of patients. While treatment outcomes were only reported in 23.2% (117/505) of cases, complete resolution (CR) was achieved in 92.3% (108/117) of patients. This was seen most commonly following combination therapy with antihistamines and corticosteroids (60.2%,65/108), corticosteroid monotherapy (17.6%, 19/108), and antihistamine monotherapy (10.2%, 11/108).

Conclusions: While adverse reactions to COVID-19 vaccinations are rare, cutaneous reactions such as PR are among the more commonly documented adverse events. Proposed mechanisms involve host immune activation against viral particles leading to pro-inflammatory cytokine and T-cell activation. While the precise etiology of PR is unclear, presentation of the characteristic herald patch is predominated by T-cells. This study highlights PR as a potential side effect of COVID-19 vaccination however, summary evidence is reassuring as complete resolution was achieved in most reported cases.

Learning Objectives

Takeaway Message

This systematic review revealed the most common trigger of drug-induced pityriasis rosea to be COVID-19 vaccines, which accounted for nearly 90% of all cases. Despite its association with COVID-19 vaccines, pityriasis rosea typically resolves without long-term effects and can be treated with antihistamines and/or corticosteroids.

Treatments for Molluscum Contagiosum: A Systematic Review

Ou Jia (Emilie) Wang¹, Mahek Shergill², Ammar S. Aldien³, Ilya Mukovozov^4,5

¹Faculty of Medicine, University of British Columbia, Vancouver, BC, ²Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, ³Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, ⁴Department of Medicine, Division of Dermatology, Women’s College Hospital, Toronto, ON, ⁵Toronto Dermatology Centre, Toronto, ON

Introduction: Molluscum contagiosum (MC) is a viral skin infection causing physical discomfort, psychosocial distress, and a significant disease burden, particularly in pediatric and immunocompromised populations. Management options currently range from no active treatment to topical, physical/surgical, immunological, and other interventions. Recent Food and Drug Administration approvals of topical cantharidin and 10.3% berdazimer gel provide new therapeutic options, prompting a comprehensive evaluation of MC treatment safety and efficacy.

Methods, Results: We conducted a systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, to evaluate and compare the efficacy, safety, recurrence, and adverse effects of MC treatments. A total of 85 studies (19,222 participants) were included, with 78% of studies focusing on pediatric patients. Cantharidin, potassium hydroxide (KOH), and imiquimod demonstrated high complete clearance rates (84.9%, 75.1%, and 70.1%) with mild local side effects. Cryotherapy and laser therapies achieved rapid complete clearance but caused pain and pigmentary changes. Recently approved treatments, such as berdazimer gel, emerge as effective options particularly for managing MC in pediatric populations. Immunotherapies like Candida antigen and MMR vaccine were effective for refractory lesions. Recurrence rates were highest in individual studies with trichloroacetic acid (41.7%) and curettage (34.2%), although long-term outcomes were infrequently reported.

Conclusions: Managing MC involves a range of treatments, including topical, physical, and immunological options, requiring consideration of patient factors (e.g., age, lesion severity, immune status). Cantharidin, KOH, cryotherapy, and podophyllotoxin remain first-line treatments, with autoinoculation showing promise, and immunotherapies and lasers used in recalcitrant cases. Standardized trials are needed to refine treatment strategies.

Learning Objectives

Takeaway Message

A Rare Presentation of Bilateral Axillary Polymastia and Pseudomamma: A Case Report

Anne Sophie Groleau, Zhuo Ran Cai

Centre hospitalier de l’Université de Montréal, Montréal, QC

Introduction: Polymastia, or accessory breast tissue, is a congenital anomaly of persistent mammary glandular tissue, typically along the “milk lines” extending from the axillae to the groin. It affects in 1-6% of women and up to 20% of cases occur in an axilla. The incidence of bilateral cases is unknown. We report a rare case of a patient with bilateral axillary polymastia and associated pseudomamma.

Methods, Results: A 35-year-old female presented to dermatology clinic for consultation. The patient was referred for evaluation of atypical naevi. On visit, patient had noted bilateral axillary skin lesions since birth. The patient had recently given birth and described painful swelling in both axillae 48-72 hours after birth under the aforementioned skin lesions. Patient noted on one occasion milk coming out of the mass in her right axilla upon stimulation. Physical exam revealed bilateral nipple and areola overlying a small mass in each axilla. No other lesions were found elsewhere. The patient was reassured and was advised to avoid stimulating the accessory breast tissue. No other treatment was offered.

Conclusions: Although considered benign, accessory breast tissues may develop breast cancer. It is thus important to recognize this congenital anomaly in order for patients to have adequate screening.

Learning Objectives

Takeaway Message

Accessory breast tissue is an under-recognized congenital anomaly and should be included in the differential diagnosis of axillary masses, especially in the primary care setting.

Regional Disparities in Skin Cancer Risk Factors, Protective Behaviors, and Awareness Across Canada: Insights from Manitoba and Atlantic Provinces

Francois Lagace, Amina Moustaqim-Barrette, Santina Conte, Ivan V. Litvinov

McGill University, Montreal, QC

Introduction: Skin cancer, particularly cutaneous melanoma (CM), is increasing in Canada with notable regional differences. Two cross-sectional studies in Manitoba and Atlantic Canada examined ultraviolet (UV) exposure, sun-protective behaviors, and melanoma awareness.

Methods, Results: In Manitoba, 3,347 participants completed the Sun Exposure and Behavior Inventory (SEBI), assessing sun exposure, protective practices, and melanoma concerns. Logistic regression and subgroup analyses identified demographic factors linked to sun-related behaviors. In Atlantic Canada, 7,861 participants were surveyed to compare regional behaviors and attitudes.

In Manitoba, high-risk behaviors were common: 67.7% reported >10 lifetime sunburns, 67.2% had blistering burns, and 52% used tanning beds. Despite risks, only 46.5% regularly used sunscreen, and 57.7% wore long sleeves. Misconceptions were widespread, with 52.3% believing tanning improves health and appearance. Women were more likely to use sunscreen (OR 2.36, p < 0.001) but also reported higher tanning bed use (OR 2.61, p < 0.001).

In Atlantic Canada, provinces with higher CM incidence, such as Prince Edward Island and Nova Scotia, reported more lifetime sunburns (OR 2.00, 95% CI 1.72–2.31) and recreational sun exposure (OR 1.95, 95% CI 1.61–2.35) but also better sun-protective behaviors, including sunscreen use (OR 1.20, 95% CI 1.04–1.37) and hat-wearing (OR 1.29, 95% CI 1.11–1.49). Higher-income participants (≥ CAD 50,000) reported more sunburns (OR 1.33, 95% CI 1.15–1.54) and tanning bed use (OR 1.37, 95% CI 1.19–1.59) but were more likely to use broad-spectrum sunscreen (OR 2.23, 95% CI 1.15–4.35).

Conclusions: High-risk sun behaviors and limited melanoma awareness are widespread in Manitoba and Atlantic Canada. Although high-incidence Atlantic provinces show better sun-protection habits, tanning misconceptions and inconsistent practices persist.

Learning Objectives

Takeaway Message

Our study, conducted in Manitoba, found that many residents have risky sun exposure habits and lack awareness about skin cancer. Over 65% reported a history of sunburns, more than half had used tanning beds, and a large majority recently tanned for pleasure. Misconceptions are common, with over 50% believing that tans are healthy or a sign of beauty. Moreover, sun protection practices are inadequate, with less than 60% using protective clothing and under 50% using sunscreen. These findings highlight the need for targeted public health campaigns to improve awareness and promote better sun protection behaviors to prevent future skin cancers in Manitoba. Similarly, our work in Atlantic Canada was able to identify significant differences across multiple variables between these groups. These findings will help guide future public health efforts aiming at preventing cutaneous melanoma and reducing its incidence in our communities.

Environmental, Geographic, and Socioeconomic Determinants of Cutaneous Melanoma in Canada

Francois Lagace, Santina Conte, Ivan V. Litvinov

McGill University, Montreal, QC

Introduction: Cutaneous melanoma (CM) is a highly aggressive skin cancer with increasing incidence in Canada, showing notable geographic and socioeconomic disparities. Understanding the role of environmental, geographic, and healthcare-related factors is crucial for developing targeted public health interventions to reduce CM risk and improve outcomes.

Methods, Results: This study analyzed 106,015 CM cases and 20,570 CM deaths in Canada from 1992 to 2017 using data from the Canadian Cancer Registry (CCR) and the Canadian Urban Environmental Health Research Consortium (CANUE). Environmental factors (UV radiation, vegetation index, temperature, precipitation), socioeconomic data (income, dermatologist density, healthcare spending), and healthcare access metrics were evaluated. Statistical analyses included negative binomial regression, mixed-effects models, and spatial autocorrelation. Age-standardized incidence (ASIR) and mortality rates (ASMR), as well as mortality-to-incidence ratios (MIR), were calculated to assess regional disparities.

Between 2011 and 2017, Canada recorded 39,605 new CM cases (ASIR: 14.12 per 100,000) and 5,890 deaths (ASMR: 2.7 per 100,000). Prince Edward Island and Nova Scotia had the highest incidence rates, while Newfoundland and Labrador and Northern Territories had the lowest. Higher CM incidence was associated with regions experiencing elevated temperatures, greater UV exposure, and abundant greenspace. Conversely, areas with frequent precipitation showed reduced CM rates. The MIR declined over time but remained higher in rural regions like Manitoba and Saskatchewan, reflecting healthcare access disparities. Socioeconomic factors, including limited dermatologist access in rural areas, further contributed to regional differences in outcomes.

Conclusions: Environmental, geographic, and socioeconomic factors significantly influence CM incidence and mortality in Canada. While early detection and treatment have improved, healthcare disparities persist, especially in rural and underserved areas. Targeted public health strategies focusing on sun protection education and equitable healthcare access are essential to mitigate CM risk and improve outcomes nationwide.

Learning Objectives

Takeaway Message

This study highlights the significant impact of environmental, geographic, and socioeconomic factors on cutaneous melanoma (CM) incidence and mortality across Canada. Analysis of over 106,000 CM cases and 20,000 CM deaths from 1992 to 2017 revealed substantial regional disparities. Provinces like Prince Edward Island and Nova Scotia exhibited the highest CM incidence rates, while Newfoundland and Labrador and the Northern Territories had notably lower rates. Higher CM risk was associated with regions experiencing elevated UV exposure, warmer temperatures, and greater greenspace—likely due to increased recreational sun exposure. Conversely, areas with more precipitation, heat events had lower CM rates, suggesting that reduced outdoor activity may lower UV risk.

Despite a national decline in the mortality-to-incidence ratio (MIR), rural and underserved areas, particularly in Manitoba, Saskatchewan, and northern British Columbia, faced worse outcomes.

Differences in Clinical Presentation Between Drug-Induced and Non-Drug-Induced Linear IgA Bullous Dermatosis: A Systematic Review

Kathleen D’Aguanno, Alexandre Nguyen, Angela Dahdhouh, Jeanne Harnois, Carolina Lucena Fernandes, Elio Kechichian

Université de Sherbrooke, Sherbrooke, QC

Introduction: Linear IgA bullous dermatosis (LABD) is a rare autoimmune blistering disorder characterized by linear deposition of IgA along the epidermal basement membrane zone. LABD may occur idiopathically or secondarily to drug exposure. There is a lack of evidence regarding the distinct clinical presentation and management of drug-induced and idiopathic LABD. The objective of this systematic review is to identify key differences in clinical presentation and management between drug-induced and non-drug-induced cases of LABD.

Methods, Results: A systematic review of published LABD cases was performed, yielding 1,945 cases in total. Among these, 487 cases (25.0%) were drug-induced, while 1,458 (75.0%) were idiopathic. Vancomycin and beta-lactam antibiotics were the most frequently implicated drugs, with drug-induced cases presenting an average of 12 days after drug initiation.

Drug-induced LABD exhibited distinct clinical features: erythematous plaques and maculopapular eruptions were significantly more common (27.5% vs. 5.1%, p<0.001), and Nikolsky’s sign was observed exclusively in drug-induced cases (4.7%). Mucosal involvement was notably higher in drug-induced LABD, affecting the oral mucosa in 23.0% and genital mucosa in 11.9% of cases, compared to 7.2% and 2.3%, respectively, in non-drug-induced cases (p<0.001 for both).

Dapsone and systemic corticosteroids were the most frequently used treatments for both subtypes, in addition to drug discontinuation when a medication was identified as the triggering factor.

Conclusions: Drug-induced LABD demonstrates unique clinical patterns, including increased mucosal involvement, a higher prevalence of maculopapular eruptions, and the presence of Nikolsky’s sign, which can help distinguish it from idiopathic LABD. Strong association with specific medications, particularly vancomycin, underscores the importance of prompt recognition and management, with drug discontinuation playing a critical role in treatment. Further research is needed to elucidate the underlying pathophysiology driving these clinical differences.

Learning Objectives

There are differences in clinical presentations between drug-induced and non-drug induced LABD.

Vancomycin and beta-lactam antibiotics are the most frequently implicated drugs in drug-induced LABD, presenting an average of 12 days after drug initiation.

Drug-induced LABD has increased mucosal involvement, a higher prevalence of maculopapular eruptions and the presence of Nikolsky’s sign.

Takeaway Message

Drug-induced LABD demonstrates unique clinical patterns, including increased mucosal involvement, a higher prevalence of maculopapular eruptions, and the presence of Nikolsky’s sign, which can help distinguish it from idiopathic LABD.

Evaluating the Implementation and Impact of BRAF Reflex Mutation Testing in Melanoma, Lung, and Colorectal Cancers

Daniel Guerra Ordaz, Sera Whitelaw, Amina Moustaqim-Barrette, May Chergui, Ivan V. Litvinov

McGill University, Montreal, QC

Introduction: Reflex molecular testing, the process of profiling specimens at diagnosis, is emerging in oncology, allowing for prompt therapy initiation, and potentially improving outcomes. This study evaluates the impact of reflex BRAF testing on treatment timelines and outcomes in melanoma, lung and colorectal cancers at the McGill University Health Center (MUHC).

Methods, Results: A retrospective chart review was conducted at the MUHC. The study included patients with melanoma, lung, and colorectal cancers who underwent BRAF testing from 2017 to 2022. Data on demographics, cancer type, stage, test ordering specialist, testing method, and treatment outcomes were extracted. Statistical analyses included descriptive and multivariable regression analyses.

518 BRAF molecular tests were performed, with 173 patients meeting the inclusion criteria [median age 72 (IQR 60-80 years), 46.2% female]. Of these, 75.7% had melanoma, 23.7% colorectal cancer and 0.58% lung cancer. Pathologists ordered 71.1% of BRAF tests, primarily relying on immunohistochemistry. By 2022, all BRAF results were available before oncology consultations. Patients with pre-consultation BRAF results were more likely to receive targeted therapy (59.4% vs 36.4%). The availability of BRAF test results was associated with quicker treatment initiation and better alignment of therapy with mutation status.

Conclusions: This study underscores the success of the pathology team at MUHC in implementing reflex BRAF mutation testing, enhancing clinical care by ensuring the timely availability of test results. Delays in testing may adversely affect clinical decision-making and therapy selection, highlighting the need for standardized reflex testing protocols across Canada to optimize patient outcomes in melanoma, lung, and colorectal cancers.

Learning Objectives

Takeaway Message

This study highlights the critical role of reflex BRAF mutation testing in improving cancer care for patients with melanoma, lung, and colorectal cancers at the McGill University Health Centre (MUHC). Reflex testing, performed automatically at diagnosis, significantly reduced delays in treatment initiation by ensuring BRAF results were available before oncology consultations. Between 2017 and 2022, 518 BRAF tests were conducted, with 75.7% of patients diagnosed with melanoma. By 2022, all BRAF results were accessible prior to oncologist visits, leading to a higher rate of targeted therapy use (59.4% vs. 36.4%) among patients with pre-consultation results. This timely access allowed for more precise and effective treatment decisions aligned with patients’ mutation status.

Efficacy and Safety of Phosphodiesterase-4 Inhibitors in Vitiligo: A Systematic Review

Reya Hanspal¹, Hibo Rijal¹, Ilya Mukovozov^2,3

¹School of Medicine, Queen’s University, Kingston, ON, ²Toronto Dermatology Centre, Toronto, ON, ³Department of Medicine, Division of Dermatology, Women’s College Hospital, Toronto, ON

Introduction: Vitiligo is a chronic autoimmune disorder characterized by melanocyte destruction, loss of pigmented melanin, and resultant depigmentation of skin. Conventional therapy consists of topical and systemic steroids, calcineurin inhibitors, immunosuppressants, and narrowband ultraviolet B (NB-UVB) phototherapy. This systematic review summarizes the treatment outcomes of phosphodiesterase-4 inhibitors (PDE4i) for the treatment of vitiligo.

Methods, Results: A MEDLINE, Cochrane, and Embase search was conducted under PRISMA guidelines using the following keywords and variations: “vitiligo” and “PDE4i”. The search yielded 11 studies with 114 participants with a mean age of 38.1 years (range: 16-71 years), consisting of 49% males. Treatments were categorized as PDE4i treatment with concomitant medications (85/114, 74.5%) or PDE4i monotherapy (29/114, 25.4%). Oral apremilast was most commonly used (110/114, 96.4%) followed by topical crisaborole (4/114, 3.5%). Treatment outcomes were reported as complete (CR), partial (PR), or no resolution (NR). PDE4i achieved CR in 1/114, PR in 87/114, and NR in 26/114 cases respectively. PDE4i monotherapy without concomitant medications led to PR in 6.9% (2/29) of cases; and PDE4i with concomitant medication resulted in PR in 100% (85/85) of cases. A 7.4% mean change in Vitiligo Area Severity Index was documented in 11.4% (n=13) of cases following apremilast therapy. Disease stabilization was reported in 26/114 cases, with apremilast plus concomitant therapy resulting in stabilization of 21 cases.

Conclusions: This review suggests partial efficacy of PDE4i in vitiligo. Limitations of this study included a small sample size and lack of equal topical vs oral PDE4i events impacting generalizability of results. Further studies are needed to confirm the findings of this review.

Learning Objectives

Takeaway Message

Vitiligo is a chronic condition that can cause significant psychological and social distress. Phosphodiesterase-4 inhibitor (PDE4i) therapies have emerged as a novel and effective approach to treatment of inflammatory diseases, with recent use in patients with vitiligo. This systematic review summarizes the efficacy and safety of PDE4i therapy for vitiligo.

Efficacy and Safety of Dupilumab in Recalcitrant Chronic Hand Eczema: A Systematic Review

Reya Hanspal¹, Hibo Rijal¹, Sonja Molin^2,3

¹School of Medicine, Queen’s University, Kingston, ON, ²Division of Dermatology, Department of Medicine, Queen’s University, Kingston, ON, ³Department of Dermatology, Venerology and Allergy, Charité – Universitätsmedizin Berlin, Berlin, Germany

Introduction: Chronic hand eczema (CHE) is an inflammatory skin disorder characterized by variable morphology including erythema, xerosis, scales, vesicles, hyperkeratosis, and fissures. Conventional therapy consists of emollients and skin protection, topical corticosteroids or calcineurin inhibitors, phototherapy, with systemic treatments reserved for refractory cases. Dupilumab is an established therapy for atopic dermatitis. This systematic review aims to summarize and identify the treatment outcomes of Dupilumab use in the context of hand eczema.

Methods, Results: A search was conducted under PRISMA guidelines on Cochrane, Embase, and MEDLINE using the following keywords and variations: “hand dermatosis” and “Dupilumab”. A total of 19 studies (publication date: 2018-2024) and 263 participants were included (Figure-1). The mean age of participants included was 51.9 years (range: 22-76 years), consisting of 54% males and 46% females. A total of 210 treatment events were documented and categorized as dupilumab combined with concomitant medications (131/210, 62.4%) or dupilumab monotherapy without concomitant medications (79/210, 37.6%) use. The most common concomitant medication used was topical corticosteroids (115/131, 87.7%). Treatment outcomes were mainly reported as complete (CR), partial (PR), or no resolution (NOR). Participants achieved CR, PR, and NOR in 21% (44/210), 76.1% (160/210), and 2.9% (6/210) of cases respectively. Select studies reported outcomes on mean change in HECSI, BSA, IGA, EASI, and DLQI.

Conclusions: This review explores the possible benefit of Dupilumab use for recalcitrant HE and support its use as a potential therapeutic option for patients’ refractory to traditional therapy. Limitations of this study included varied outcome metrics and HE classification and small sample sizes documented. Further studies are needed to confirm the findings of this review.

Learning Objectives

Takeaway Message

Chronic hand eczema (CHE) is an inflammatory skin disorder associated with significant impairment of quality of life. Standard therapies focus on symptom control, but with recent therapeutic treatments emerging, it is more possible that CHE can be managed by targeting the underlying disease mechanisms. Dupilumab is a human monoclonal antibody that inhibits interleukin-4 and interleukin-13 and has recently been used in the treatment of patients with CHE. This systematic review supports the efficacy and safety of Dupilumab therapy for CHE.

Lucio’s Phenomenon in a Non-Endemic Region: A Case Report

Adam C. Yu¹, Airiss R. Chan², Mariusz Sapijaszko², Eunice Y. Chow²

¹Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, ²Division of Dermatology, Department of Medicine, University of Alberta, Edmonton, AB

Introduction: Leprosy, despite being declared "eliminated" by the World Health Organization in 2000, remains a significant health challenge in endemic regions. Global reports show over 200,000 new cases since 2017, with India, Brazil, and Indonesia accounting for the majority. Lucio’s phenomenon, a rare vascular necrotic reaction associated with lepromatous leprosy, is particularly challenging to diagnose, especially in non-endemic regions. This case report discusses a rare instance of Lucio’s phenomenon in Canada.

Methods, Results: A 77-year-old South Asian male presented with widespread retiform purpura, ulcerations, and necrosis on the limbs. He had a significant travel history to India and a medical background including hypothyroidism and stroke. Initial laboratory tests revealed positive autoimmune markers, including antinuclear antibody, anti-Jo1 antibody, rheumatoid factor and pANCA (MPO-positive). A skin biopsy showed granulomatous dermatitis with acid-fast bacilli, and PCR testing confirmed Mycobacterium leprae. The positive rheumatological markers suggested a potential diagnosis of ANCA-vasculitis but ultimately, the diagnosis of lepromatous leprosy with Lucio’s phenomenon was made. The patient was treated with a 24-month multi-drug therapy regimen, including clofazimine, rifampin, dapsone, and prednisone. Significant improvement was observed, with no new symptoms or lesions.

Conclusions: Leprosy remains a significant health challenge in endemic regions and is still observed in non-endemic areas. This case report highlights a rare instance of lepromatous leprosy with Lucio’s phenomenon in Canada. In conjunction with Infectious Diseases and a positive PCR result for Mycobacterium leprae, we were able to arrive at the correct diagnosis. However, mycobacterial infections, such as leprosy, can present with clinical signs and laboratory findings suggestive of autoimmune rheumatologic diseases, posing significant diagnostic challenges.The infection was likely misdiagnosed multiple times due to the rarity of leprosy in non-endemic regions, demonstrating the critical role of a multidisciplinary approach in the accurate diagnosis and treatment of this infection.

Learning Objectives

Takeaway Message

Leprosy, although considered "eliminated" by the WHO, remains prevalent in endemic regions and is increasingly recognized in non-endemic areas due to globalization. Mycobacterial infections, such as leprosy, can present with clinical signs and laboratory findings suggestive of autoimmune rheumatologic diseases, posing significant diagnostic challenges. This case highlights the importance of early recognition of Lucio’s phenomenon, a rare manifestation of lepromatous leprosy, and underscores the need for a multidisciplinary approach involving dermatology and infectious diseases. Accurate diagnosis and management are especially critical in patients with relevant travel histories or exposure risks.

Topical Corticosteroid Potencies: Reimagining a New Universal Classification System

Taylor C. Skinner¹, Rebecca Law¹, Howard Maibach²

¹Memorial University of Newfoundland, St. John’s, NL, ²University of California San Francisco, San Francisco, CA

Introduction: Topical corticosteroids (TCS) are a class of medications commonly used for a wide variety of dermatologic conditions. Unfortunately, there is no universally accepted classification system, and many countries have their own independent sorting arrangements. This can create confusion when choosing corticosteroids in the clinical setting, since the potency of any given TCS varies depending on the particular classification system used.

Methods, Results: Literature searches were conducted through multiple online databases, such as PubMed and Embase, with a focus on articles published within the last 20 years (2003-2023). A total of 493 articles were screened and 33 were found to be applicable and relevant. Dermatology practice guidelines from the United States, Europe, New Zealand, and Japan were also assessed to explore clinical relevance regarding steroid potencies and dosing. In this review, a TCS was classified based on the general consensus of all five classification systems. For example, if a steroid is classified as high potency in the US but super-potent in both the European and Japanese systems, the pharmacokinetics of the vehicle formulation was considered, if relevant, and the TCS classified according to majority.

Conclusions: The classification system proposed in this review tends to fall more heavily in line with the US-based classification systems as a means of providing specific groupings that are relevant to clinical practice and that consider the pharmacokinetic and pharmacodynamic factors that influence the potency of topical medications. Ideally, a universal classification system of TCS potency, such as the one presented in this review, will facilitate decision making for clinicians prescribing and dispensing these medications.

Learning Objectives

Takeaway Message

A universal classification system of TCS potency, which considers the currently available classification systems along with the pharmacokinetic and pharmacodynamic factors of TCS, will reduce uncertainty and facilitate consistent decision making for clinicians prescribing and dispensing these medications.

Theories of Pathogenesis in Paradoxical Alopecia Areata During Dupilumab Therapy

Eric P. McMullen¹, Parsa Abdi², Iryna Savinova³, Jeffrey Donovan^4,5

¹Division of Dermatology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ²Faculty of Medicine, Memorial University of Newfoundland, St. Johns, NL, ³Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, ⁴Department of Dermatology, University of British Columbia, Vancouver, BC, ⁵Donovan Hair Clinic, Whistler, BC

Introduction: Alopecia areata (AA) is a complex, immune-mediated hair loss condition, with Th1 cells implicated in its pathogenesis. Dupilumab, an inhibitor of Th2-mediated cytokine signalling via IL-4 and IL-13, treats various immune-mediated conditions, including AA, but has also been shown to induce or exacerbate this condition.

Methods, Results: Predictors of these divergent responses remain unclear. However, dupilumab responders were more likely to have: (1) baseline IgE levels ≥200 IU/ml (63.6% responders [SALT30+] versus 24.5% non-responders [SALT0–30]; P=0.01) and (2) higher mean baseline IgE levels (946.2 IU/ml responders versus 338.8 IU/ml non-responders [SALT0–30]; P=0.04). Patients with a personal or family history of atopy were more likely to experience significant regrowth at 24 weeks (90.9% responders [SALT30+] versus 30.6% non-responders [SALT0–30]; P=0.01), although this difference was no longer present at 48 weeks (P=0.22). Higher baseline serum IgE levels were noted in responders (range: 2,129–58,737 IU/ml) compared to non-responders (range: 122–433 IU/ml). Two theories may explain dupilumab’s paradoxical effect in AA (Figure 1). Theory 1 suggests dupilumab targets the Th2 response, potentially enhancing Th1 activity and exacerbating AA through increased inflammation. Theory 2 suggests dupilumab may correct regulatory T-cell function, reducing IL-4 levels and may facilitate the transition of hair follicles from telogen to anagen phase, promoting hair regrowth in AA. De novo AA cases post-dupilumab are also possible. The polarity of Th1 and Th2 responses may be important to consider in managing AA, along with potential Th17 pathway involvement, which may highlight new possible AA therapeutic pathways. Dupilumab dose modification may offer another strategy for managing post-dupilumab AA and should be further studied.

Conclusions: Future research is needed to delineate the roles of these cytokine pathways in AA pathogenesis, investigate patient-specific pathway heterogeneity, and confirm serum IgE involvement.

Learning Objectives

Takeaway Message

Dupilumab, an inhibitor of Th2-mediated cytokine signalling via IL-4 and IL-13, is a known treatment for alopecia areata but has also been shown to induce or exacerbate this condition.

Pruritus and Neuropsychiatric Symptoms Among Patients with Darier Disease – an Overlooked and Interconnected Challenge

Grace Xiong¹, Muskaan Sachdeva², Gil Yosipovitch³, Michael Ziv⁴, Roni P. Dodiuk-Gad^4,2

¹Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, ²Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, ³Miami Itch Centre, Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Coral Gables, FL, ⁴Department of Dermatology, Emek Medical Centre, Rappaport Faculty of Medicine, Technion - Institute of Technology, Haifa, Israel

Introduction: Darier disease (DD) is a rare genetic autosomal dominant disorder caused by ATP2A2 gene mutations affecting calcium homeostasis in keratinocytes. Pruritus, a frequently overlooked symptom in DD, can lead to physical and emotional complications, especially in patients with DD who are genetically predisposed to psychiatric comorbidities. Thus, this study aimed to analyze pruritus and other related dysesthetic symptoms in patients with DD, and explore their correlation with disease severity and body surface area (BSA) involvement.

Materials, Results: The information analyzed in this study was extracted from the database of a previously published clinical study on DD. The data related to pruritus, which has yet to be published, was collected using two methods: (1) Dermatology Quality of life index, and (2) a physician-led interview using a clinical questionnaire. A total of 76 patients, with equal distribution of gender and a mean age 44 years, were analyzed. The prevalence of pruritus was 90.8%, far surpassing other symptoms including pain (34.3%), tingling (38.2%), discomfort (57.9%), burning (32.9%), and malodor (43.4%). Various types and locations of DD lesions were pruritic (Figure 1). More patients with severe (92.3%) and moderate disease (97.3%) reported itch, compared to mild (84.0%). While pruritus was also associated with %BSA involvement, the findings were not statistically significant. Patients reporting pruritus also had significantly higher DLQI itch scores (2.4 ± 1.0) than those who did not (1.5 ± 0.6), indicating accurate symptom reporting (p=0.03).

Conclusions: A striking majority of DD patients experience pruritus, with higher prevalence in severe disease and greater %BSA involvement. Clinicians should recognize pruritus as a key therapeutic target and adopt comprehensive treatment approaches that both address the neuropsychiatric comorbidities and additional psychological burden of pruritus. Moreover, the potential role of pruritus in the exacerbation of genetically predisposed neuropsychiatric conditions among patients with DD requires further evaluation.

Learning Objectives

Takeaway Message

Patients with Darier disease frequently experience pruritus, which can exacerbate the psychological burden of their genetically predisposed neuropsychiatric conditions. Therefore, managing pruritus effectively necessitates a comprehensive approach that incorporates screening for psychiatric comorbidities and combining dermatologic treatments with psychological interventions.

Assessment of Dermatologists in Ontario Accepting OHIP Referrals for Hair Loss Evaluation

Victoria Young¹, Kelsey A. Orrell², Renée A. Beach^1,2

¹Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ²DermAtelier on Avenue Medical & Cosmetic Dermatology, Toronto, ON

Introduction: The Ontario Health Insurance Plan (OHIP) insures appointments for the assessment and diagnosis of hair loss, or alopecia. Although anecdotal, discussion suggests that dermatologists are increasingly declining referrals for this condition. There has been a lack of objective surveillance to determine the proportion of dermatologists in Ontario who accept OHIP referrals for hair loss. This study aimed to determine the proportion of dermatologists in Ontario accepting OHIP referrals for hair loss. Secondary objectives included investigating wait times, consultation fees for non-OHIP visits, and factors influencing referral acceptance or rejection.

Methods, Results: A cross-sectional telephone survey was conducted in which 284 dermatologists listed by the College of Physicians and Surgeons of Ontario (CPSO) were contacted. The study investigated the acceptance of OHIP referrals for hair loss, wait times for assessment in-office, additional referral requirements, and private consultation fees. Descriptive statistics were employed to summarize the data. Of the 284 offices, 38.38% (109/284) accepted OHIP referrals for hair loss, 48.59% (138/284) did not, and 13.03% (37/284) were unreachable. The average wait time for offices accepting referrals was 4.51 ± 4.07 months. Non-OHIP consultation fees ranged from $135 to $299 CAD. Some offices limited referrals to specific diagnoses such as alopecia areata and male androgenetic alopecia.

Conclusions: A total of 48.59% of dermatologists in Ontario do not accept OHIP referrals for hair loss, while the status of 13.03% of offices remains unknown. This reality raises concerns about accessibility to care, highlighting the need for further research into the factors influencing referral acceptance.

Learning Objectives

Takeaway Message

The results of this study reveal significant barriers to dermatological care for hair loss in Ontario, with nearly half of dermatologists not accepting OHIP referrals for hair loss. These results highlight a gap in patients’ access to care, particularly for those who are unable to pay for private consultations. The study also highlights the complexity of variables, including wait times, consultation fees, and specific diagnostic requirements, that influence referral acceptance. These barriers may disproportionately affect underserved populations who rely on OHIP for their healthcare requirements.

The results suggest that the current state of the medical system has led to a large proportion of dermatologists to exclude alopecia assessments from their care. Additionally, future research which details the variables that affect dermatologists’ choices to accept or reject referrals, which include the potential influence of systemic pressures like physician workload, patient demand, financial limitations and remuneration, would be valuable.

Improving access to care is essential to the improvement of patient outcomes and the achievement that everyone, regardless of socioeconomic background, has fair access to timely and effective dermatological care.

Acquired Lymphangioma Circumscriptum on the Abdomen During Pregnancy

Heidi Oi-Yee Li¹, Linda Mardiros², Jennifer Lipson¹

¹Division of Dermatology, The Ottawa Hospital, Ottawa, ON, ²University of Ottawa, Ottawa, ON

Introduction: Lymphangioma circumscriptum (LC) is an uncommon benign disorder of lymphatic vessel malformation and proliferation. The clinical presentation of LC can be heterogenous with important diagnostic mimickers to consider. To our knowledge, acquired LC during pregnancy has only been reported on the vulva. Herein, we report a novel case of acquired LC during pregnancy on the abdomen.

Methods, Results: A 34-year-old woman presented with numerous papules draining clear fluid on her lower abdomen during the third trimester of her third pregnancy. She denies a history of similar lesions during her previous two pregnancies. She is healthy with no past medical history including no previous radiation or abdominal surgeries. Physical examination showed numerous clustered groups of hypopigmented flat topped papules with some papules in a linear distribution on the lower abdomen below the umbilicus. A punch biopsy was performed and showed epidermal acanthosis and hyperkeratosis and dilated lymphatic vessels in the superficial and upper dermis. The favoured diagnosis was an acquired variant of LC. Further imaging was done to rule out deeper lymphatic involvement and underlying abdominal pathology. An abdominal ultrasound showed a benign appearing 8 mm subcutaneous cyst in the abdominal wall and a pelvic and transvaginal sonogram was unremarkable. As the lesions were asymptomatic, no treatment was required.

Conclusions: Although acquired LC on the vulva during pregnancy has been previously reported, this is the first case of acquired LC on the abdomen during pregnancy. Given the clinical history and work-up, this case of acquired LC is likely secondary to the increased physiological demands and hormonal changes during pregnancy that impair lymphovenous drainage on the abdomen. Dermatologists should recognize and differentiate this rare manifestation of acquired LC in pregnancy from other dermatoses that may have similar clinical presentations but require different management approaches.

Learning Objectives

Takeaway Message

Acquired lymphangioma circumscriptum may present on the abdomen during pregnancy and is an important differential diagnosis to consider in pregnancy-related dermatoses.

Plant-Based Diets and Photosensitivity: A Scoping Review

Kim H. Tran, Eunice Y. Chow, Mariusz Sapijaszko

University of Alberta, Edmonton, AB

Introduction: The skin is continuously exposed to ultraviolet (UV) radiation, which increases the risk of skin conditions such as melanoma, nonmelanoma skin cancer, photodamage, and sunburn. Currently, there is a lack of knowledge on the role of plant-based diets (vegan, vegetarian, Mediterranean) on increasing the overall risk for photosensitivity/phototoxicity and minimal erythema dose (MED).

Methods, Results: MEDLINE and PubMed databases were searched for reviews, original studies, case reports, and case series between 1946 up to January 2025 using key terms. Reference lists of eligible articles were hand-searched. Of 1054 screened articles, 98 studies met inclusion criteria. Plant-based diets rich in psoralens and furocoumarins, especially citrus and grapefruits, reduce MED values and increase skin cancer risks due to their photosensitizing effects. Similarly, folate is phototoxic due to its generation of reactive oxygen species when exposed to UV. Conversely, plant-based diets rich in carotenoids (i.e., red paprika, carrots) are protective against UV damage. The Mediterranean diet, which is primarily a plant-based diet, is also photoprotective. Plant-based diets are also lower in niacin compared to meat-based diets, which increases the risk for pellagra. In contrast, ketogenic diets, which are rich in fat and protein, seem to reduce photosensitivity. Cholesterol and fatty acids also help reduce UV-induced erythema and photosensitivity by modulating the oxidative stress, membrane fluidity and lipid metabolism pathways. Interestingly, alcohol consumption is associated with cutaneous carcinoma because its by-product, acetaldehyde, induces oxidative DNA damage along with activation of prostaglandin synthesis; whilst caffeinated products (e.g. tea, coffee), seem to be protective against cutaneous carcinoma.

Conclusions: Diets high in psoralens, folate, and alcohol increase the risk of photosensitivity and cutaneous carcinomas. Consuming diets rich in carotenoids, fatty acids, and following Mediterranean dietary patterns can be protective against UV-induced damage and skin cancer.

Learning Objectives

Takeaway Message

Diet plays a significant role in modulating the skin’s response to UV radiation and the risk of skin conditions. Plant-based diets can have both protective and harmful effects depending on their composition. Diets rich in carotenoids, fatty acids, and following Mediterranean patterns are photoprotective, while those high in psoralens, folate, and alcohol increase photosensitivity and skin cancer risk.

An Unusual Case of Mycobacterium Marinum Cutaneous Infection in an Immunocompetent Patient: A Diagnostic Challenge

Hélène Rukundo¹, Carole Xavier², Marcel A. Behr³, Aurélie Marti⁴

¹McGill University, Gatineau, QC, ²Hôpital de Gatineau - Pathologie, Gatineau, QC, ³McGill - Département d’infectiologie, Montréal, QC, ⁴Hôpital de Gatineau - Dermatologie, Gatineau, QC

Introduction: Mycobacterium marinum, a non-tuberculous mycobacterium, is typically associated with aquatic environments, causing skin infections in individuals exposed to contaminated water. However, it can also affect patients without apparent risk factors, complicating diagnosis. Its chronic granulomatous skin lesions can mimic other dermatologic conditions, and standard microbiological tests may yield false negatives.

Methods, Results: A 45 year old healthy female with no history of exposure to aquatic environments, soil, or plants presented with paronychia on her right index finger one month after a minor door injury. Two months later, she developed two inflammatory nodules on her right forearm, producing a sporotrichoid spread.

Four months later, the paronychia persisted, and a new nodule appeared. A course of cefadroxil and topical corticosteroids did not improve the condition. A 5mm skin biopsy of the forearm nodule revealed granulomatous inflammation, but Ziehl-Neelsen staining and mycobacterial cultures were negative after 8 weeks of incubation. A second skin biopsy for mycobacterial culture was performed three months later, still negative, but Ziehl-Neelsen staining revealed two acid-fast bacilli on one slide, suggesting mycobacterial infection.

Two months later, a third skin biopsy (6mm) for mycobacterial culture on a new forearm nodule finally confirmed the presence of Mycobacterium marinum by 16S rRNA Sequencing.

Following diagnosis, a regimen of rifampicin and clarithromycin was started, leading to significant improvement. Three weeks later, the patient developed severe gastrointestinal symptoms, prompting treatment cessation. Clostridium difficiletoxin test was negative, and GI symptoms resolved within a week. Rifampicin was resumed, and doxycycline replaced clarithromycin one week later. Treatment is ongoing

Conclusions: This case underscores the importance of considering M. marinum in chronic granulomatous skin lesions, even in patients without traditional risk factors. It emphasizes the importance of repeated biopsies for mycobacterial culture to ensure accurate diagnosis and prompt treatment.

Learning Objectives

Takeaway Message

This case highlights the critical importance of maintaining a high index of suspicion for Mycobacterium marinum in patients presenting with chronic granulomatous sporotrichoid skin lesions, even in the absence of traditional risk factors. The delayed detection of the bacteria, with Ziehl-Neelsen staining initially negative and only later revealing two acid-fast bacilli on the second skin biopsy, underscores the diagnostic challenges posed by atypical mycobacterial infections.

It emphasizes the need of obtaining repeated, adequately deep and wide biopsies when clinical suspicion remains high, along with multiple slides for pathological review. Smaller or insufficient biopsy samples can fail to capture inflammatory changes and low bacterial loads, leading to false-negative results and delayed diagnosis.

Advanced diagnostic methods, including PCR targeting the 16S rRNA and Ziehl-Neelsen staining, are essential, as conventional methods such as cultures often fail to provide timely or definitive results. Early diagnosis and targeted antimicrobial therapy are crucial to achieving favorable outcomes in these often underdiagnosed and underrecognized infections.

Pustular Reaction in Adult-Onset Immunodeficiency due to Anti-Interferon-Gamma Autoantibodies

Narachai Julanon^1,2, Pojsakorn Danpanichkul³, Phichayut Phinyo⁴, Charoen Choonhakarn¹, Suteeraporn Chaowattanapanit¹, Siriluck Anunnatsiri¹, Ploenchan Chetchotisakd¹, Salin Kiratikanon⁴, Rujira Rujiwetpongstorn⁴, Napatra Tovanabutra⁴, Siri Chiewchanvit⁴, Romanee Chaiwarith⁴, Mati Chuamanochan⁴

¹Khon Kaen University, Khon Kaen, Thailand, ²University of Toronto, Toronto, ON, ³Texas Tech University Health Sciences Center, Lubbock, TX, ⁴Chiang Mai University, Chiang Mai, Thailand

Introduction: Cutaneous manifestations in adult-onset immunodeficiency (AOID) due to anti-interferon-gamma autoantibody (AIGA) are common and classified as infective or reactive disorders. Reactive manifestations primarily include neutrophilic dermatoses, notably Sweet syndrome, followed by pustular reaction. However, detailed descriptions of pustular reaction in AOID within large patient cohorts remain scarce.

Methods, Results: The objective was to compare the clinical profile between adult patients with pustular reaction in AOID due to AIGA and those with generalized pustular psoriasis (GPP). A cross-sectional descriptive study was conducted at dermatology clinic of Maharaj Nakorn Chiang Mai Hospital, Chiang Mai and Srinagarind Hospital, Khon Kaen, Thailand. A total of 64 AOID patients with pustular reaction were included in the study. Of those, 59.38% were female. The mean (SD) age was 53.16 (10.27) years. Discrete pin-head-sized pustules on erythematous base were located on the trunk and extremities (figure 1). Lake of pus was observed in 2 patients. Annular configuration was observed in 1 patient. Fifty-four cases (84.4%) of AOID patients with pustular reaction had concomitant opportunistic infections (OI). The most identified OI was a rapidly growing mycobacterium. Compared with 77 patients with GPP, pathognomonic clinical features of each disease were identified. Lymphadenopathy, hepatomegaly, and splenomegaly are indicative of pustular reaction of AOID. Geographic tongue, and nail involvement are indicative of GPP. In the absence of these feature, multivariable analysis showed that the combination of concomittant OI, high globulin level, and high alkaline phosphatase level constituted the formula to predict the probability of pustular reaction of AOID with the outstanding discriminative ability (AuROC 0.97; 95% CI: 0.94, 1.00)

Conclusions: Lymphadenopathy, hepatomegaly, and splenomegaly were perfect predictors of pustular reaction of AOID. In the absence of these features, combination of concomittant OI, globulin level, and alkaline phosphatase level can be used to calculate the probability of reactive pustular reaction.

Learning Objectives

Takeaway Message

In a patient with pustular skin lesions, there are some pathognomonic clinical clues for differentiation pustular reaction of adult-onset immunodeficiency associated with anti-interferon-gamma autoantibodies from generalized pustular psoriasis. This study advocated for a focused evaluation of the nails, tongue, lymph nodes, liver, and spleen to facilitate differentiation between these two distinct pustular conditions. In the absence of these features, we can use predictive scoring system to predict the probability.

Importance of Carnitine in Dermatology

Eunice Y. Chow, Mariusz Sapijaszko

Division of Dermatology, Faculty of Medicine, University of Alberta, Edmonton, AB

Introduction: Carnitine plays a key role in fatty acid transport for mitochondrial energy production and offers health benefits, including anti-inflammatory and antioxidant effects. This review explores carnitine’s role in dermatology, focusing on its potential as a biomarker and therapeutic applications, both topically and orally.

Methods, Results: A systematic search was conducted on January 11, 2025, in Medline, EMBASE, and PubMed using subject headings and keywords for "carnitine" and "dermatology." Articles on acetyltransferases, acyltransferases, breast diseases, and metabolic diseases were excluded. The search was limited to English-language, human studies with abstracts. Of 420 articles identified, 66 met the eligibility criteria for data extraction.

Carnitine and its derivatives exhibit variable levels across different dermatologic diseases, supporting their potential as biomarkers. Decreased levels were noted in restrictive dermopathy, hereditary angioedema, syphilis, atopic dermatitis, chronic pruritus of unknown origin, and severe recessive dystrophic epidermolysis bullosa with dilated cardiomyopathy. Elevated levels were observed in sarcoidosis, systemic sclerosis, atopic dermatitis with high IgE, keloid scars, psoriasis, genetically linked acne vulgaris, common variable immunodeficiency, and metastatic melanoma.

Topically, carnitine has shown efficacy in reducing sebum, decreasing hyperpigmentation post- laser treatment, improving skin tolerability with adapalene in acne, reducing acne severity, and enhancing quality of life. It also reduces cellulite appearance and thigh circumference.

Orally, carnitine has proven effective in reducing inflammation, alleviating isotretinoin-related liver and muscle effects, easing muscle spasms in vismodegib patients, countering wasting in pemphigus vulgaris during glucocorticoid therapy, and improving adipocytokines, mental health and inflammatory markers in PCOS. It has also shown benefits in preventing cardiomyopathy progression in severe recessive dystrophic epidermolysis bullosa, reducing advanced glycation end products, and improving walking distance and ulcer healing in peripheral vascular disease.

Conclusions: Carnitine and its derivatives have therapeutic potential in dermatology, offering benefits both topically and orally, warranting further exploration of their clinical applications.

Learning Objectives

Takeaway Message

Carnitine is an important molecule in health and diseases of the skin. It can be used as a marker of multiple skin conditions as well as potential topical and oral therapeutic modality in the management of dermatologic diseases and the side effects of some of the therapies.

Predictors for the Development of Rosacea: A Systematic Review and Meta-Analysis

Daniel G. Rayner¹, Maria D. Rueda¹, David Gou², Touraj Khosravi-Hafshejani^3,4, Jan P. Dutz^4,5

¹Schulich School of Medicine and Dentistry, Western University, London, ON, ²Faculty of Health Sciences, McMaster University, Hamilton, ON, ³Clinician Investigator Program, Faculty of Medicine, University of British Columbia, Vancouver, BC, ⁴Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, ⁵Senior Scientist, BC Children’s Hospital Research Institute, Vancouver, BC

Introduction: The exact pathogenesis of rosacea remains unclear, and there is insufficient evidence on its predictors. Understanding the modifiable and non-modifiable predictors of rosacea may inform optimal clinical management. Thus, we conducted a systematic review to summarize the predictors of rosacea.

Methods, Results: We searched MEDLINE, Embase, and CINAHL to January 1st, 2025, for studies reporting predictors of rosacea using multivariable regression. Paired reviewers independently screened citations and extracted data. Random-effects meta-analyses pooled odds ratios (OR) for each predictor. We used the GRADE approach to assess the certainty of evidence. We included 45 studies (median age: 39.4 years; median 76% female) and 29 predictors were amenable to meta-analysis. Body mass index (BMI; per 5-kg/m² increase; OR 1.28, 95%CI 1.05–1.57; risk difference [RD] 0.4% more; moderate certainty), alcohol consumption (≥3 drinks/week; OR 1.40, 95%CI 1.05–1.87; RD 0.5% more; moderate certainty), pet ownership (OR 2.57, 95%CI 1.73–3.83; RD 1.5% more; moderate certainty), age (per 5-year increase; OR 1.22, 95%CI 1.17–1.28; RD 0.3% more; low certainty), female sex (OR 1.91, 95%CI 1.15–3.18; RD 0.6% more; low certainty), and family history of rosacea (OR 2.49, 95%CI 1.14–5.43; RD 1.5% more; low certainty) were associated with an increased risk of rosacea. Sunscreen use (OR 0.43, 95%CI 0.31–0.60; RD 0.9% fewer; high certainty) was associated with a decreased risk of rosacea. The predictive value of smoking was uncertain.

Conclusions: We identified several modifiable predictors of rosacea, including BMI, alcohol consumption, pet ownership, and sunscreen use. Pets, BMI, and alcohol may influence demodex exposure, hormonal, and vascular changes, respectively, that may be pathogenic to rosacea, whereas sunscreen protects against UV-induced damage of keratinocytes and release of LL-37 and dsRNA. Clinicians should focus on counselling patients, particularly those with several non-modifiable factors, on these predictors to reduce their rosacea risk.

Learning Objectives

Takeaway Message

We identified several robust modifiable predictors of rosacea, including body mass index, alcohol consumption, pet ownership, and sunscreen use. Clinicians should focus on counselling patients, particularly those with several non-modifiable risk factors, on these predictors to reduce their risk of rosacea.

Epidemiology of Patient Consults to the Dermatological Service at a Western Canadian University Institution; A Retrospective Study

Rochelle Tonkin, Brian Rankin, Emma Price, Jori Hardin

University of Calgary, Calgary, AB

Introduction: We highlight the characteristics of patients and consults to the dermatology on-call service in a western Canadian university institution.

Methods, Results: Dermatology consults between July 2023 and February 2024 were retrospectively reviewed. All consults were initially fielded by senior residents from the dermatology residency program and reviewed with the attending physician prior to management. In total, 664 dermatology consults were recorded over 27 weeks, including 297 (44.7%) from inpatient services, 89 (13.4%) from outpatient services, 273 (41.1%) from the emergency department. The average completion time for consults, including telephone consult, review, and documentation, was 87.3 minutes; the average time spent on the telephone was 21.0 minutes. Mean age of the patients was 46.6 ± 25.7 years; 312 (47.0%) were female and 348 (52.4%) were male. Reported skin types were white (433 [65.2%]), brown (114 [17.2%]), Asian (44 [6.6%]), and black (23 [3.5%]); skin type was not recorded for 50 (7.5%) of the patients. Of the consults, 144 (21.7%) required visiting a hospital, with 25 (17.4%) of these requiring more than 2 visits. Most patients were diagnosed based on clinical findings only, though 112 (16.9%) patients required skin biopsy and histopathological examination. The most common dermatologic disorders were inflammatory dermatoses (159 [23.9%]), infectious dermatoses (136 [20.5%]), allergic reactions and contact dermatitis (74 [11.1%]), drug reactions (70 [10.5%]), and vasculitis (45 [6.8%]). SJS/TEN, DRESS, and other severe cutaneous adverse reactions accounted for 8 (1.4%) of all consults. Among patients with pre-diagnoses provided by non-dermatological physicians, the diagnosis was changed in 363 (54.7%) of cases following consultation with dermatology; management was changed in 539 (81.2%) of cases.

Conclusions: This study offers a snapshot of the dermatology on-call service and serves as a foundation for future assessments of patient care, as well as the goals and objectives of the residency training program.

Learning Objectives

Takeaway Message

This retrospective review provides a glimpse of the dermatology on-call service at a single university institution and serves as a foundation for future assessments of patient care, as well as the goals and objectives of the residency training program.

Lupus Miliaris Disseminatus Faciei: A Rare Facial Granulomatous Disorder

Jason Kreutz¹, Fiona Landells¹, Fatemeh Jafarian¹, Karen Naert², P. Régine Mydlarski¹

¹Division of Dermatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, ²Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary and Calgary Laboratory Services, Calgary, AB

Introduction: Lupus miliaris disseminatus faciei (LMDF) is a rare cutaneous granulomatous disorder of the face. Historically classified as a tuberculid, LMDF is now considered an idiopathic condition that shares features with rosacea and sarcoidosis. The cause of LMDF is unknown, but it may represent a reaction to M. tuberculosis, atypical mycobacteria, D. folliculorum, or C. acnes. LMDF may also be triggered by exposure to foreign bodies like zirconium, cyst contents, and stem cell transplants. The histologic hallmark of LMDF is a granulomatous infiltrate, sometimes associated with pilosebaceous units. Clinically, skin-coloured to yellow-brown papules are found on the face and eyelids. LMDF is typically self-limiting, but timely therapeutic intervention may mitigate scarring. Variable improvement has been reported with systemic steroids, isotretinoin, dapsone, tetracycline or nitroimidazole-based antibiotics, antimalarials, antituberculosis therapy, tranilast, apremilast, tacrolimus, cyclosporine, and JAK inhibitors. Laser resurfacing, dermabrasion, chemical peels, and pulse dye lasers may also prove beneficial.

Methods, Results: Herein, we report the case of a 33-year-old male with a 2-year history of asymptomatic erythematous to yellow-brown papules scattered on the central face, ears and neck. Associated open and closed comedones were noted, and extensive scarring was observed. Histology revealed a granulomatous dermatitis consisting of clusters of epithelioid histiocytes with background lymphocytic inflammation and central necrosis. Skin cultures for bacteria, mycobacteria, and fungi were negative and a CT scan of the chest, abdomen, and pelvis was unremarkable; therefore, a diagnosis of LMDF was favoured. Although doxycycline treatment failed, the patient improved with a tapering prednisone course and isotretinoin 60 mg daily.

Conclusions: LMDF is a self-limited idiopathic granulomatous condition of the face that carries a significant risk of scarring. While it often resolves spontaneously, early intervention is crucial to minimize cosmetic and psychological impacts. The variable efficacy of treatments highlights the need for tailored therapeutic approaches.

Learning Objectives

Takeaway Message

LMDF is a rare, self-limited, idiopathic, granulomatous facial condition that scars. Histological, laboratory, and radiologic investigations are required to exclude other etiologies. Given the variable efficacy of treatments, tailored and patient-specific therapeutic approaches are recommended.

Clinical Manifestations and Therapeutic Management of Chondrodermatitis Nodularis Helicis: A Systematic Review

Megan Park¹, Bianca Te², Orhan Yilmaz³, Nethmi Rajapakse¹, Samiha Mohsen¹, Ilya Mukovozov^4,5

¹Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ²Faculty of Medicine, University of British Columbia, Vancouver, BC, ³College of Medicine, University of Saskatchewan, Saskatoon, SK, ⁴Toronto Dermatology Centre, Toronto, ON, ⁵Division of Dermatology, Women’s College Hospital, Toronto, ON

Introduction: Chondrodermatitis nodularis helicis (CNH) is a benign, inflammatory condition of the ear, presenting as a painful, solitary nodule on the helix or antihelix, often with scaling or crusting. Trauma, actinic damage, cold exposure, collagen defects, and autoimmune diseases are potential contributing factors to disease pathogenesis. This systematic review aims to provide a summary of reported cases of CNH, highlighting its clinical manifestations and therapeutic approaches.

Methods, Results: A systematic search of MEDLINE and Embase (from inception to June 2024) was conducted per PRISMA guidelines, using the keywords “chondrodermatitis nodularis helicis” and “chondrodermatitis nodularis chronica helicis.” Case reports, series, and observational studies with CNH diagnoses were included without restrictions.

Following screening of 203 articles, 71 studies, encompassing 1468 individuals, were included in the study. Mean patient age was 61.6 years (range, 8-86 years); 40.6% (466/1147) were female, and 59.3% (681/1147) were male. The most common comorbidities were skin cancers (25.5%, 24/94) and autoimmune/connective tissue diseases (21.3%, 20/94). Fifty-five percent (272/492) had right ear CNH, 38.6% (190/492) left ear, and 6.1% (30/492) both, with lesions averaging 9.0 mm in diameter (range 3-70 mm, 332/1468). Biopsies for diagnosis were performed in 78.9% (1158/1468) of cases. Pain was the most common symptom (96.3%, 843/875), while 28.0% (245/875) reported tenderness and 7.4% (65/875) bleeding. Suspected etiologies included tobacco smoking (34.0%, 115/338), environmental exposures (28.4%, 96/338), and mechanical causes (27.2%, 92/338). Treatments were described for 50.3% (738/1468) of patients, with 62.1% (458/738) undergoing surgery. Notable non-surgical interventions included photodynamic therapy (6.7%, 50/738), topical nitroglycerin (5.7%, 42/738), and conservative treatments (17.1%, 126/738).

Conclusions: Limitations include the predominance of case reports and case series, unclear histological correlations, and insufficient information on long-term treatment efficacy. Despite these limitations, this study offers valuable insights into the demographics, clinical presentation, and management options for CNH.

Learning Objectives

Takeaway Message

Chondrodermatitis nodularis helicis is a painful yet benign ear condition primarily affecting older males, often associated with mechanical pressure and environmental exposures, with surgery being the most common treatment. This review provides an updated summary of chondrodermatitis nodularis helicis demographics, clinical presentation, and management, serving as a resource to guide diagnosis and treatment.

A Systematic Review and Meta-Analysis of Drug Survival of Dupilumab in Atopic Dermatitis

Daniel G. Rayner¹, Wayne Sun¹, Eric P. McMullen², Laurence Mainville², Samiha Mohsen³, Vincent Piguet^2,4, Aaron M. Drucker^2,4

¹Schulich School of Medicine and Dentistry, Western University, London, ON, ²Division of Dermatology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ³Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ⁴Division of Dermatology, Women’s College Hospital, Toronto, ON

Introduction: Dupilumab, an IL-4/11 inhibitor, was the first approved targeted systemic therapy for atopic dermatitis (AD), approved in Canada in 2017. While it is considered safe and effective for long-term use, studies estimating the drug survival of dupilumab and studying predictors of discontinuation have produced variable results.

Methods, Results: We conducted a systematic review and meta-analysis to estimate the drug survival of dupilumab and assess predictors of discontinuation. We searched MEDLINE, Embase, and CENTRAL from inception to January 2025 for studies reporting Kaplan-Meier curves for dupilumab survival or predictors of dupilumab discontinuation in patients with AD. Paired reviewers screened citations and extracted data. Random-effects meta-analyses pooled Kaplan-Meier curves and effect estimates for predictors. Using the GRADE approach, we assessed the certainty of evidence. We identified 24 studies reporting on 8,161 patients (median age: 39.1 years; median 46% female). Three studies (13%) included children (≤17 years) only. The pooled drug survival of dupilumab at various timepoints were: 12-months (91.4%, 95%CI 88.4–94.4%), 36-months (84.1%, 95%CI 79.5–88.9%), and 60-months (70.3%, 95%CI 53.7–92.2%), with low heterogeneity (I² = 0%) (Figure). Survival rates of dupilumab in children were less certain (12-month: 92.4%. 95%CI 84.3–100%; 36-month: 76.3%. 95%CI 64.2–90.7%). No studies reported 60-month dupilumab survival rates in children. Ten unique risk factors predicting dupilumab discontinuation were amenable to meta-analysis. Moderate certainty evidence suggests that age and prior cyclosporine use are probably not associated with dupilumab survival. Low certainty evidence suggests that sex, baseline EASI and pain scores, concomitant immunosuppressants, atopy, and asthma or rhinitis may not be associated with dupilumab survival. The predictive value of allergic conjunctivitis and age of AD onset is uncertain.

Conclusions: Dupilumab showed good long-term survival in patients with AD. Future research is needed to provide more precise estimates for children and determine reliable predictors of discontinuation.

Learning Objectives

Takeaway Message

While it is considered safe and effective for long-term use, studies evaluating the drug survival of dupilumab in atopic dermatitis have produced variable results. Using survival data from 24 studies, we found that dupilumab had good long-term survival in patients with atopic dermatitis to 60 months. Future studies are needed to provide more precise survival estimates for children and to determine reliable predictors of dupilumab discontinuation.

Trends in Public Interest Related to Hidradenitis Suppurativa in Canada (2019-2024): Analysis of Regional Variations, and Seasonal Patterns

Karla Robles-Velasco¹, Rosilene Lanzini¹, Hermenio Lima^1,2

¹LEADER Research Inc., Hamilton, ON, ²Division of Dermatology, Department of Medicine, Faculty, of Health Sciences, McMaster University, Hamilton, ON

Introduction: Hidradenitis suppurativa (HS) is a chronic skin condition marked by recurrent, painful abscesses. This study analyzes trends in public interest and search behaviors related to HS from 2019 to 2024 among Canadians.

Methods, Results: We examined Relative Search Volumes (RSV) for HS-related terms over the past five years using search data. Categories analyzed include definitions, symptoms, treatments, causes, locations, and networks. A regional analysis within Canada and monthly trends were also conducted. A p value <0.05 was considered statistically significant. The mean annual RSV for HS increased by +23.74% from 55.33 in 2019 to 68.46 in 2024, with the largest spike in 2020 (+36.33%). The RSV for most categories, including definitions, treatments, and locations, remained stable or showed gradual increases over time. Definition-related terms consistently had the highest RSV, with "hidradenitis" at 100.0, and "suppurativa" at 91.5. Symptom-related searches were less emphasized, maintaining an RSV of 2, while treatment-related searches such as "hidradenitis treatment" (6) and "humira" (2.5) gained attention. Regionally, Yukon and Northwest Territories showed the highest interest (RSV 100), while Newfoundland and Labrador demonstrated significant fluctuations, with sharp decreases in 2024. Monthly trends indicated peaks in summer and fall and dips in winter and spring.

Conclusions: Public interest in HS has grown over the past five years, with a notable increase during the pandemic year (2020). Search activity remains highest for definition-related terms, with steady interest in treatments and network-related information. Seasonal and regional variations suggest that environmental and geographic factors may influence search behaviors.

Learning Objectives

Takeaway Message

Public interest in hidradenitis suppurativa has grown significantly over the past five years, with a peak during the pandemic year (2020). Searches focus primarily on definitions and treatments, with notable regional and seasonal variations that highlight the need for targeted public health strategies and educational efforts.

A Systematic Review of Vaccine-Induced Sarcoidosis Suggests Increased Risk of Sarcoidosis Following COVID-19 mRNA Vaccine

Miranda K. Branyiczky¹, Shanti Mehta², Dea Metko¹, Eric P. McMullen³, Laurence Mainville^2,3, Vincent Piguet^2,3,4

¹Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, ²Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ³Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, ⁴Division of Dermatology, Department of Medicine, Women’s College Hospital, Toronto, ON

Introduction: Sarcoidosis, an idiopathic granulomatous disease, arises from abnormal cell-mediated immune responses to environmental antigens, such as drugs or vaccines, in genetically susceptible individuals. This systematic review examines cases of sarcoidosis associated with vaccination to understand clinical presentations, vaccine types, and disease outcomes.

Methods, Results: A search of Embase, MEDLINE, Scopus, ClinicalTrials.gov, International Clinical Trials Registry Platform, and MedWatch was conducted until October 2024. Of the 1,363 originally identified articles, 28 with 32 patients (mean age = 50.1 years, 56.3% female) were analyzed. Sarcoidosis followed mRNA (43.8%), viral vector (18.8%), inactivated (12.5%), dendritic cell (9.4%), peptide (9.4%), recombinant (3.1%), and live-attenuated (3.1%) vaccines. Greater severity (≥2 organs involved) was mostly seen with vector, inactivated, and live-attenuated vaccines. Most vaccines were administered for disease prevention, primarily targeting COVID-19 (65.6%) or influenza (6.3%), while others were used for treating malignancies, such as metastatic melanoma (12.5%) and non-polyposis colorectal cancer (6.3%). Sarcoidosis onset latency was longer for cancer-treatment vaccines (mean = 1,277.5 days) than infection-prevention vaccines (mean = 24.7 days). Three patients (9.4%) reported constitutional symptoms (e.g., fever, fatigue, appetite loss).

Cutaneous sarcoidosis occurred in most (65.6%) cases, with a subset involving tattooed areas or previous injection sites, followed by pulmonary (56.3%), ophthalmologic (18.8%), and musculoskeletal (12.5%) involvement. Diagnosis was biopsy-confirmed in 87.5% of cases. Treatments included topical (51.7%) and systemic therapies (51.7%), with 20.7% requiring no treatment.

Conclusions: Mechanisms of vaccine-induced sarcoidosis remain unclear, but may involve immune activation by vaccine antigens or adjuvants, with molecular mimicry between vaccine proteins and self-peptides or immune dysregulation as contributing factors. While rare, clinicians should recognize sarcoidosis as a potential adverse event following vaccination. Cutaneous cases may resolve spontaneously, but work-up is essential to exclude systemic involvement which may require glucocorticoids or immunomodulators. Future research should elucidate mechanisms of vaccine-induced sarcoidosis and optimal treatments.

Learning Objectives

Takeaway Message

Clinicians should maintain awareness of vaccine-related sarcoidosis, particularly following COVID-19 mRNA vaccination, and employ comprehensive diagnostic evaluations to rule out systemic involvement. Treatment strategies must be tailored to the disease’s severity, with mild cases often resolving without intervention.

The Association Between Bariatric Surgery and Improvement in Psoriasis: A Systematic Review

Miranda K. Branyiczky¹, Megan S. Lowe², Ronald Vender^3,4

¹Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, ²School of Medicine, Queen’s University, Kingston, ON, ³Division of Dermatology, McMaster University, Hamilton, ON, ⁴Dermatrials Research Inc., Hamilton, ON

Introduction: Obesity, a known risk factor for psoriasis, is linked to increased disease severity and frequency, with metabolic syndrome often compounding disease burden and reducing quality of life. Weight loss in obese patients can improve psoriasis severity, enhance treatment responses, and improve metabolic health. Metabolic and bariatric surgery (MBS) has emerged as an effective intervention for weight loss in obese patients. This systematic review evaluates the association between MBS and psoriasis severity.

Methods, Results: Embase, MEDLINE, and Scopus were searched until October 2024. Search terms included "psoriasis" and "bariatric surgery." Screening by two reviewers yielded 14 studies encompassing 169 patients. The mean patient age was 46.8 years (range=24-56), with 74.0% female and an average baseline BMI of 43.7 kg/m². Most patients underwent gastric bypass (75.1%), followed by sleeve gastrectomy (17.8%). Psoriasis severity ranged from mild (15.6%, PASI<5 or BSA<3%) to moderate (76.3%, PASI=5-10 or BSA=3-10%) and severe (8.2%, PASI>10 or BSA>10%) preoperatively. All studies documented a meaningful weight loss (average post-MBS BMI=32.9 kg/m2, range in BMI reduction=8-25 kg/m2) with significant improvements in psoriasis severity: 97.2% of patients experienced mild or resolved psoriasis, and only 2.4% reported worsening. Although most patients continued psoriasis treatments post-MBS, many required downgraded therapies. Two studies noted improvements in Dermatology Life Quality Index, with one showing statistical significance.

Conclusions: MBS may improve psoriasis outcomes following surgery. Resulting weight loss decreases tumor necrosis factor-α expression in adipose tissue, a driver of keratinocyte proliferation in psoriatic plaques. Furthermore, early effects of MBS can include reduced proinflammatory mediators (i.e., CRP, leptin) which may improve psoriasis. While promising, findings are limited by heterogeneity in study design, variability in outcome reporting, and inclusion of case reports. Further controlled trials are necessary to validate long-term effects and establish MBS as a potential adjunctive therapy for psoriasis.

Learning Objectives

Takeaway Message

Metabolic and bariatric surgery demonstrates promise in reducing psoriasis severity and enhancing treatment outcomes through substantial weight loss and associated changes in inflammatory drivers. The procedure offers additional benefits, including potential downgrading of required therapies and improvement in comorbid conditions, including metabolic syndrome. However, the current body of evidence is limited by variability in study designs, heterogeneity in reported outcomes, and reliance on observational data. Further well-designed, controlled trials are necessary to establish the long-term efficacy and safety of MBS as a complementary strategy for managing psoriasis in obese patients.

Deep Granuloma Annulare Responsive to Adalimumab, Subsequently Inducing Paradoxical Psoriasis: A Case Report

Bohmyi Choi^1,2, Steven J. Glassman²

¹Faculty of Medicine, University of Ottawa, Ottawa, ON, ²Division of Dermatology, University of Ottawa, Ottawa, ON

Introduction: Tumour necrosis factor (TNF)-α inhibitors such as adalimumab are now being reported as successful treatments for granuloma annulare, a granulomatous skin condition with no well-established standard of treatment. A side effect of TNF-α inhibitors noted in the literature is paradoxical psoriasis. We report the first case to our knowledge of granuloma annulare responsive to adalimumab, which subsequently induced severe paradoxical pustular psoriasis.

Methods, Results: A 35-year-old female presented with a 7-year-history of tender nodules on her bilateral ankles and feet, causing significant quality of life impairment. She was a cigarette smoker. Her past medical history was notable for remote lichen planus which was in remission. Physical examination revealed rather subtle pink to violaceous indurated deep dermal arcuate plaques on the dorsal feet and ankles. Biopsy showed palisading granulomas typical of granuloma annulare. She started methotrexate 15 mg weekly and later 20 mg weekly, without much improvement. This was replaced with adalimumab 40 mg q2weeks with significant improvement. However, six months after starting adalimumab, she noticed a new pruritic eruption that began on her palms and soles, before spreading to her trunk, arms, and legs. She had never had a similar rash previously, and had no history of psoriasis, or any other new medications. The rash revealed many pustules on erythematous bases on the palms and soles, with later dissemination but no erythroderma. The original dermal plaques were no longer appreciated. Adalimumab was stopped and she was on methotrexate for 6 months, with complete resolution of pustular psoriasis, and no recurrence of granuloma annulare after one year.

Conclusions: This case report highlights the efficacy of adalimumab in deep granuloma annulare yet confirms the possibility of paradoxical pustular psoriasis as a side effect in this setting. Biologics are nevertheless worth trying in this recalcitrant condition.

Learning Objectives

Takeaway Message

Adalimumab may be an effective therapeutic option in patients with deep granuloma annulare, but it can induce paradoxical pustular psoriasis.

Treatment of Refractory PRP with Off-label Guselkumab and Abrocitinib: A Promising Combination Therapy

Tracey Brown-Maher

Memorial University of Newfoundland, St. John’s, NL, Newfoundland and Labrador Health Services, St. John’s, NL

Introduction: Pityriasis rubra pilaris (PRP) is a chronic papulosquamous skin disease with erythrodermatous changes, palmar/plantar keratoderma and skin desquamation. It has a major impact on QOL with little response to traditional treatments (emollients, topical steroids/keratolytics, phototherapy, acitretin, methotrexate, or cyclosporine, or a combination). A recent RCT of guselkumab in PRP¹ and case reports of JAK inhibitors with some success² have been reported. I present a case of severe PRP treated with combination of guseklumab/abrocitinib with promising results and a happy patient.

Methods, Results: A 73 year-old female presented with a three year history of PRP. She had failed NBUVB phototherapy, cyclosporine, topical steroids and keratolytics, prednisone, and was currently taking acitretin alternating dose 25mg/35mg daily. She was almost erythrodermic with severe palmar/plantar keratoderma and desquamation. She started combination of methotrexate and acitretin which failed. Ustekinumab 90mg every twelve weeks was initiated off-label with alitretinoin 30mg daily; no change. Ustekinumab was increased to every six weeks for two years. Due to minimal progress, guselkumab off-label was suggested as there was a US clinical trial ongoing. Four months later, with some islands of sparing, it was suggested to add in an oral JAK inhibitor, abrocitinib at 100mg daily, as there were case reports of using JAKs. Patient reported her pruritis resolved in one day.

At six months, face and hands were clear. Body was 50% improved, with islands of sparing and decreased erythema/scaling on extremities and trunk. She was extremely satisfied.

Conclusions: My case highlights that combination therapy of an IL-23 and JAK inhibitor are effective off-label in PRP. Current treatments approved for both psoriasis and atopic dermatitis seem to provide benefit, and combination therapy may be more beneficial. More research is necessary to find an effective single agent or to identify ideal doses of combination therapies.

Learning Objectives

To present a difficult case of PRP

To illustrate how off-label treatment can help in orphan disease, such as PRP

To illustrate that combination therapy with IL-23 guselkumab and oral JAK abrocitinib is safe and effective for PRP

Takeaway Message

Combination therapy of IL-23 and oral JAK inhibitors may prove beneficial for treating an orphan disease such as PRP.

Efficacy and Safety of Dupilumab Versus Narrowband UVB for the Treatment of Chronic Hand Dermatitis: A Retrospective Cohort Study

Miranda K. Branyiczky¹, Noor Sakka², Mohammed Bawazir³, Ajith Cy^3,4, Mohannad Abu-Hilal^1,3

¹Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, ²University of Jordan School of Medicine, Amman, Jordan, ³Division of Dermatology, McMaster University, Hamilton, ON, ⁴Alliance Clinical Trials and Probity Medical Research, Waterloo, ON

Introduction: Chronic hand dermatitis (CHD) is a common, debilitating condition with a significant social and economic burden. Treatment for steroid-refractory CHD remains challenging, with options including narrowband ultraviolet B (NB-UVB) phototherapy and systemic agents such as dupilumab, a monoclonal antibody targeting interleukin-4/13 signalling. While both therapies have demonstrated efficacy in CHD, data comparing their outcomes are limited. This retrospective study assessed the effectiveness and safety of dupilumab versus NB-UVB for moderate-to-severe CHD.

Methods, Results: We reviewed electronic medical records (January 2019–May 2024) of adult patients (≥18 years) with CHD subtypes, including hyperkeratotic hand dermatitis (HHD), dyshidrotic hand eczema (DHE), and fingertip dermatitis (FTD). All patients had moderate-to-severe CHD (Physician Global Assessment [PGA] 3-4) and were treated with dupilumab or NB-UVB after failing ≥8 weeks of potent corticosteroids. Primary outcomes included the proportion of patients achieving a PGA score of 0/1 at week 16. Secondary outcomes assessed quality of life (QoL) improvements via Dermatology Life Quality Index (DLQI) scores and adverse events (AEs).

Sixty-three patients (mean age 39.1 years) were analyzed, with HHD (73.0%) as the most common subtype. Dupilumab (n=30) resulted in a higher proportion of patients achieving PGA 0/1 than NB-UVB (66.7% vs. 39.4%, p=0.044). Significant DLQI score improvements were observed in both groups (p<0.001), with comparable mean final scores (p=0.729). AEs were mild and occurred in 23.3% of dupilumab patients compared to 15.2% of NB-UVB patients.

Conclusions: Both dupilumab and NB-UVB significantly improved disease severity and QoL in CHD, with dupilumab demonstrating superior efficacy in achieving clinical remission. This could be related to the higher proportion of HHD patients, as thickened and hyperkeratotic changes may hinder NB-UVB penetration to dermal lymphocytes. Both dupilumab and NB-UVB offer favourable safety profiles and remain effective options for treating CHD. Further studies are warranted to optimize treatment strategies.

Learning Objectives

Takeaway Message

Dupilumab and NB-UVB are both effective treatments for chronic hand dermatitis (CHD) that is refractory to corticosteroids, significantly improving disease severity and quality of life. Dupilumab demonstrates greater efficacy in achieving disease remission but may face accessibility challenges due to cost. NB-UVB remains a practical and effective alternative, particularly for patients who prefer non-pharmacologic therapy or lack access to systemic options. Tailoring treatment to the patient’s disease subtype, severity, and individual circumstances is essential for optimizing outcomes.

Measuring Dermatology Service Accessibility in BC from 2013-2017

Mahan Maazi, Haitao Li, Neil Kitson

University of British Columbia, Vancouver, BC

Introduction: Geography plays a critical role in access to dermatology services, with disparities affecting patients in rural and urban areas differently. This study aimed to measure the geographic impact on access to dermatology by analyzing anonymized referral data. Understanding these disparities can help inform strategies to improve equitable access, particularly with the increasing adoption of telemedicine.

Methods, Results: We utilized anonymized data from the BC Medical Services Commission, encompassing 42,179 dermatology referrals made between 2013 and 2017. Geographic information systems (GIS) software (ArcGIS) was used to map referral patterns and perform basic analyses. Data were grouped by Local Health Area (an administrative unit defined by the Ministry of Health) to calculate the number of completed dermatology referrals per 1,000 population. Metrics analyzed included travel distance, time, and estimated costs associated with each referral.

Preliminary findings revealed significant variability in travel distances, times, and costs, with patients in rural Local Health Areas facing greater barriers to accessing dermatology services. Urban areas demonstrated higher referral completion rates with shorter travel times and lower associated costs. The limitations of this approach, such as its retrospective nature and reliance on administrative data, are noted.

Conclusions: This analysis establishes a baseline to evaluate access disparities prior to the widespread adoption of telemedicine. Future comparisons with experimental telemedicine service data (May 2020–June 2023) and complete provincial referral data for the same period will provide insights into the impact of telemedicine during the pandemic. These findings may guide strategies to improve equitable access to dermatological care.

Learning Objectives

Takeaway Message

Access to dermatological care in British Columbia is heavily influenced by geography, with significant disparities in travel distances, times, and costs based on location. By mapping dermatology referrals using ArcGIS, this study provides a quantitative analysis of access challenges at the Local Health Area level during 2013–2017. These findings establish a baseline to compare with data collected during the rise of telemedicine from 2020–2023, offering valuable insights into the potential of teledermatology to bridge gaps in healthcare access. The study highlights the importance of leveraging geographic and telemedicine data to inform targeted interventions that improve equity in specialist care delivery.

Immune Checkpoint Inhibitor-Associated Squamous Cell Carcinoma: A Systematic Review

Jia Qi Adam Bai¹, Aliyah King¹, Jillian Macdonald¹, Michael R. Migden², Marcus G. Tan¹

¹University of Ottawa, Ottawa, ON, ²University of Texas MD Anderson Cancer Center, Houston, TX

Introduction: Immune checkpoint inhibitors (ICIs) are groundbreaking cancer therapies that harness the body’s immune system to combat advanced cancers. However, ICIs may also cause immune-related adverse events (irAEs), including the paradoxical development of cutaneous squamous cell carcinomas (cSCCs), which ICIs are indicated to treat. This review investigates the characteristics, management, and outcomes of cSCC following ICIs.

Methods, Results: MEDLINE, Embase, and CENTRAL were searched up to July 5, 2024. A total of 1,152 studies were identified, with 32 studies involving 177,128 patients (mean age 67; 33% female) included. Studies did not differentiate cSCCs resulting from ICI or ultraviolet radiation. cSCCs were reported in 384 (0.003%) patients on ICIs, totaling 504 lesions. Keratoacanthomas (KAs) were the most common cSCC subtype (34.7%). Pembrolizumab (37.8%), cemiplimab (30.8%), and nivolumab (23.8%) were the three most ICIs associated. Forty-two of 85 patients (49.4%) discontinued ICIs following cSCC development. Among these 42 patients, 11 achieved spontaneous remission of cSCCs after ICI discontinuation alone. Of 17 patients who discontinued ICIs and received medical or surgical treatment of cSCCs, 92.3% achieved reduction in lesion size or count, and 53.8% achieved disease remission after an average of 6.9 months. Among 27 patients who continued ICIs and received medical or surgical treatment of cSCCs, 100% achieved reduction in lesion size or count, and 70.4% achieved disease remission after an average of 5.5 months. There were no reports of metastasis or mortality resulting from ICI-associated cSCCs.

Conclusions: These findings underscore the importance of balancing the therapeutic benefits of ICIs with vigilant monitoring and management of dermatologic irAEs. It is possible that ICI-related cSCC may be associated with a favorable prognosis, like the development of vitiligo following the initiation of ICIs for melanomas. This review highlights the need for prospective studies to evaluate long-term risks, management strategies, and outcomes of ICI-associated cSCC.

Learning Objectives

To identify the characteristics of cutaneous squamous cell carcinomas (cSCCs) associated with immune checkpoint inhibitors (ICIs).

To understand the management and prognosis of ICI-associated cSCCs.

To examine gaps in knowledge and propose directions for future research in managing ICI-associated cSCC.

Takeaway Message

Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy by activating the body’s immune response against tumors that may otherwise evade detection. However, they come with notable immune-related adverse events (irAEs), including the paradoxical development of cutaneous squamous cell carcinomas (cSCCs). This systematic review underscores that while cSCCs are rare among patients on ICIs, its outcomes are generally favorable and requires a nuanced management approach.

The findings of this study highlight an association between ICIs and the development of cSCCs. Pembrolizumab was the most frequently associated ICI, likely in part due to its widespread use, but the overall incidence of ICI-associated cSCCs remains low. The prognosis of ICI-associated cSCCs is promising. Discontinuing ICIs alone can result in resolution of cSCCs. Continuing ICIs while incorporating adjunctive treatments such as corticosteroids, acitretin, or niacinamide has also proven to be highly effective, with most lesions improving or resolving entirely. These approaches highlight that both discontinuation and continuation strategies, when tailored to individual patient needs, can lead to successful management without compromising oncologic care.

Clinicians must balance the benefits of ICIs with their side effects to ensure optimal patient outcomes. Early recognition and management of cutaneous irAEs not only improves patient quality of life but also allows continuation of life-saving ICI therapy. Future prospective studies are critical to evaluate the long-term risks and outcomes of ICI-associated cSCCs, and to maximize the therapeutic potential of ICIs while minimizing any harm.

Baseline Characteristics of a Canadian Cohort of Hidradenitis Suppurativa Patients Prior to Bimekizumab Treatment

Irina Turchin^1,2,3, Tracey Brown-Maher^4,5,6, Robyn Miller^5,6, Hélène Veillette^7,8, David Croitoru⁹, Kyle Cullingham^10,11

¹Division of Clinical Dermatology & Cutaneous Science, Department of Medicine, Dalhousie University, Halifax, NS, ²Brunswick Dermatology Center, Fredericton, NB, ³Probity Medical Research, Waterloo, ON, ⁴Dermatology, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, NL, ⁵Skincare Studio Dermatology Centre, St. John’s, NL, ⁶NL Clinical Trials Incorporated, St. John’s, NL, ⁷Dermatology Division, Department of Medicine, Centre hospitalier universitaire de Québec-Université Laval, Québec, QC, ⁸La Cité Médicale, Québec, QC, ⁹Division of Dermatology, Department of Medicine, University Health Network, Toronto, ON, ¹⁰Dermatology Division, Department of Medicine, University of Saskatchewan, Saskatoon, SK, ¹¹Saskatoon Dermatology Centre, Saskatoon, SK

Introduction: Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease characterized by recurrent nodules, abscesses, and draining and non-draining tunnels. Currently, there are two biologics approved in Canada for the treatment of moderate-to-severe HS, adalimumab (anti-TNF) and secukinumab (anti-IL-17A). However, there remains a high unmet need to manage moderate-to-severe HS. Bimekizumab (BKZ) is a humanized monoclonal antibody that selectively inhibits IL-17A and IL-17F, with broader activity against IL-17. Herein, we present baseline demographics and clinical characteristics of patients with HS prior to the initiation of BKZ.

Methods, Results: This retrospective chart review included 27 patients (mean age: 44 ± 14 years) with moderate-to-severe HS prior to initiation of BKZ. Data was collected between May 2022 and September 2024. Most patients were female (n=17, 63%) and white (n=23, 85%), with 48% (n=13) being current smokers. 22 patients (81%) had severe disease, with 18 patients (67%) classified as having Hurley stage III disease. The most frequently affected areas were the axillae (n=18, 67%) and groin (n=15, 56%). 10 patients (38%) had inflammatory nodule and abscess (AN) count >10. Majority of the patients had draining tunnels (n=23, 85%) with frequent flares (n=26, 96%) and pain scores between 6 to 10 (n=19, 70%). The most commonly reported comorbidities were depression (n=10, 37%), anxiety (n=9, 33%,), and psoriasis (n=9, 33%). 26 patients (96%) were previously treated with at least one antibiotic and at least one biologic. 25 patients (93%) received adalimumab and 8 patients (30%) received secukinumab prior to BKZ treatment. 25 patients (93%) had a history of prior adjunct systemic therapy, and 21 patients (78%) had undergone a prior surgical procedure.

Conclusions: This retrospective chart review revealed a high disease burden, significant comorbidities, and a history of several treatments and surgical procedures in a cohort of HS patients, emphasizing the need for new HS therapies.

Learning Objectives

Takeaway Message

Hidradenitis suppurativa (HS) affects at least 1-2% of the population in Canada. Despite two approved biologic therapies for moderate-to-severe HS in Canada, some patients continue to have high disease burden highlighting the significant unmet need for new therapies.

Qualitative Analysis and Chart Review Comparing Ideal Referral Attributes to Referrals Received at an Academic Centre in Nova Scotia, Canada

Michelle Baldwin¹, Amanda Gormley¹, Peter Green², Ashley Sutherland²

¹Faculty of Medicine, Dalhousie University, Halifax, NS, ²Division of Clinical Dermatology and Cutaneous Science, Department of Medicine, Dalhousie University, Halifax, NS

Introduction: Referrals are integral to the delivery of healthcare, including in dermatology. To prevent delays and provide safe care, it is crucial that the information provided on referrals is appropriate and complete. Despite their importance, referrals have long been criticized for lacking relevant information. This study aims to identify the attributes and format of an ideal dermatology referral and compare this to the referrals that are currently received. This analysis will provide insights into areas requiring improvement, thereby informing the implementation of strategies aimed at enhancing referral quality.

Methods, Results: We conducted a survey to dermatologists assessing the usefulness of specific pieces of information provided on dermatology referrals, and a retrospective chart review to assess the presence or absence of these attributes on current referrals. We performed descriptive statistics on multiple-choice survey questions and chart review data, and thematic analysis on open-ended survey questions. We assessed 240 referrals and survey responses from eight dermatologists. Data indicated that the three most useful qualities were ‘typed document as opposed to handwritten’, ‘patient seen in person prior to referral’ and ‘provisional diagnosis/differential diagnosis’. The chart review found these attributes were included in 83.8%, 81.7%, and 57.5% of referrals, respectively. ‘Biopsy and relevant investigations’ was ranked as the most important inclusion of referrals, which was included in only 10% of referrals analyzed in the chart review. Thematic analysis revealed a preference for typed referrals over hand-written, a difference in the information provided on the referrals depending on source, and that essential information is often missing, yet, too much information is not helpful.

Conclusions: This study identified significant gaps between the information dermatologists consider valuable for triaging and the information provided on current referrals. To address such discrepancies, we recommend the implementation of a standardized referral form to aid in the delivery of timely and safe dermatologic care.

Learning Objectives

Our objective is to determine the most valuable information and format for dermatology referrals to facilitate appropriate triaging and compare it with current referral practices at an academic centre in Nova Scotia. This research aims to identify areas for improvement in the dermatology referral processes to gain an understanding of core issues that should be addressed.

Takeaway Message

The referrals currently being received are not addressing the needs of dermatologists and are lacking information that has been identified as important. This can impact the ability to triage effectively and has downstream implications for patient wait times. Strategies should be adopted to address these gaps.

Primary Cutaneous Blastomycosis of the Foot with Significant Delay in Diagnosis

Anastasia Shamsuyarova, Denis Peshcha

Northern Ontario School of Medicine University, Thunder Bay, ON

Introduction: Blastomycosis is an invasive fungal disease typically acquired through inhalation, with the lungs as the primary site of infection. Primary cutaneous blastomycosis is exceedingly rare, with fewer than 50 documented cases. In Ontario, 581 blastomycosis-related hospitalizations occurred between 2006 and 2015, 42% of which were in northern regions like Kenora, Rainy River, and Sioux Lookout.

Methods, Results: We report a 45-year-old male from rural Northern Ontario who developed a nodule on his foot in September 2022. The lesion grew progressively and began to weep. A biopsy performed in March 2023 was misdiagnosed as a wart by a general pathologist. The patient was referred to dermatology in May 2023. Examination revealed a fungating, infiltrative mass with a verrucous surface and sinus tracts. Differential diagnoses included atypical infections such as blastomycosis or mycetoma. A repeat biopsy with tissue culture showed pseudoepitheliomatous hyperplasia but was negative for infectious agents, including bacteria, fungi, and AFB. A foot X-ray ruled out bone involvement. The patient was lost to follow-up but returned in November 2023 with significant lesion progression. Another biopsy and culture were initially negative. Suspecting blastomycosis-like pyoderma gangrenosum, intralesional triamcinolone was administered twice, with minimal improvement. Finally, repeated cultures from triamcinolone injected areas grew filamentous fungi after nine days, and Blastomyces dermatitidis was confirmed at two weeks. The patient was started on oral itraconazole and referred to Infectious Disease. At four weeks, the lesion showed marked improvement, and systemic workup revealed no other infection sites and clear chest Xray. Unfortunately, the patient was lost to dermatologic follow-up.

Conclusions: This case highlights the diagnostic challenges of blastomycosis, underscoring its reputation as “the great pretender.” Repeated cultures are critical for isolating the causative agent and ensuring appropriate treatment.

Learning Objectives

Takeaway Message

Blastomycosis remains to be “the great pretender”

Aquagenic Syringeal Acrokeratoderma: Case Report and a Review of the Literature

Moyin-Oluwa L. Onasanya¹, Arunima Sivanand², Robert Gniadecki²

¹University of Saskatchewan, Saskatoon, SK, ²University of Alberta, Edmonton, AB

Introduction: Aquagenic syringeal acrokeratoderma (ASA) is a rare dermatological condition characterized by transient water-induced skin wrinkling with bilateral edematous white papules and plaques on the palms or soles, often accompanied by burning pain. ASA is an acquired disorder, most common in young women and strongly associated with cystic fibrosis (CF). The condition can also occur in non-CF contexts, including secondary to medication triggers such as NSAIDs (e.g. aspirin), spironolactone, and isotretinoin. Pathogenesis hypotheses include increased sodium concentration in the stratum corneum leading to water retention, aberrant eccrine ducts, and stratum corneum barrier dysfunction. This case highlights ASA in a non-CF-associated presentation, contributing to the sparse literature on this condition.

Methods, Results: A 40-year-old male, 1-year post-lung transplant for alpha-1 antitrypsin deficiency, presented for skin cancer screening. Transplant-related medications included aspirin. Incidentally, he reported a 7–8-month history of transient bilateral white papules and plaques on the central palms following water exposure, associated with burning pain and hyperhidrosis. The rash severely impacted his quality of life, limiting daily activities such as showering. Examination revealed white papules coalescing into plaques on the bilateral palms, more prominent on the right.

Histopathology from a punch biopsy of the right palm revealed acral skin with orthokeratotic hyperkeratosis, prominent acrosyringeal openings, and eccrine gland hyperplasia. CFTR genetic testing was negative. ASA was diagnosed, and management included discontinuing aspirin and initiating nightly topical aluminum chloride hexahydrate 20% solution to the palms, with symptom improvement on follow-up.

Conclusions: ASA is a rare dermatologic condition that significantly impacts quality of life. Though strongly associated with CF, ASA can also occur in non-CF contexts, as demonstrated in this case. Effective management requires addressing triggers, including medications and concurrent symptoms like hyperhidrosis. First-line treatments include topical aluminum chloride. This case illustrates the importance of recognizing and treating ASA to limit morbidity.

Learning Objectives

Takeaway Message

Aquagenic syringeal acrokeratoderma is a rare dermatologic condition characterized by transient, water-induced papules and plaques, which can significantly impact ’ quality of life. This case highlights a non-cystic fibrosis-related presentation of ASA, likely triggered by aspirin use. Our case highlights the importance of recognizing this rare condition, performing a thorough history of potential triggers, and the evidence-based treatments that can decrease morbidity. Clinicians should maintain a high index of suspicion for ASA in a patient presenting with water-induced skin changes on the palms and soles.

Linear IgA/IgG Bullous Dermatosis Associated with Linagliptin: A Case Report

Rahila Shaikh, Katherine Aw, Steven J. Glassman, Stephanie Petkiewicz

University of Ottawa, Ottawa, ON

Introduction: Linear IgA/IgG bullous dermatosis (LAGBD) is a rare subepidermal blistering disease marked by linear deposits of both IgA and IgG at the dermoepidermal junction. It is sometimes considered a variant of bullous pemphigoid as it has overlapping features of both bullous pemphigoid and linear IgA bullous dermatosis. Whilst cases of regular bullous pemphigoid have been causally associated with gliptins, we report the first case of LAGBD associated with gliptin therapy.

Methods, Results: A 60-year-old man with diabetes and on linagliptin and empagliflozin for several years developed generalized pruritus for a year and blisters on the torso and limbs for one month. Examination revealed many tense bullae and crusted erosions on erythematous bases on the torso and limbs, with a few oral erosions. Skin biopsy of an intact bulla showed a subepidermal split with eosinophils and direct immunofluorescence of perilesional skin showed 2-3+ linear staining of both IgA and IgG at the dermoepidermal junction. The clinical and histologic features supported a diagnosis of LAGBD. The linagliptin was replaced with metformin, and he was treated with prednisone, dapsone and topical corticosteroids, with a slow improvement. He remains on dapsone 100mg daily, and mycophenolate mofetil may be added based on his response.

Conclusions: LAGBD is a rare subtype of bullous pemphigoid that may also be triggered by the gliptin class of antidiabetic medication. The condition can persist despite discontinuation of the offending drug but usually responds well to dapsone or immune suppressants like mycophenolate mofetil.

Learning Objectives

Takeaway Message

Consider gliptin therapy as a possible trigger for linear IgA/IgG bullous dermatosis.

Understanding Melanoma’s Tumor Microenvironment: A Dual-Target Immunomodulatory Strategy to Overcome Melanoma Resistance

Adam Mouncef^1,2, Radu Alexandru Paun^3,2, Ling Li³, Thusanth Thuraisingam¹, Maryam Tabrizian^3,4, Danuta Radzioch^1,5,2

¹Department of Medicine, McGill University, Montreal, QC, ²Research Institute of the McGill University Health Centre, Montreal, QC, ³Department of Biomedical Engineering, McGill University, Montreal, QC, ⁴Faculty of Dentistry and Oral Health Sciences, McGill University, Montreal, QC, ⁵Department of Human Genetics, McGill University, Montreal, QC

Introduction: Melanoma, the most aggressive form of skin cancer, is especially challenging to treat due to its high metastatic potential. Despite recent advances in immunotherapy, over 40% of metastatic melanoma patients fail to respond to current treatments, highlighting the need for novel therapeutic approaches. This study investigates a dual-targeted strategy combining BIO (6-bromo-indirubin-3’-oxime), which inhibits glycogen synthase kinase-3 and cyclin-dependent kinases to suppress inflammatory pathways within the tumor microenvironment (TME), with the active disulfiram metabolite, CuET (diethyldithiocarbamate-copper complex), inducing proteotoxic stress and cell death. By targeting survival and immune-evasion pathways, this combination aims to overcome the adaptive resistance mechanisms limiting current melanoma therapies’ efficacy.

Methods, Results: Our study assessed the effects of BIO, CuET, or their combination in B16F10 and YUMM1.7 melanoma models in C57BL/6 mice. Tumor growth and survival were monitored, and immunomodulatory effects were assessed via cytokine profiling of plasma and tumor tissues using multiplexed ELISA and RT-PCR to quantify cytokine expression levels, respectively. The combination reduced tumor volume by 76% in YUMM1.7 models and extended median survival from 26.5 to 31.5 days compared to vehicle controls. Moreover, the combination therapy decreased pro-inflammatory cytokines in both plasma and tumor tissues of B16F10 models, indicating effective TME modulation through immune regulation. To assess the safety of BIO, intraperitoneal doses of 10 mg/kg and 20 mg/kg were tested, showing no significant weight loss or signs of acute toxicity, indicating a favorable safety profile.

Conclusions: These findings demonstrate that the combination of BIO and CuET reduces tumor volume, extends survival, modulates the immune environment, and is safe at tested doses. This novel approach advances our understanding of melanoma biology and addresses a critical gap in current therapeutic strategies. If translated into clinical practice, it holds the potential to significantly enhance patient outcomes and transform the management of therapy-resistant melanoma.

Learning Objectives

Takeaway Message

Innovative combination therapies that target multiple pathways have the potential to redefine how we currently approach refractory metastatic melanoma. By addressing resistance mechanisms, namely by reducing inflammation in the tumor microenvironment, new strategies pave the way for more effective and personalized care in advanced melanoma. The findings provide actionable insights that could influence future treatment paradigms and improve patient outcomes in dermatological oncology.

Skin Microbiota in the Pathogenesis and Therapy of Cutaneous T-cell Lymphoma: A Scoping Review

Sonia Czyz¹, Joshua Quan¹, Jori Hardin²

¹Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, ²Department of Dermatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB

Introduction: Cutaneous T-cell lymphoma (CTCL) is a rare and complex immunologic malignancy of the skin. Currently, the mechanisms driving CTCL pathogenesis remain incompletely understood. The commensal microbiota of tumor-bearing skin represents a critical component of the neoplastic microenvironment, potentially influencing disease progression. Indeed, the human skin microbiota constitutes dynamic microbial communities that can regulate host cellular signaling pathways. Advancements in microbiota analyses suggested an association between skin microbiota and CTCL etiopathogenesis. Accordingly, the objective of this scoping review was to investigate the existing literature addressing the (1) composition of the skin microbiota in patients with CTCL and (2) potential role of microbial-targeted therapies in improving clinical outcomes for this patient population.

Methods, Results: A search of OVID’s Medline and Embase databases was conducted to identify original research articles evaluating the skin microbiota or microbial-based therapies in patients with mycosis fungoides or Sézary syndrome, the two most prevalent subtypes of CTCL. Two independent reviewers screened titles and abstracts, then full texts, resolving discrepancies with a third reviewer. Of the 2,336 non-duplicate records identified, 43 studies were included. The review methodology adhered to the guidelines outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR).

Conclusions: Several studies highlighted correlations between the skin microbiota and CTCL, identifying a range of implicated microorganisms, including bacteria, fungi, and viruses. Inconsistencies across studies have precluded the establishment of a definitive relationship between skin microbial compositions and CTCL. However, growing evidence underscores cutaneous microbial dysregulation, particularly the overgrowth of virulent S. aureus, as a key factor in CTCL progression for some patients. Additionally, studies showed that microbial-targeted therapies, like antibiotics, may positively impact CTCL patient outcomes. Nonetheless, further research, including rigorously designed clinical trials, is essential to developing standardized treatment protocols and elucidating efficacy and risks of such therapeutic strategies.

Learning Objectives

Takeaway Message

The relationship between skin microbiota and cutaneous T-cell lymphoma (CTCL) remains complex and not yet fully understood. Emerging evidence highlights the significant role of microbial dysregulation, particularly Staphylococcus aureus overgrowth, in disease progression for some patients. This growing body of research is paving the way for microbial-targeted therapies, which may offer promising avenues to improve clinical outcomes for patients with CTCL.

Improvement of Generalized Granuloma Annulare with Adalimumab: A Case Report

Yara Al Horoub, Kristen Walker

University of Saskatchewan, Saskatoon, SK

Introduction: Granuloma annulare (GA) is a benign, inflammatory condition of unknown etiology, characterized by erythematous annular plaques, frequently on distal extremities. Generalized GA can be difficult to treat, with varying success in therapeutic approaches.

Methods, Results: This is a case of a 59-year-old female with refractory generalized GA successfully managed with adalimumab, requiring ongoing 40mg weekly treatment for 2 years. While there are a handful of published case reports/series suggesting that adalimumab can be used to treat generalized GA, dosing regimens and the need for long-term use remain inconsistent.

Conclusions: This case adds further evidence for considering adalimumab as a sustained therapeutic option for recalcitrant generalized GA. The patient responded to adalimumab, a TNF- α antagonist, administered biweekly for a year, then switched to weekly intervals. Most GA lesions improved within 2 months and continued to improve throughout the treatment. Adalimumab may be proposed as a therapeutic treatment for recalcitrant forms of generalized GA.

Learning Objectives

Understand the manifestations of granuloma annulare

Understanding current literature on granuloma annulare

Managing granuloma annulare with biologics

Takeaway Message

Granuloma annulare may be treated with adalimumab

The Sinister Side of 5 Alpha Reductase Inhibitor Use: Drug-Induced Melasma

Hiba Elhaj¹, Renée A. Beach^2,3, Kelsey A. Orrell²

¹McGill University, Montreal, QC, ²DermAtelier on Avenue, Toronto, ON, ³University of Toronto, Toronto, ON

Introduction: Melasma is a common, recalcitrant hyperpigmentation disorder characterized by irregular, darkened patches on sun-exposed skin. Although melasma predominantly affects women, it can also occur in men. Its pathogenesis involves hormonal mediation, ultraviolet and heat exposure, and genetic predisposition. Finasteride and dutasteride, 5-alpha reductase inhibitors (5-ARIs), are off-label treatments for androgen-related conditions in women, and on-label treatments for androgenetic alopecia and benign prostatic hypertrophy in men. Side effects include sexual dysfunction and gynecomastia, while dermatologic reactions are rare. Only one case has documented melasma following 5-ARI use.

Methods, Results: We report two cases of drug-induced melasma associated with 5-ARI use.

Conclusions: These cases highlight the potential for 5-ARIs to induce melasma in both men and women taking finasteride without prior melasma. Dermatologists should consider this rare side effect when assessing new-onset hyperpigmentation, especially in patients with 5-ARI use. Early recognition and management can minimize cosmetic impact.

Learning Objectives

Takeaway Message

Dermatologists increasingly prescribe 5-alpha reductase inhibitors on- and off-label for alopecia. This therapeutic class can result in drug-induced melasma in both men and women. Proper pre-treatment counselling, early clinical recognition and multi-modal management, including medication discontinuation and dermatologic treatments, are key to minimizing its cosmetic and psychological impact.

Ustekinumab in the Management of Pyoderma Gangrenosum: A Single-Centre Case Series

Anna M. Rzepka, Ami Wang, Kevin Yi Mi Ren, Scott Bradshaw, Tao Wang, Mark Schneider, Lourdes Ramirez Hobak, Yuka Asai

Queen’s University, Kingston, ON

Introduction: Pyoderma gangrenosum (PG) is a debilitating and difficult-to-treat condition characterized by rapidly progressing ulcers with neutrophilic infiltrate. Limited reports have shown that ustekinumab, an interleukin-23 inhibitor, can promote PG healing. This case series explores the clinical features, management, and outcomes of patients with PG treated with ustekinumab at a single academic centre.

Methods, Results: A retrospective review of electronic medical records was conducted for PG patients treated with ustekinumab (Stelara) from 2014 to 2024 at our academic dermatology clinic, following Local Ethics Committee approval.

Eight patients were identified (mean age 63.6 [SD = 14.2] years, 6 female), including one patient with confirmed ulcerative colitis. All PG ulcers were located on the lower legs. All patients failed topical corticosteroid therapy and at least one systemic therapy (e.g., prednisone, dapsone, colchicine) prior to initiating ustekinumab. Ustekinumab was started at a mean of 7.9 (SD = 3.7) months after initial dermatology consultation. Six patients were started on 45 mg injections and two on 90 mg, with all patients eventually increasing to monthly dosing. The average treatment duration was 13.5 (SD = 3.6) months.

Two patients achieved complete ulcer healing at 7 and 12 months, while one patient remains on treatment with ongoing improvement after 16 months. Two patients showed initial progress that plateaued, prompting therapy change. One patient was unresponsive to ustekinumab, with persistent PG despite subsequent biologic therapies. Two patients were non-adherent to wound care and/or declined concurrent interventions, resulting in ulcer deterioration. No significant ustekinumab-related adverse events were reported.

Conclusions: Ustekinumab promoted healing in most cases of treatment-resistant pyoderma gangrenosum (PG), with two patients achieving complete resolution. Critically, patient adherence and concurrent management played a significant role in outcomes. Larger prospective studies are needed to evaluate ustekinumab efficacy, safety, and optimal dosing in PG management.

Learning Objectives

Takeaway Message

Ustekinumab used in conjunction with appropriate wound care may promote healing of treatment-resistant pyoderma gangrenosum, yet large-scale prospective studies are needed to understand efficacy and optimal treatment regimens

Incidence, Prevalence, and Mortality of Localized Scleroderma in Quebec, Canada: A Population-Based Study

Stephanie Ghazal

McGill University Health Centre, Montreal, QC

Introduction: Localized scleroderma (LS) is an understudied autoimmune disease causing skin/subcutaneous tissue fibrosis. Only 6 studies report LS incidence and/or prevalence, with significant design limitations and risk of bias. None originate from Canada or investigate mortality/geospatial epidemiology. We studied LS incidence, prevalence, mortality and spatiotemporal trends in Quebec, Canada, stratified by sex/age.

Methods, Results: Quebec populational health administrative databases were used to identify cases from 1989-2019. Crude incidence rate, age standardized incidence rate (ASIR), prevalence and mortality were analyzed using Negative Binomial (NB) random walk models, and spatial analyses using a Poisson Besag-York-Mollié regression model. There were 6,063 incident LS cases over the study period (mean age 53.00 +/- 20.22 years at diagnosis). The overall ASIR was 3.25/100,000 person-years [95% Confidence Interval (CI) 3.17 to 3.33) with 3:1 female predominance. In females, the ASIR initially increased then plateaued and decreased after 2013 (Average Annual Percent Change (AAPC) -1.95 [95%CI -3.65 to -0.21]%). In males, the ASIR steadily decreased (AAPC -3.32 [95%CI -5.00 to -1.80]%). The highest incidence rate was observed in the 60-79 year-old age group for females and 80+ group for males. ASIR varied geographically with hotspots in the South of Quebec. The average prevalence was 24.54/100,000 [95%CI 24.32 to 24.76]. The overall standardized mortality ratio (SMR) was comparable for females (1.04 [95%CI 0.95 to 1.14]) and males (1.14 [95%CI 0.98-1.33]) and decreased steadily over time for both sexes (from 1.31 [95%CI 1.06-1.58] in 1996 to 0.81 [95%CI 0.66-0.98] in 2019). SMR analysis revealed excess death only in females aged 40-59 years.

Conclusions: We report an increase in LS ASIR in Quebec since 1989, followed by a decrease after 2013, with increasing prevalence from 1996-2019. SMR analysis confirmed that LS is morbid rather than life-threatening. We demonstrate an uneven geographic distribution of LS incidence in Quebec.

Learning Objectives

Takeaway Message

In this study of LS epidemiology in Quebec, females were noted to have an initial increase in LS incidence from 1996 to 2004, followed by a plateau and a decrease after 2013, while males were shown to have a steady decrease in incidence over the study period. Prevalence increased steadily from 1996-2019. SMR analysis revealed that excess death occurred only in females aged 40-59 years, which needs further investigations. LS incidence varied geographically with hotspots in the South of the province, highlighting the importance of additional research on environmental risk factors.

Minoxbeard (noun.): Beard Grown Using Minoxidil

Seyyon Satkunanathan, Reetesh Bose

University of Ottawa, Ottawa, ON

Introduction: Minoxidil, a widely recognized treatment for scalp hair growth, has also garnered interest among individuals seeking facial hair enhancement. The subreddit (online forum) r/Minoxbeards, with over 100,000 members globally, represents a fast-growing community dedicated to sharing personal experiences, progress, and advice on using minoxidil for beard growth. Despite anecdotal success and increasing popularity, scientific evidence supporting its effectiveness and safety for this off-label use remains limited.

Methods, Results: This study explores the anecdotal and scientific evidence surrounding minoxidil use for beard growth. Subreddit members typically apply 5% minoxidil, either as liquid or foam, to the face, often twice daily. Some also incorporate dermarollers (needles ranging from 0.25-1.0mm) to enhance absorption. Currently, this usage occurs in an uncontrolled and heterogeneous manner. Subreddit activity reveals widespread anecdotal success, with over 20,000 new members joining annually. A literature search of available scientific evidence for minoxidil for beard growth was also conducted. However, scientific literature remains scarce, with fewer than 10 studies over the past 15 years, including two RCTs and two case reports. While these studies suggest minoxidil’s potential for promoting facial hair growth with minimal side effects, subreddit-reported outcomes may overestimate efficacy due to variability and lack of standardized measures.

Conclusions: The growing popularity of minoxidil for beard growth, particularly within online communities, underscores the need for robust clinical research to validate anecdotal claims and establish evidence-based guidelines. Standardizing assessment tools, patient-reported outcomes, and engaging large online communities like r/Minoxbeards to document results, could harness massive real-world data potential. Standardized protocols for application, photographic and side effect documentation within subreddit forums, could potentially reduce this heterogeneity and produce a platform for research that might surpass the scale and cost-efficiency of traditional clinical trials. Further studies are needed to determine the feasibility and ethical considerations of virtual, real-world based research.

Learning Objectives

Takeaway Message

Leveraging large online communities like r/Minoxbeards to integrate standardize treatment protocols, patient-reported outcomes, and data documentation could enable more powerful real-world studies at a larger scale and lower cost than traditional clinical trials. This approach would provide a more accurate representation of treatment efficacy and safety, benefiting both patients and researchers.

Efficacy and Safety of Fractional CO₂ Laser Therapy for Onychomycosis: A Systematic Review and Meta-Analysis

Grace Xiong¹, Jia Qi Adam Bai², Jeemin Kim³, Chaocheng Liu⁴

¹Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, ²Faculty of Medicine, University of Ottawa, Ottawa, ON, ³Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea, ⁴Department of Dermatology & Skin Science, University of British Columbia, Vancouver, BC

Introduction: Onychomycosis is a fungal nail infection with limited success using conventional antifungal treatments. Fractional CO₂ laser therapy has emerged as a minimally invasive option that enhances drug delivery and exhibits direct antifungal effects. This systematic review and meta-analysis evaluates the efficacy and safety of fractional CO₂ laser therapy for onychomycosis.

Methods, Results: MEDLINE, Embase, CINAHL, and CENTRAL were searched through June 2024 to identify 14 studies with mycologic confirmation and no systemic antifungal use within 3 months prior to fractional CO₂ laser therapy. Random-effects meta-analysis was conducted to yield pooled proportions. A cohort of 1,052 patients (mean age: 42.8 years; 39.9% male) was included. Average disease duration was 3.8 years. Laser treatment was most commonly given in 2-week intervals, over four sessions. Full characteristics are shown in Table 1. Laser monotherapy achieved a mycological cure rate of 62% [95% CI: 0.44–0.79]. Combination laser and topical antifungal had a mycological cure rate of 62% [95% CI: 0.38, 0.85], clinical cure rate of 55% [95% CI: 0.35, 0.76], and complete cure rate of 40% [95% CI: 0.29, 0.52]. Fractional CO₂ laser with topical terbinafine had the highest clinical cure rate, at 71% [95% CI: 0.51–0.90]. Patient satisfaction was higher with combination therapies (62% [95% CI: 0.52, 0.71]) than laser monotherapy (37% [95% CI: 0.2, 0.54]). Adverse effects included self-limiting pain and swelling. Recurrence averaged 4.5% over 3–6 months.

Conclusions: Fractional CO₂ laser therapy appears effective and safe for onychomycosis, either as monotherapy or combined with topical antifungals. However, the advantage of lasers may lie in accelerating the efficacy of topical treatments rather than surpassing them. Furthermore, cost and accessibility may limit its widespread adoption. Future research should explore long-term outcomes, combination with oral antifungals, and cost-effectiveness to optimize its role in managing this persistent condition.

Learning Objectives

Takeaway Message

Fractional CO₂ laser therapy offers a promising, minimally invasive option for treating onychomycosis, which can be used either as monotherapy or as an adjunct to topical antifungals. While it achieves good cure rates, particularly when combined with topical terbinafine, and high patient satisfaction with minimal adverse effects, its primary benefit may lie in accelerating the effectiveness of topical therapies as cure rates are comparable to previous studies of long-term oral antifungal use. Barriers of laser such as cost and accessibility, coupled with the persistent nature of this condition highlight the need for further research to improve patient outcomes.

Blue Scars? Treating Traumatic Tattooing from IV Drug Use to Reduce Social Stigma: A Case Report and Literature Review

Caitlyn Glover¹, Vincent Richer^1,2

¹Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, BC, ²Pacific Derm, Vancouver, BC

Introduction: Traumatic tattooing occurs when insoluble pigmented particles are deposited within the dermis in the setting of abrasive, explosive, or penetrating injuries. Patients may wish to seek treatment for several reasons including symptoms secondary to inflammatory changes, emotional distress from the reminder of a traumatic event, and/or for cosmetic reasons. Here we report a case of blue traumatic tattoos acquired years ago in the context of IV drug use, their successful treatment with the picosecond alexandrite 755 nm laser, and review the literature regarding prevention and treatment of traumatic tattooing.

Methods, Results: We performed test spots with the long-pulsed Nd:YAG and picosecond alexandrite lasers, confirming effectiveness of the picosecond alexandrite laser. Subsequently, two treatment sessions with the picosecond alexandrite laser were performed at 8-week intervals with significant clinical improvement. PubMed and Medline searches were performed to identify studies examining prevention and treatment of traumatic tattoos. Forty-six studies were identified, including 14 prevention studies and 34 treatment studies. Prevention strategies included various surgical techniques for the removal of superficial and deep deposits following the injury. Treatment strategies included various surgical techniques, but non-ablative laser-based modalities were most commonly reported.

Conclusions: Consensus is established that wounds should be thoroughly cleansed of foreign debris within 24h to prevent traumatic tattooing. For established tattoos, the treatment of choice is a non-ablative nanosecond or picosecond laser, but alternatives should be considered for combustible debris. Treating traumatic tattoos acquired in the context of previous IV drug use has the potential to reduce social stigma.

Learning Objectives

Takeaway Message

While prevention of traumatic tattoos with thorough cleansing of wounds is preferable, non-ablative nanosecond and picosecond lasers are generally safe and effective for the treatment of established traumatic tattoos.

Wrinkles in the System: A Decade of Canadian Medico-Legal Cases Involving Botulinum Toxin Injections

Ammar S. Aldien¹, Eric P. McMullen², Hassan Elhawary³, Benjamin Barankin⁴, Ilya Mukovozov^4,5

¹Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, ²Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, ³Division of Plastic Surgery, McGill University Health Center, Montreal, QC, ⁴Toronto Dermatology Centre, Toronto, ON, ⁵Division of Dermatology, Women’s College Hospital, Toronto, ON

Introduction: Despite physicians’ increased botulinum toxin use in Canada, little is known about the related medico-legal issues. This study examines all Botox-related medico-legal cases and identifies trends to improve clinical practice.

Methods, Results: A retrospective review of closed medico-legal cases from 2014 to 2023 was conducted using Canadian Medical Protective Association (CMPA) data. College complaints and legal cases were included. Patient allegations, medical complications, and contributing factors, as determined by experts, were analyzed. Cases involving the medical and cosmetic use of Botox were included.

Of 70,883 CMPA closed medico-legal cases from 2014 to 2023, 70 met the inclusion criteria. Among these, 48 (68.6%) were college complaints and 22 (31.4%) were court proceedings. A total of 72 physicians were involved, including 37 (51.4%) family physicians; the remainder (n=35, 48.6%) were dermatologists, plastic surgeons, and neurologists, amongst others (as each was less than n=10; exact numbers were undisclosed). Most patients (65.7%) sought Botox for skin disorders (rhytides, excess skin, scarring, fibrosis) or headaches (14.3%). Patients’ most commonly reported complaints included inadequate informed consent (38.5%) and deficient assessment (24.3%). Reported complications included localized bleeding, allergic reactions, infections, and skin changes. Of cases reporting contributing factors, the leading identified issues were failure to obtain informed consent (n=18/42, 42.9%) followed by incomplete documentation (n=17/42, 40.5%), including failures to document physical assessments, injection locations and dosages, treated conditions, and informed consent discussions (n=17/42, 40.5%). Additionally, office issues (n=17/42, 40.5%), such as failure to provide after-hours physician contact and inappropriate discounts, were identified.

Conclusions: Per patients and experts, the leading complaint related to Botox based on CMPA data is inadequate informed consent. This, along with issues relating to assessment and documentation, highlights the need for educational initiatives during residency and in clinical practice. Addressing these gaps could improve patient safety and reduce medico-legal risks.

Learning Objectives

Takeaway Message

Medico-legal complaints related to Botox mostly arise from inadequate informed consent, poor assessment, and incomplete documentation. This highlights the need to integrate medico-legal cases in training programs and educational initiatives to fill gaps in clinical practice.

Hyaluronic Acid Facial Filler Complications in the East Asian Population: A Systematic Review

Megan Park¹, Edgar Akuffo-Addo², Alexandra Veitch³, Amn Marwaha⁴, Ilya Mukovozov^5,6

¹Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ²Divison of Dermatology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ³Faculty of Health Sciences, Queen’s University, Kingston, ON, ⁴Schulich School of Medicine and Dentistry, Western University, London, ON, ⁵Toronto Dermatology Centre, Toronto, ON, ⁶Division of Dermatology, Women’s College Hospital, Toronto, ON

Introduction: Hyaluronic acid (HA) filler injections are widely used for their minimal invasiveness, rapid onset of action, and short recovery time. Despite a growing demand for non-invasive aesthetic treatments among the East Asian population, most filler guidelines are based on Caucasian data, overlooking anatomical and aesthetic differences in East Asians. This systematic review aims to summarize the characteristics of HA filler complications in the East Asian population.

Methods, Results: In accordance with PRISMA guidelines, MEDLINE and Embase databases were systematically searched (up to January 2024) using various permutations of the key words “filler” AND “complication.” Observational studies on HA filler complications in East Asian adults were included. Self-administered cases and expected sequelae like minor swelling were excluded. Due to limited reports of race or ethnicity in literature, studies conducted in China, Taiwan, South Korea, or Japan, were also included, without specific mention of patient ethnicity.

Of 3595 articles screened, 84 studies met inclusion criteria, encompassing 536 patients (92.4% female, mean age 32.4 years) with complications. Forty percent (89/223) of patients experienced complications within seconds to minutes after injection; 8.9% (20/223) within 24 hours; 32.7% (73/223) within one week; and 7.6% (41/536) after one week. The nose had the highest complication rate (39.9%, 214/536), consistent with previous findings as the highest risk site for vision loss after filler injection. Treatments were reported in 410 patients, with 77.1% (316/410) receiving hyaluronidase. Significant sequelae were reported in 19.8% (108/536) of patients, most notably 21 patients with skin necrosis and 82 patients with vision loss.

Conclusions: Despite limited reporting on ethnicity and HA filler types, reliance on case reports, and inclusion of studies mainly outside of North America, this review highlights significant complications associated with HA facial fillers in the East Asian population, primarily in the nose and nasolabial fold regions.

Learning Objectives

Takeaway Message

This review highlights significant complications of hyaluronic acid facial fillers in East Asian patients, particularly in the nose and nasolabial fold regions. Physicians should be knowledgeable in the anatomical considerations of East Asian patients, particularly the high-risk injection sites such as the dorsal nasal artery, which can lead to severe vascular occlusions.

Novel Non-Surgical Blepharoplasty Utilizing 35% TCA

Savanah Haidar¹, Yossi Cohen¹, Ivan V. Litvinov¹, Naif Al Jahani¹, Andrea Rey², Yassein Shamout¹

¹McGill University, Montreal, QC, ²Self Clinic, Buenos Aires, Argentina

Introduction: Traditional blepharoplasty consists of invasive surgical techniques requiring skin incisions for a desired outcome of eyelid rejuvenation. More recently, there has been a trend towards non-invasive procedures such as chemical peels, fillers, and laser therapies with impressive outcomes that have been at par with surgical techniques. However, these alternatives require combination of treatments to achieve comparable results. This study introduces a novel non-surgical eyelid rejuvenation technique using solely 35% trichloroacetic acid (TCA).

Methods, Results: The procedure involved applying two even layers of 35% TCA to achieve level two frosting under local anesthesia. Post-procedural care includes Vaseline ointment and medications to prevent periorbital swelling, infection, and other complications, ensuring patient comfort and optimal recovery. Results demonstrated significant improvement of eyelid appearance including skin tightening, reduction of fine lines and a smoother skin appearance. Patients reported high satisfaction with natural-looking results, quick recovery time and minimal complications.

Conclusions: This novel technique offers an effective and minimally invasive alternative to surgical methods, particularly in instances when surgery is not available, such as in low resource healthcare settings.

Learning Objectives

To introduce a novel eyelid rejuvenation technique using 35% TCA as a standalone treatment

To offer a minimally invasive alternative to surgery, particularly in instances when surgery is not available, such as in low resource healthcare settings

To offer effective non-invasive blepharoplasty with comparable results to traditional surgical methods

To offer a minimally invasive technique for patients with Fitzpatrick skin type 1 and 2

Takeaway Message

This novel blepharoplasty technique using 35% TCA as a standalone treatment offers a non-invasive alternative to traditional surgical methods, particularly for those with Fitzpatrick skin type 1 and 2 or in instances when surgery is not available, such as in low resource healthcare settings.

Do Intradermal Hyaluronic Acid Injections Improve Skin Quality Parameters Associated with Skin Aging? A VISIA Imaging Analysis

Mina Youakim, Emma Heck, Michal Martinka, Danny Guo

University of Calgary, Calgary, AB

Introduction: Skin aging is characterized by textural irregularities, enlarged pores, and fine wrinkles. Intradermal hyaluronic acid injections (iHA) offer potential benefits in improving skin quality by enhancing hydration, elasticity, and smoothness. This pilot study aims to evaluate the efficacy of iHA injections on skin texture, pore size, and wrinkles using VISIA imaging analysis at baseline and 4 weeks post-treatment.

Methods, Results: Sixteen participants with mild to moderate skin aging were recruited. Each received 2mL of iHA injections into the mid-face according to manufacturer guidelines. Standardized VISIA imaging was performed at baseline and 4 weeks post-treatment to assess objective measures of texture, pore size, and wrinkle severity. Statistical analysis was conducted using paired t-tests to compare changes from baseline to follow-up. A significance level of p < 0.05 was used. At 4 weeks, statistically significant improvements were observed in skin texture (p = 0.03281) and pore size (p = 0.00947). Wrinkle severity showed a trend toward statistical significance (p = 0.08114). Participants reported subjective improvement in overall skin smoothness and radiance. No adverse events were recorded, and the treatment was well-tolerated by all participants.

Conclusions: This pilot study demonstrates that iHA injections significantly improve skin texture and pore size at 4 weeks post-treatment, with wrinkles trending toward significance. These findings highlight the potential of iHA as an effective injectable treatment for skin quality enhancement. Further studies with larger sample sizes and longer follow-up periods are warranted to confirm these results and explore long-term benefits.

Learning Objectives

Takeaway Message

Intradermal hyaluronic acid injections are a promising avenue for further exploration in the field of cosmetic dermatology and skin quality enhancement. Although this pilot study featured a small sample size, the statistically significant improvements reported in multiple skin quality parameters after only 4 weeks, together with noted subjective improvements and treatment tolerability, serve as a springboard from which to investigate these treatments in larger studies.

A Systematic Review of Measurement Instruments to Assess Quality of Life in Pediatric Patients with Alopecia Areata

Shanti Mehta¹, Dea Metko², Cathryn Sibbald³

¹Temerty Faculty of Medicine, University of Toronto, Toronto, Toronto, ON, ²Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, ³Division of Pediatric Dermatology, The Hospital for Sick Children, University of Toronto, Toronto, ON

Introduction: Alopecia areata (AA) is a chronic autoimmune disorder that causes hair loss and can significantly impact the emotional well-being and quality of life (QoL) of pediatric patients. Despite the importance of assessing QoL in this population, no consensus exists on the most appropriate measurement tool. Existing tools, such as the Children’s Dermatology Life Quality Index (CDLQI), are often not fully applicable to AA, as they focus on physical symptoms like pain or pruritus, which are less relevant in AA. This systematic review evaluates QoL instruments used in pediatric AA to assess their comprehensiveness and applicability.

Methods, Results: We conducted a comprehensive search of MEDLINE, Embase, Scopus, and Web of Science from inception to September 2024, following PRISMA guidelines. Twelve studies were included, which utilized 18 different QoL instruments in pediatric AA. Two of these instruments were specific to AA, while the rest were validated for pediatric populations in general. The majority of instruments were self-reported (66.7%), with some using proxy reporting (27.8%). The most commonly used instrument was the CDLQI (58.3%). Instruments assessed various domains, including emotional well-being, social functioning, psychological stress, self-image, family dynamics, and school function. The number of domains covered ranged from 1 to 8, with a median of 3.

Conclusions: The heterogeneity in the domains covered by these QoL instruments highlights the lack of consensus on the most critical aspects to measure in pediatric AA, leading to inconsistencies in reported outcomes. While generic tools are commonly used, few are dermatology-specific or validated for AA. Future QoL tools should comprehensively address emotional well-being, peer relationships, family dynamics, and academic functioning, integrating both self-reported and proxy-reported measures. Validation across diverse populations is also essential to ensure broad applicability. The absence of a comprehensive, validated QoL tool for pediatric AA limits the understanding and management of the condition.

Learning Objectives

Takeaway Message

Tinea Capitis Caused by Trichophyton Benhamiae in Two Children: An Emerging Zoophilic Dermatophytic Infection

Amélie Gilbert-Falardeau¹, Isabelle Auger², Geneviève Thérien²

¹Université Laval, Québec, QC, ²Centre hospitalier universitaire de Québec - Université Laval, Québec, QC

Introduction: The incidence of Trichophyton benhamiae has been rising over the past two decades. This zoophilic dermatophyte associated mostly with infected guinea pigs causes highly inflammatory lesions in children. Dermatologists must suspect and recognize this pathogen in order to initiate prompt treatment.

Methods, Results: Two healthy children, aged 6 and 7 years, presented with erythematous, scaly, alopecic plaques with centrifugal enlargement on the scalp progressing for few weeks. They also had developed multiple erythematous papules on the body.

Both children have had contact with guinea pigs over the past few weeks.

Culture of scale from affected children scalp revealed Trichophyton benhamiae infection in both patients and a diagnostic of tinea capitis with kerion formation and secondary autoeczematization was made.

Both patients were treated with topical ciclopirox and systemic terbinafine for 6 to 8 weeks, resulting in complete resolution of body and scalp lesions, with hair regrowth. The guinea pig was also treated to prevent reinfection.

Conclusions: Zoonosis associated with Trichophyton benhamiae was first reported in humans in 2002 in Japan, causing acute and inflammatory lesions. The increasing number of cases worldwide may be linked to the appearance of a new yellow phenotype in culture, the rising number of guinea pigs as pets and the high rate of asymptomatic animals.

Approximately 87% of guinea pigs are asymptomatic carriers and can potentially transmit the infection to humans and other animals through direct contact, hair and scales.

Children are more often affected due to more frequent contact with these animals, and typically present with tinea corporis followed by tinea faciae and tinea capitis.

Systemic treatment with terbinafine has demonstrated in vitro superiority compared to other antifungals, and no cases of in vitro resistance have been reported.

Veterinary treatment of both asymptomatic and symptomatic animals is essential to prevent reinfection.

Learning Objectives

To inform about the existence of a new zoophilic dermatophyte that primarily affects pediatric patients.

To present the key epidemiological and clinical aspects of this pathogen based on two cases and a review of the literature.

To highlight the importance of early treatment of the patient and the infected animal.

Takeaway Message

The incidence of infections caused by Trichophyton benhamiae is rising and should be suspected in a child presenting with inflammatory lesions and a history of contact with guinea pig. Prompt treatment in both children and animals is crucial to prevent complications and reinfections.

Triggers, Clinical Manifestations, and Management of Pediatric Erythema Nodosum: A Systematic Review

Florence Lagacé-Thomassin, Hannah Nguyen, Justin Gervais, Imane Labzagui, Anya Bussière-Filion, Kerlysha-Danielle Guerrier, Carolina Lucena Fernandes, Elio Kechichian

Université de Sherbrooke, Sherbrooke, QC

Introduction: Erythema nodosum (EN) is a septal panniculitis clinically characterized by tender, erythematous subcutaneous nodules, most commonly on the shins. Although EN is the most common form of panniculitis, it is underreported in children and infants, and there are no established guidelines to diagnose and manage pediatric erythema nodosum (PEN). This review synthesizes current evidence on triggers, clinical manifestations, and treatment options, and proposes a management algorithm for PEN.

Methods, Results: A systematic literature review of PEN was conducted. 239 articles and 959 patients were included (mean age 10.2 years; range 0.58-17.5 years). Infections were the main triggers: bacterial infections in 302 patients (31.5%), predominantly streptococcal, tuberculosis in 193 patients (20.1%), leprosy in 38 patients (4.0%), followed by idiopathic cases in 80 patients (8.3%), inflammatory bowel diseases (IBD) in 66 patients (6.9%), Behçet’s disease in 61 patients (6.4%), drug related in 28 patients (2.9%) and to a lesser extent various other infectious agents, genetic diseases, vaccines, autoimmune and inflammatory conditions, and malignancies. Geographic variations were noted: tuberculosis, bacterial infections, drug related conditions and IBD predominated in North America and European countries; Behçet’s disease was more common in Turkey, Iran and Israel; and leprosy was more prevalent in India, Indonesia, and Brazil. The United Kingdom, Canada, and Italy report the highest number of cases of pediatric erythema nodosum. The diagnosis was primarily clinical, with only 111 patients (11.6%) undergoing skin biopsy. The majority of patients received supportive care, including NSAIDs, in addition to management of the underlying cause.

Conclusions: Pediatric erythema nodosum is mainly triggered by infections, with significant geographic variations in etiology. Diagnosis mainly relies on clinical assessment, with biopsies used sparingly. This review highlights supportive care and addressing the underlying cause as the cornerstone of treatment in PEN and provides a basis for developing guidelines to improve management.

Learning Objectives

Takeaway Message

A Rare Presentation of Livedoid Vasculopathy in a Pediatric Patient with Sickle Cell Disease

Daniela Cino^1,2, Carmen Liy Wong^2,3

¹Division of Dermatology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, ²Faculty of Medicine, University of Ottawa, Ottawa, ON, ³Division of Dermatology and Rheumatology, Children’s Hospital of Eastern Ontario, Ottawa, ON

Introduction: We present a case of biopsy-proven livedoid vasculopathy causing acral ulcerations in a patient with sickle cell disease (SCD), a rare presentation with a challenging prognosis.

Methods, Results: A 14-year-old female with SCD presented with a 4-month history of tender ulcerations on the toes. For SCD, she has been treated with longstanding hydroxyurea 1000mg daily with baseline hemoglobin in the 70s (g/L). On examination, she had multiple depigmented stellate atrophic plaques and ulcerations on the bilateral toes (Fig1).

The biopsy showed reduplicated thick-wall capillary type spaces showing prominent endothelial proliferation with thrombi. Minor lymphocytic infiltrate was present, however no vasculitis was evident. The superficial dermis showed a reactive vascular pattern compatible with livedoid vasculopathy. The findings were not compatible with hydroxyurea-induced ulceration.

Rheumatology did not suspect inflammatory vasculitis, as she was otherwise well. For wound care, topical antibiotics and calcineurin inhibitors were used. As per our recommendations, hematology titrated to hydroxyurea 1500mg daily. Two months later, the ulcers healed completely.

Conclusions: Livedoid vasculopathy presents with painful, irregular ulcers on the lower extremities that heal with stellate scars. This is a rare condition typically affecting middle-aged women. It is caused by vaso-occlusion of dermal vessels. It can be idiopathic or secondary to hypercoagulable disorders, autoimmune disease and infections. Histopathologically, it shows hyalinization of vessels, thrombi causing vascular occlusion and minimal inflammation.

To the best of our knowledge, we present the first case of biopsy proven livedoid vasculopathy in a pediatric patient secondary to SCD. Livedoid vasculopathy has been reported in a middle-aged male with SCD and in a case of sickle cell trait. Livedoid vasculopathy secondary to SCD may be due to capillary stasis, impaired microcirculation and impaired oxygenation. Improvement of the ulcers is secondary to optimization of the SCD, and may benefit from pentoxifylline, hydroxyurea and blood transfusions.

Learning Objectives

Takeaway Message

Livedoid vasculopathy is a rare disease presenting with ulceration and stellate hypopigmented scars. The strongest risk factor for development is a hypercoagulable state. To the best of our knowledge, we present the first case of a pediatric patient that developed livedoid vasculopathy secondary to SCD. The diagnosis can be made based on the clinical presentation and characteristic histology findings.

Dramatic Clearance of Extensive Psoriasis in a Pediatric Patient with Upadacitinib

Michal Moshkovich¹, Jenna Mistry¹, Maxwell Sauder², Cathryn Sibbald^2,3

¹Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ²Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, ³Division of Dermatology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON

Introduction: Psoriasis is a chronic inflammatory skin condition that commonly presents on the knees, elbows, trunk, and scalp, but can involve the palmoplantar surfaces. FDA-approved treatments for pediatric psoriasis are limited, often requiring off-label use of systemic agents. Upadacitinib, a selective Janus kinase 1 inhibitor approved for atopic dermatitis, has shown efficacy in adult psoriasis and psoriatic arthritis. This report highlights the dramatic clearance achieved with upadacitinib monotherapy in an 8-year-old boy with severe, refractory palmoplantar psoriasis.

Methods, Results: The patient presented with severe palmoplantar psoriasis at age 3, progressing to widespread disease by age 8, with genital involvement, painful fissures, and impaired mobility. He underwent extensive treatments, including methotrexate, acitretin, cyclosporine, ustekinumab, ixekizumab, apremilast, secukinumab, and deucravacitinib, alongside topical therapies including clobetasol, roflumilast, halobetasol and betamethasone diproprionate-based preparations. Despite moderate responses to some regimens, sustained control was not achieved, and treatment side effects, including elevated liver enzymes, dyslipidemia and gastrointestinal discomfort, further limited options. In November 2023, he required hospitalization due to worsening of psoriasis over >60% of his body and debilitating pain from palmoplantar fissures, despite triple combination systemic therapy (secukinumab, acitretin and deucravacitinib). Ultimately, upadacitinib 15 mg daily was initiated with concurrent discontinuation of all other systemics, resulting in dramatic improvement within two weeks, with near-complete resolution of all plaques and fissures. Pain subsided entirely, enabling the patient to return to school and sports. At six months, he remained plaque-free, with no adverse effects from upadacitinib.

Conclusions: This case underscores upadacitinib’s potential as a transformative treatment for severe, refractory pediatric psoriasis, particularly for palmoplantar and possible paradoxical disease. Its rapid efficacy and tolerability in this patient suggest it may offer unique benefits over biologics and other systemic therapies. Larger studies are warranted to validate its use in similar cases, offering hope for patients with otherwise unresponsive disease.

Learning Objectives

Takeaway Message

Our patient demonstrates remarkable efficacy and tolerability of upadacitinib in treating severe, refractory pediatric palmoplantar and paradoxical psoriasis. The sustained plaque clearance and significant pain improvement observed highlight the drug’s potential as an alternative to traditional systemic and biologic therapies. This case underscores the importance of exploring novel treatments for otherwise unresponsive pediatric psoriasis, with further studies needed to validate upadacitinib’s role in broader clinical practice.

Epidermolysis Bullosa Acquisita: A Rare Pediatric Presentation of a Rare Blistering Disorder

Janis Chang^1,2, Carmen Liy Wong^1,3, Nordau Kanigsberg^1,3

¹University of Ottawa, Ottawa, ON, ²The Ottawa Hospital, Ottawa, ON, ³Children’s Hospital of Eastern Ontario, Ottawa, ON

Introduction: We present the case of a patient first assessed at age four with acral blisters and nail dystrophy, and provisionally diagnosed with epidermolysis bullosa (EB). He later also developed oral ulcers, felt to be consistent with mucosal EB involvement. He had a complex medical history including microcephaly, developmental delay, and thrombocytopenia, as well as recurrent episodes of fever, vomiting, and lethargy.

Methods, Results: Genetic testing was non-diagnostic, showing variants of unknown significance in two genes: IGF1R and ZFC3H. He was started on a trial of colchicine for suspected autoinflammatory disorder. Colchicine and intermittent courses of prednisone improved his mucocutaneous blistering for three years, however at age 11, he was re-referred to Dermatology due to worsening blistering. Biopsies were taken, with direct immunofluorescence showing strong linear IgG and C3 staining. His working diagnosis was thus changed to epidermolysis bullosa acquisita (EBA), and dapsone was added. He responded well to dapsone 50 mg daily, with occasional ongoing blister formation on acral and oral mucosal sites.

Conclusions: EBA is a rare acquired subepidermal blistering disease associated with autoimmunity to collagen VII. It is even more rare in the pediatric population, with a 2021 systematic review identifying only 40 cases in the literature. 29 of these 40 cases had mucosal involvement, as did our patient. The mechanobullous type has been described as mimicking dystrophic EB, with acral blisters that heal with scarring, milia, or dyspigmentation. Diagnosis relies on clinicopathologic correlation, particularly immunofluorescence microscopy. Linear IgG at the basement membrane is a classic finding on direct immunofluorescence. Differentiating EBA from EB is critical, as there is a role for initiating immunomodulatory or immunosuppressive therapy in cases of EBA. Systemic corticosteroids and dapsone—which our patient responded well to—are frequently treatments of choice for pediatric EBA, while colchicine has shown some benefit in adult EBA.

Learning Objectives

Takeaway Message

While EBA is a rare disease in children, it should nonetheless be considered on the bullous disease differential—prompt diagnosis can lead to initiation of appropriate systemic therapy, and better patient outcomes.

Underrepresentation of Visible Minorities in Medical References in a Canadian University: A Call for Inclusion Reform

Kerlysha-Danielle Guerrier, Beatrice Andra Oaden, Carolina Lucena Fernandes, Elio Kechichian

Université de Sherbrooke, Sherbrooke, QC

Introduction: The lack of representation of people of color in dermatology has been a recurrent issue. Recognizing the diverse clinical manifestations of skin diseases across all skin phototypes is crucial for effective healthcare, whether for inflammatory or cancerous conditions. Illustrative diversity in medical education is essential to ensure equitable healthcare. Historically, medical training programs have often underrepresented non-white skin patients. The objective of this study is to assess the representation of skin of color in the medical references provided to the medical students.

Methods, Results: An analysis of the photos used in the study material provided to medical students, including the dermatology-specific references was conducted. The following data was evaluated: the Fitzpatrick Classification of Skin Types I through VI and the type of disease represented. The photos were later classified into two groups: lighter skin (I-II-III) and darker skin (IV-V-VI) for comparison. A total of 1,081 photos were analyzed. Among these, illustrations of skin types IV-V-VI accounted for 7.4% while, 92.6% of the photos depict lighter skin types I-II-III. For dermatology-specific courses, the percentage of darker skin types was 8.9%. Darker skin types were not represented at all in potentially life-threatening diseases or in high-yield prevalent and endemic diseases in Eastern Quebec such as Lyme disease.

Conclusions: Darker phototypes remain underrepresented in the medical education framework. Integrating a broader representation of skin phototypes in medical education is essential to enhance learning and equip future healthcare professionals to provide equitable care.

Learning Objectives

Takeaway Message

Comparative Outcomes of Surgical, Non-Surgical, and Combination Therapies for Keloids and Hypertrophic Scars in Skin of Color

Andy D. Lee¹, Sean Jeong¹, Rachel Kim¹, Kristen A.R. Yee², Megan Park¹, Ryan S.Q. Geng¹, Cathryn Sibbald³, Robert Bobotsis⁴

¹Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ²Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, ³Division of Pediatric Dermatology, The Hospital for Sick Children, University of Toronto, Toronto, ON, ⁴Division of Dermatology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON

Introduction: Keloids and hypertrophic scars are fibroproliferative disorders characterized by excessive collagen deposition following cutaneous injury. Individuals with skin of color (SOC) experience a disproportionately higher burden, likely due to genetic factors affecting collagen and melanocyte function. These lesions often recur and can significantly impact quality of life. Clinical management in SOC is challenging, requiring a nuanced understanding of available treatment strategies. This systematic review evaluates outcomes of surgical, nonsurgical, and combination therapies for keloids and hypertrophic scars in SOC, focusing on recurrence rates and adverse events.

Methods, Results: We systematically searched two electronic databases, identifying 37 studies encompassing 2,004 SOC patients with keloids or hypertrophic scars. Monotherapy was reported in 50% of cases, including surgical excision, various forms of radiation, corticosteroids, or cryotherapy. Surgical excision alone achieved 68% complete resolution but exhibited elevated recurrence. Radiation monotherapy provided up to 73% resolution, yet adverse events, such as infection and wound dehiscence, were higher. Combination approaches yielded 88% complete resolution but demonstrated notable side effects, particularly pigmentary changes. Across all regimens, 13% of patients experienced pigmentation alterations, emphasizing the need for caution in SOC. Combination regimens incorporating corticosteroids or pressure therapy showed moderate to high success rates but required careful monitoring for adverse effects. Studies were limited by small sample sizes, variable follow-up durations, and retrospective designs. Additionally, cost-effectiveness data were scarce, underscoring the need for more comprehensive economic evaluations.

Conclusions: Combination therapies generally outperformed monotherapies in keloid and hypertrophic scar management for SOC. Clinicians must weigh recurrence risk and pigmentary complications when individualizing treatment. Despite encouraging outcomes, study heterogeneity and lack of standardized measures limit definitive conclusions. Further high-quality research is needed to refine protocols and improve long-term outcomes, considering both efficacy and patient-reported quality-of-life measures.

Learning Objectives

Takeaway Message

Combination therapies generally yield superior outcomes but require careful attention to adverse events in SOC.

The Lived Experiences of Atopic Dermatitis Patients in a Rural Indigenous Community: A Qualitative Study

Jonah W. Perlmutter¹, Polycronis P. Akouris¹, Sierra Fremont², Jensen Yeung^3,4,5, Rachel Asiniwasis^6,7

¹Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ²Princess Margaret Cancer Centre, University Health Network, Toronto, ON, ³Sunnybrook Health Sciences Centre, Toronto, ON, ⁴Women’s College Hospital, Toronto, ON, ⁵Probity Medical Research, Waterloo, ON, ⁶University of Saskatchewan, Regina, SK, ⁷First Nations University of Canada, Regina, SK

Introduction: Atopic dermatitis (AD) represents the most common skin condition affecting Indigenous Peoples in Canada, significantly impacting physical and psychological well-being. Indigenous Peoples living in northern and remote communities face disproportionately poorer health outcomes due to complex social, historical, and socioeconomic factors. Limited studies exist to characterize these disparities. This study aims to address this gap by exploring the lived experiences of patients with AD in an Indigenous community of 5,000 residents where full-time medical care is unavailable.

Methods, Results: The methods and data analysis were designed in collaboration with community members while adhering to the First Nations principles of OCAP (ownership, control, access, and possession). Using semi-structured interviews with 11 participants diagnosed with AD, we identified key themes through inductive and deductive analysis. Participants cited physical discomfort (91% frequency, 13 mentions), challenges with local care (82% frequency, 19 mentions), systemic bias and discrimination (82% frequency, 15 mentions), impact on function (82% frequency, 13 mentions), challenges accessing specialized care (73% frequency, 18 mentions), psychological distress (73% frequency, 14 mentions), accommodating their conditions (73% frequency, 12 mentions), and discomfort discussing traditional medicine use (73% frequency, 8 mentions) as primary concerns. All participants suggested solutions to improve care (27 mentions), including access to a full-time physician, incorporating virtual care, improving access to clean drinking water, and improving cultural competency amongst physicians.

Conclusions: These findings highlight the critical need to address the gaps in dermatological care for Indigenous Peoples through community-driven solutions. Tailored interventions, such as improving access to specialized care, fostering cultural competency among healthcare providers, and incorporating virtual care options, are essential to mitigate these challenges. Future research should expand to other Indigenous communities, employing larger sample sizes to enhance the generalizability of these insights and support the development of equitable, culturally sensitive healthcare strategies.

Learning Objectives

Characterize current limitations in access to care amongst Indigenous Peoples in rural and remote communities with atopic dermatitis.

Characterize the biopsychosocial impact of poor access to dermatology services amongst Indigenous communities.

Characterize potential solutions to improve future health outcomes amongst Indigenous patients in remote communities with atopic dermatitis at local, provincial, national, and cultural levels.

Understand the importance of cultural competency amongst dermatologists when interacting with Indigenous patients.

Takeaway Message

This study underscores the profound impact of atopic dermatitis on Indigenous Peoples living in rural or remote communities and highlights significant healthcare disparities driven by social, historical, cultural, and socioeconomic factors. By identifying key barriers and supporting community-lead solutions—such as improving access to specialized care, fostering cultural competency among dermatologists, and leveraging virtual care—this research advocates for urgent, culturally sensitive interventions to bridge gaps in dermatological care and improve health equity for Indigenous communities.

Bacterial Skin and Soft Tissue Infections in Canada: A Scoping Review

Simal Qureshi¹, Rachel Asiniwasis²

¹Memorial University of Newfoundland, St. John’s, NL, ²Division of Dermatology, College of Medicine, University of Saskatchewan, Regina, SK

Introduction: Bacterial skin and soft tissue infections (SSTIs) are a significant health burden, particularly in underserved populations across Canada. Indigenous communities in rural and northern regions of Canada face disproportionate rates of SSTIs due to barriers such as limited healthcare access, overcrowded living conditions, and comorbidities like diabetes and cardiovascular disease. This scoping review focuses on Canadian-based research to evaluate SSTI prevalence, clinical outcomes, and actionable solutions.

Methods, Results: A systematic search of databases, including PubMed and Embase, along with manual citation screening, identified studies on bacterial SSTIs in Indigenous populations in rural and remote communities in Canada. Data on prevalence, risk factors, clinical presentations, and interventions were extracted and analyzed.

The scoping review identified high SSTI prevalence and incidence in rural, remote and northern Indigenous communities, with methicillin-resistant Staphylococcus aureus (MRSA) and group A Streptococcus (GAS) as the most commonly identified pathogens. Key findings include:

Conclusions: Canadian-based research highlights a critical need to address SSTI disparities in Indigenous rural and remote communities. Comprehensive approaches, including enhanced dermatological care, antibiotic stewardship, and telemedicine, are promising measures to reduce disease burden. Future research should emphasize culturally-competent, community-driven strategies to mitigate SSTI risks and improve access to care for Indigenous populations.

Learning Objectives

Takeaway Message

Bacterial SSTIs disproportionately affect rural and Indigenous populations in Canada, driven by systemic social, environmental and healthcare inequities. It is important to note that chronic skin conditions frequently serve as pathways for infections, highlighting the need for future research and focused dermatological care. Potential solutions for improving care include enhancing telemedicine and educational community-specific programs to address healthcare barriers and improve skin outcomes.

Transforming Dermatology Education to Improve Care for Remote Indigenous Communities

Anastasia Shamsuyarova

Northern Ontario School of Medicine University, Thunder Bay, ON

Introduction: Indigenous populations in Canada, particularly those in remote communities, face significant health disparities, including limited access to specialized dermatologic care. Conditions like atopic dermatitis (AD) are often undertreated due to geographic, cultural, and systemic barriers. Significant number of severe AD cases complicated by superinfections, stigmatization and mental health .Administrative burdens associated with the Non-Insured Health Benefits (NIHB) program further hinder access to medications and treatments. This abstract summarizes my experience as a dermatologist providing care and education to Indigenous populations from remote communities with a focus on outcomes, challenges, and recommendations for improving care delivery.

Methods:

Results:

Conclusions: Delivering dermatologic care to Indigenous populations in remote communities requires a multifaceted approach that combines cultural competence, education, and systemic support. Addressing administrative burdens within NIHB and investing in culturally trained professionals are essential to improving access and quality of care. My experience highlights the importance of integrating cultural safety into healthcare delivery and underscores the need for targeted funding and adjustments to dermatology training programs to include trainees exposure to Indigenous population in remote communities.

Learning Objectives

Takeaway Message

Reflections on my experience and proposed solution points for discussion:

Association Between Socioeconomic Status and Melanoma Stage at Presentation: A Systematic Review

Amina Moustaqim-Barrette, Hiba Elhaj, Ivan V. Litvinov

McGill University, Montreal, QC

Introduction: The 5-year relative survival rate for patients with stage zero melanoma or melanoma-in-situ is 97%, compared to 30% for those with stage IV disease. Multiple studies have shown overall melanoma incidence to be highest among high socioeconomic status (SES) individuals, emerging research evaluating correlates of late-stage melanoma diagnosis – mostly from the US – suggests low SES to be an important predictor of late-stage disease.

Methods, Results: We performed a systematic search of EMBASE and MEDLINE were completed in accordance with PRISMA guidelines. Of 606 studies screened for inclusion, only two studies were included after full text review (Figure-1), and both studies relied on data from the Ontario Cancer Registry (OCR).

The study by Pitre et al., published in 2019, included all patients identified with histologically confirmed melanoma from the OCR between 2004 and 2012. The study included 9591 cases for which staging information was available and defined advanced melanoma as stage III or IV disease. Individuals of low neighbourhood income quintile were significantly more likely to be diagnosed with late-stage disease (Hazard Ratio 0.92 (0.89-0.96), p<0.001).

The second study by Mavor et al., published in 2018, included 8042 histologically confirmed melanoma cases from the OCR from 2007-2012. The study used the Ontario Marginalization Index (ONMarg) score as a proxy for low SES and found individuals in the fifth quintile of the ONMarg index were statistically more likely to present with advanced stage of melanoma, compared to the lowest ONMarg quintile (Relative Risk 1.10 (1.01–1.20).

Conclusions: While melanoma incidence is greatest in high SES groups, this review suggests that individuals bearing the most severe outcomes of melanoma skin cancer may be of low SES. More research is needed to understand how socioeconomic factors, including race/ethnicity, education and occupation impact stage of melanoma diagnosis in Canada.

Learning Objectives

Takeaway Message

Melanoma skin cancer remains a significant public health problem in Canada. It is well established that early diagnosis dramatically improves outcomes, with a 97% five-year survival rate for stage 0 melanoma compared to 30% for stage IV. While melanoma incidence is highest among individuals of high socioeconomic status (SES), we identified two Canadian studies which suggest low SES correlates with advanced-stage diagnoses.

Although fair skin and high SES are primary risk factors for melanoma development, those with the most severe outcomes may disproportionately belong to lower SES groups. The reviewed studies did not directly address race or ethnicity, but their correlation with low SES in Canada suggests potential disparities in melanoma diagnosis warrant further exploration. This review calls for more comprehensive research to understand how socioeconomic and demographic factors, including education, occupation, and race/ethnicity, influence late-stage melanoma diagnosis and outcomes in Canada.

Age-Adjusted Mortality Rate Trends of Non-Malignant Skin Diseases in the United States by Race and Urbanization, 1999-2020: A Joinpoint Analysis

Nirav Saini¹, Rayyan Zuberi¹, Sarah S. Rashid¹, Fatemeh Jafarian^1,2

¹University of Calgary, Calgary, AB, ²McGill University, Montreal, QC

Introduction: Non-malignant skin conditions substantially contribute to overall morbidity and mortality; yet, they are often overshadowed in the literature by malignant skin conditions. Prior literature has underscored the exacerbating effects of race and urbanization on health outcomes. The aim of this study was to examine the age-adjusted mortality rates for non-malignant skin diseases, including subcutaneous diseases (ICD L00-L98) in the United States over the last two decades by racial group and levels of urbanization.

Methods, Results: A retrospective population-based analysis was conducted using the CDC WONDER database. Age-adjusted data was obtained as a function of urbanization and race, then analyzed using a Joinpoint regression analysis to visualize trends. Joinpoint regression showed statistically significant shifts in trends for age-adjusted mortality rates across both urbanization and race. Although the mortality rates for the Black/African American group was significantly greater than other groups, a significant decline was noted over time. There was also a significant decline for Asian or Pacific Islander groups; notably this rate remained significantly lower than the other groups. Rates for White groups and American Indian or Alaska Native groups were stable; however, the latter was persistently higher than the former. Urban groups demonstrated a declining mortality, whereas rural areas found an increasing trend.

Conclusions: These findings underscore increasing burden of disparities, which may be due to a less robust healthcare infrastructure, access to dermatologists, and socioeconomic disparities, particularly in rural areas. Moreover, increased mortality rates among African American and American Indian or Alaska Native populations may be due to limited access to healthcare, structural racism, and potential misdiagnoses for marginalized racial groups. Urbanization and race may furthermore intersect, and each variable is likely multifactorial. Future work must address these systemic inequities in healthcare by reforming policy, clinical training, and increased access to speciality care, to mitigate disparities.

Learning Objectives

Takeaway Message

The goal of this analysis was to assess how the mortality trends across two decades in non-malignant skin diseases in the United States vary by two important socioeconomic determinants: race and urbanization. This study elucidated a crucial finding with regard to race; notably, that two marginalized groups—African American and American Indian/Alaska Native—experienced substantially higher mortality rates than other racial groups. Possible reasons for these findings include misdiagnoses in higher Fitzpatrick scores, limited healthcare access for minorities, and barriers due to structural racism. However, this study shows that urbanization level further elucidates another challenge: living in a rural setting. In particular, urban areas experienced a decline in mortality rates whereas rural areas experienced an increase.

This study is valuable because it reinforces the urgent need to address inequities by race and urban region. Possible strategies may include mandating structural policies, optimizing dermatologist accessibility, or implementing mandatory anti-bias training. Ultimately, the most efficient strategy for alleviating the disproportionate burden of skin diseases and subcutaneous diseases in vulnerable populations and underserved regions may be a holistic and multi-pronged approach.

Medical Students’ Perspectives on Equity, Diversity, and Inclusion in Canadian Dermatology Residency Programs

Darshana Seeburruth¹, Edgar Akuffo-Addo², Dimitra E. Bednar², Samantha Bestavros¹, Ahmed Bagit¹, Ebenezer Oladogba², Marissa Joseph^2,3

¹Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ²Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, ³Division of Dermatology, Women’s College Hospital, Toronto, ON

Introduction: Diversity in medical training is crucial for equitable healthcare, yet dermatology remains among the least diverse specialties in North America. Prior research found that fewer than 2% of medical students from equity-deserving groups choose to pursue dermatology. Alarmingly, there is no data regarding medical students’ perceptions of equity, diversity, and inclusion (EDI) efforts in Canadian dermatology programs. This study explored student perspectives to identify areas for improvement.

Methods, Results: An anonymous survey was distributed to Canadian medical students via university listservs and social media. Subgroup analyses based on race/ethnicity and socioeconomic status (SES) were performed using Chi-square tests. In total, n=361 participants from all 17 Canadian medical schools responded. There was overwhelming interest in dermatology (99.4%, n=359/361). All participants identified barriers to pursuing the specialty, including its competitiveness (96.1%; n=347/361), limited mentorship (85%; n=307/361), and insufficient exposure (80.9%; n=292/361). Although 82% (n=296/361) valued EDI efforts in residency selection, 83.4% (n=301/361) were unaware of dermatology EDI initiatives, 80.1% (n=289/361) found EDI information “non-transparent”, and 83.6% (n=302/361) were not satisfied with current EDI efforts. Black and South Asian students prioritized EDI initiatives significantly more than White students (p=.01 and p=.001, respectively), but reported lower awareness (p=.01; p=.04) and satisfaction (p=0.02 for Black students), suggesting gaps in visibility and outreach for racialized groups. SES-based comparisons revealed no significant differences.

Conclusions: This study identified substantial gaps in awareness, transparency, and satisfaction with EDI efforts of Canadian dermatology programs, particularly among racialized groups. Based on participant feedback, we propose targeted recommendations across six key EDI areas (Table 1). Additionally, a lack of mentorship and exposure to dermatology emerged as key barriers to pursuing the specialty. To address this, we advocate for the establishment of a national dermatology mentorship program, alongside accessible webinars for medical students, to promote diversity and inclusivity in Canadian dermatology.

Learning Objectives

Takeaway Message

There are significant gaps in awareness, transparency, and satisfaction with EDI initiatives of Canadian dermatology residency programs, particularly for racialized groups, highlighting the need for improved EDI visibility and targeted efforts to enhance diversity within the specialty.

Representation of Skin of Colour on Canadian Dermatology Patient Education Websites: A Call to Action

Darshana Seeburruth¹, Samantha Bestavros¹, Eunice Aluko¹, Ahmed Bagit¹, Edgar Akuffo-Addo², Marissa Joseph^2,3

¹Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ²Division of Dermatology, Department of Medicine, Toronto, ON, ³Division of Dermatology, Women’s College Hospital, Toronto, ON

Introduction: The underrepresentation of skin of colour (SOC) in dermatology education is a longstanding issue. Yet, the extent of this issue on Canadian dermatology patient education websites remains largely unexplored. With 82.4% of dermatology patients relying on online resources for medical information, it is essential that these websites reflect diverse skin tones. This study assessed SOC representation on Canadian dermatology patient education websites and identified areas for improvement.

Methods, Results: This cross-sectional analysis, from November 2024, examined 13 Canadian dermatology patient education websites, featuring 809 images of skin pathology (Table 1). Two independent reviewers categorized images into light skin (Fitzpatrick I-IV), dark skin (Fitzpatrick V-VI), or indeterminate. Overall, 96.2% (778/809) of images depicted light skin, 3.6% (29/809) dark skin, and 0.2% (2/809) were indeterminate. Six websites (46.2%) websites, including the Canadian Dermatology Association and Canadian Skin Cancer Foundation, had no images of richly pigmented skin. The Neurofibromatosis Society of Ontario had the highest proportion of dark skin images (13.6%, 3/22). On average, light skin tones appeared 93% more frequently than dark skin tones. Melanoma was the most frequently depicted condition, with 98.8% (251/254) of the images featuring light skin. Notably, 79.5% (31/39) of conditions lacked images of richly pigmented skin, with light skin depicted 92.5% more often than dark skin.

Conclusions: Our findings reveal a substantial lack of diversity in skin pathology images on Canadian dermatology patient education websites. The absence of richly pigmented skin images may increase the risk of missed diagnoses and inadequate care for people of colour. Our study emphasizes the need for Canadian dermatology organizations to include more images of richly pigmented skin to ensure equitable patient education. In today’s digital landscape, where patients increasingly turn to the internet for medical information, promoting reliable resources with diverse representation is not just beneficial—it is a necessity.

Learning Objectives

Takeaway Message

This study highlights a critical gap in the representation of richly pigmented skin tones on Canadian dermatology patient education websites. This gap may lead to missed diagnoses and suboptimal care for people of color. Including diverse skin tones on these websites is essential for ensuring accurate and equitable patient education, especially as more patients turn to online resources for medical information.

Skin Color Representation in Dedicated Ethnic and Skin of Color Dermatology Textbooks

Melody Li¹, William Liu¹, Jincheng Wang²

¹University of British Columbia, Vancouver, BC, ²Dalhousie University, Halifax, NS

Introduction: Skin of color (SoC) is currently underrepresented in general dermatological education resources. Historical depictions often focus on infectious diseases without adequate depiction of common disorders, contributing to inequity and diagnostic delays for SoC patients. Growing awareness has led to the publication of books dedicated to ethnic and SoC dermatology, but descriptive studies across multiple resources have not been performed. The goal of this study was to examine breadth and features of SoC representation in specialized textbooks.

Methods, Results: Five SoC dermatology textbooks (Archer, Alexis, Jackson-Richards, Silverberg, Taylor and Elbuluk) were selected. A total of 1535 clinical photographs were reviewed independently by 2 authors and rated according to the Fitzpatrick skin type (FST). SoC was defined as FST IV-VI. Discrepancies were resolved by averaging both ratings . Duplicates and non-clinical images were excluded. Presence of erythema and pigmentary changes were compared between SoC and non-SoC images via chi-squared test. In total, 1299 images (84.6%) were classified as SoC, with the following distribution across FST: type IV (501, 38.6%), type V (462, 35.6%), and type VI (336, 25.9%). Statistically significant differences were observed in the proportion of erythema, depigmentation, and post-inflammatory hyperpigmentation between SoC and non-SoC images. Erythema was more frequently represented in non-SoC images, while depigmentation and post-inflammatory hyperpigmentation was more commonly observed in SoC images.

Conclusions: SoC images are robustly depicted in dedicated SoC textbooks. However, images with lighter FST (IV/V) appeared more frequently, indicating unequal distribution of included skin tones. The proportion of erythema and pigmentary changes differed significantly between SoC and non-SoC patients, suggesting the need for better representation and denotation of subtle clinical signs (erythema, inflammation, color) in darker skin tones within educational materials. Further work is needed to examine other resources and represent all dermatologic diseases across all skin types by creating comprehensive, accessible resources.

Learning Objectives

Takeaway Message

Skin of color images are robustly depicted in dedicated resources but lighter skin types appear more frequently (FST IV/V). Clinical sequelae of skin disease (erythema, pigmentary change) appears more frequently in predisposed skin types. Further work is needed to examine other resources and improve verbal description of subtle clinical signs in dermatologic images.

Sex-Related Differences in Patient Characteristics and Response to Advanced Therapies in Plaque Psoriasis Randomized Controlled Trials: Systematic Review and Meta-Analysis

Darshana Seeburruth¹, Fatima Gafoor¹, Maria-Gabriela Rodriguez Herrera², Dimitra E. Bednar³, Cheryl Rosen^2,3

¹Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ²Division of Dermatology, Toronto Western Hospital, Toronto, ON, ³Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON

Introduction: Sex-related differences in clinical characteristics and outcomes exist in psoriasis, yet data from chronic plaque psoriasis randomized controlled trials (RCTs) are limited. This systematic review and meta-analysis assessed sex-related differences in baseline characteristics and efficacy of advanced therapies in plaque psoriasis RCTs.

Methods, Results: Embase, MEDLINE, and Central databases were searched following PRISMA guidelines. After independent screening by two reviewers (DS, FG), 22 studies (21 RCTs) encompassing 13,301 participants (63% male) were included. Random-effects models calculated pooled effects of Psoriasis Area Severity Index (PASI) outcomes by sex and by drug class. Thirteen studies (14 trials) reported sex-disaggregated baseline characteristics and 15 studies (21 trials) reported efficacy outcomes. At baseline, males had higher waist-to-hip ratios (mean difference (MD) 0.10 [95% CI: 0.07–0.13]), lower odds of large waist circumference (odds ratio (OR) 0.47 [0.25–0.88]), and higher odds of nail psoriasis (OR 2.28 [1.56–3.34]). Females were more likely to have low HDL cholesterol (OR 0.50 [0.28–0.88]) and reported more itch (MD -1.27 [-2.11– -0.43]), pain (MD -1.05 [-2.11– -0.01]), discomfort (MD -1.07 [-1.97– -0.17]), and joint pain (OR 0.69 [0.49–0.98]). Males had more work impairment (OR 1.64 [1.03–2.61]) but less impaired sexual function (OR 0.71 [0.57–0.88]) and higher sexual satisfaction (MD 0.90 [0.18–1.62]). Males had higher PASI-75 response rates than females with TNF inhibitors (OR 0.42 [0.31–0.58]), but no difference was observed with IL-23 or IL-12/23 inhibitors. PASI-90 response rates did not differ by sex with IL-23 or IL-17 inhibitors.

Conclusions: Our study found significant sex-based differences in baseline characteristics and treatment efficacy in plaque psoriasis RCTs. While efficacy was generally comparable, males showed higher PASI-75 response rates with TNF inhibitors. The scarcity of sex-disaggregated data highlights the need for future trials to report these details to improve treatment outcomes for all patients.

Learning Objectives

Takeaway Message

Sex-based differences in baseline characteristics and treatment responses in plaque psoriasis randomized controlled trials highlight the need for future clinical trials to report sex-disaggregated data to ensure improved and equitable treatment outcomes for all patients.

Beliefs and Attitudes towards Sunscreen and Sun Protection Practices Among South Asians in British Columbia: A Survey Study

Harman Toor¹, Mahtab S. Gill², Tashmeeta Ahad^1,3

¹Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, ²Faculty of Medicine, University of British Columbia, Vancouver, BC, ³Vancouver Coastal Health Research Institute, Vancouver, BC

Introduction: South Asians form a significant proportion of Canada’s Skin of Colour (SOC) population, yet there is limited knowledge about their sun protection beliefs, attitudes, and practices. Our study aimed to explore such factors.

Methods, Results: A cross-sectional survey was conducted from April to October 2024 using an online questionnaire to evaluate sun protection beliefs, attitudes, knowledge and behaviours among South Asian adults in British Columbia. 62 participants were recruited, with a 90% response rate, using convenience sampling through community outreach events and social media.

Most were born in Canada or South Asia, and 41% were aged 25-34 years. More females (43%) used sunscreen daily compared to males (12%). Although 69% believed in sun protection health benefits, 30% rarely or never wore sunscreen. Motivators included preventing sunburn (68%), maintaining youthful skin (65%), and reducing their skin cancer risk (63%). A minority (25%) used sun protection for lighter skin complexion. Most were unsure if religious coverings provided adequate sun protection. Social media (41%) was the most common source of information. Barriers included forgetfulness (69%), low perceived risk (41%), discomfort (24%), and cosmetic concerns (17%) like "white cast" (61%). Preferences for organic versus inorganic sunscreens were mixed.

Conclusions: Most participants acknowledged the importance of sun protection for health, preventing sunburn and photoaging. A significant proportion also believed it would help them prevent skin cancer, despite having a lower background risk, relative to those with European ancestry. Barriers such as forgetfulness, discomfort, and cosmetic concerns limited sunscreen use. Australia has recently tailored sunscreen recommendations based on skin type, recognizing variability in risks and sun protective needs among their diverse population. Similar approaches could be considered in Canada to better address the needs of SOC populations.

Learning Objectives

Takeaway Message

This cross-sectional survey explores sunscreen and sun protection beliefs, attitudes, knowledge and behaviours among South Asians in British Columbia. While the majority believed sun protection was important for health, many reported rarely or never using sunscreen. Key barriers included forgetfulness, low perceived risk, and cosmetic concerns like a “white cast.” Females and younger participants were more likely to use sunscreen daily. Social media was the most common information source, highlighting gaps in reliable education and providing an opportunity for targeted public health messaging tailored to skin type, cultural factors, and ancestry.

Increasing Access to Dermatological Care in Resource Limited Settings via Teledermatology

Thineesha Gnaneswaran¹, Kelsey A. Orrell^2,3

¹University of Toronto, Toronto, ON, ²DermAtelier on Avenue, Toronto, ON, ³Cleveland Clinic Canada Downtown, Toronto, ON

Introduction: Skin disease is recognized as the fourth leading cause for substantial morbidity, affecting more than 2 billion individuals worldwide. Access to dermatologists can aid in the early detection of conditions to reduce morbidity. However, currently the population of actively practicing dermatologists does not meet the threshold to attend to the medical needs of “resource-rich” geographic locations. Across the globe there are several initiatives being undertaken to address the prevalent gap in access to dermatological services in resource limited settings (RLS) however there lacks an overarching global approach. Dermatology is well suited for telemedical services as diagnoses are often visually dependent and certain conditions can be captured through photographic imaging. Thus, further exploration and strategic implementation of teledermatology (TD) is essential to bridging the gap in access to dermatological care in RLS.

Methods, Results: This narrative review uses databases including PubMed and Science Direct to explore how access to dermatological services has and can be improved via TD within RLS and how this can be replicated in similar settings across the globe. Results: TD directly increases access to care by minimizing geographic, time and cost-related barriers. However, despite its ability to increase access to care, there are unique barriers to implementation including privacy concerns, acceptability as well as the lack of resources required to implement TD.

Conclusions: The use of TD has been shown to increase patient access to medical services in cases where in-person consultations are not feasible. There is cited diagnostic concordance between in-person and virtually consulted dermatologists and numerous reports of positive patient experiences and willingness to seek care through TD which further supports the use of this technology to increase access to dermatologic care. Future research should focus on mitigating major TD implementation challenges to enable its integration across a variety of geographic contexts.

Learning Objectives

Takeaway Message

Learnings and Outcomes from a Retrospective Study of Patients in Alberta’s first Psychodermatology Clinic

Lauren Wong¹, Tarek Turk¹, Parsa Abdi², Kevin Li¹, Abdullah Ramadhan¹, Adam Abba-Aji¹, Marlene Dytoc¹

¹University of Alberta, Edmonton, AB, ²Memorial University of Newfoundland, St. John’s, NL

Introduction: Psychodermatologic conditions, which encompass both dermatologic and psychological symptoms, are often complex and inadequately managed by medical practitioners, leading to suboptimal patient outcomes. The establishment of dedicated psychodermatology clinics, involving collaboration between dermatologists and psychiatrists, aims to bridge this gap. There is interest in expanding these services and determining a model that optimizes psychodermatologic patient outcomes. This study retrospectively evaluates patient outcomes, follow-up adherence, and challenges encountered at Alberta’s first psychodermatology clinic to inform future service models.

Methods, Results: A retrospective chart review was conducted for patients referred to the Skin Health Clinic in Edmonton, Alberta, from 2021 to 2023. Sixteen patients were analyzed, predominantly female (87.5%) with a mean age of 53.1 years. All patients were diagnosed with a psychodermatologic condition and received comprehensive treatment plans involving dermatologic and/or psychiatric therapies. Challenges identified included medication nonadherence and inconsistent follow-up attendance, with 18.8% having no follow-up, 43.8% attending one follow-up, and 37.5% attending multiple follow-ups. Among patients with complete score data, PHQ-9 scores significantly decreased from 12.00 to 6.25 (p < 0.05), indicating reduced depressive symptoms. Additionally, patients with more follow-up visits generally showed greater improvements in their conditions and reductions in at least one questionnaire score, highlighting the importance of consistent follow-up in treatment efficacy.

Conclusions: The integrated psychodermatology clinic model in Alberta was created to address current gaps in care for individuals with psychodermatologic conditions. Patients benefited from collaborative consultations, as evident through improvement with at least one scoring tool. However, medication nonadherence and inconsistent follow-up remain significant challenges. Enhancing patient education, identifying and reducing barriers to follow-up, and implementing strategies to improve adherence are essential for optimizing psychodermatologic patient outcomes. This retrospective study provides foundational insights into the effectiveness and challenges of psychodermatology services within a Canadian healthcare setting, informing future improvements and service models.

Learning Objectives

Takeaway Message

Collaborative consultations with dermatologists and psychiatrists in dedicated psychodermatology clinics significantly improve patient outcomes, yet overcoming challenges related to medication adherence and follow-up is crucial for sustained therapeutic success.

Systematic Review of Psychodermatologic Assessment Tools: Informing the Development of the Canadian Psychodermatology Scale

Parsa Abdi¹, Clayton Clark², Kevin Li³, Tarek Turk³, Marlene Dytoc²

¹Faculty of Medicine, Memorial University of Newfoundland, St. Johns, NL, ²Division of Dermatology, Department of Medicine, University of Alberta, Edmonton, AB, ³Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB

Introduction: Primary psychodermatologic disorders (PPDs) such as body dysmorphic disorder, trichotillomania, and excoriation disorder present significant challenges in dermatological and psychiatric assessment due to their complex psychological and dermatological symptoms. Reliable and valid screening tools are essential for effective diagnosis and management, yet there is a lack of consensus on the most appropriate instruments. This systematic review aims to evaluate existing PPDs assessment tools in terms of their diagnostic accuracy and clinical utility, thereby informing the development of the Canadian Psychodermatology Scale (CPDS).

Methods, Results: A systematic review was conducted, identifying 81 studies that employed 45 different psychodermatologic tools, of which thirteen studies provided empirical data on diagnostic accuracy. Tools were assessed for their psychometric properties, including sensitivity, specificity, reliability, and validity. The Body Dysmorphic Disorder Questionnaire (BDDQ) and its variants demonstrated high diagnostic accuracy, with the BDDQ showing a sensitivity of 0.97 [95% CI: 0.82-1.00] and specificity of 0.91 [95% CI: 0.86-0.95]. The Skin Picking Scale-Revised (SPS-R) showed high diagnostic accuracy for excoriation disorder, with a sensitivity of 0.89 [95% CI: 0.84-0.94] and specificity of 0.95 [95% CI: 0.93-0.96]. Similarly, the Massachusetts General Hospital Hairpulling Scale (MGH-HPS), frequently utilized for trichotillomania, exhibited strong psychometric properties, with a sensitivity of 0.90 [95% CI: 0.81-0.96] and specificity of 0.72 [95% CI: 0.63-0.80].

Conclusions: This systematic review highlights the variability in diagnostic accuracy and comprehensiveness of existing psychodermatologic assessment tools. There is a lack of consensus on optimal tools for PPDs, and limited instruments are available that effectively screen for the full range of psychodermatologic conditions. To address these gaps, we are developing the CPDS, a standardized, multidimensional screening tool designed to facilitate early identification and management of psychodermatologic disorders in clinical practice. Future research should focus on validating the CPDS and integrating it into routine workflows to enhance patient outcomes.

Learning Objectives

Takeaway Message

Current psychodermatologic assessment tools exhibit significant variability in diagnostic accuracy and comprehensiveness, underscoring the need for standardized, multidimensional instruments. The development of the Canadian Psychodermatology Scale aims to bridge these gaps, facilitating early identification and effective management of psychodermatologic disorders, thereby enhancing patient outcomes in clinical practice.

Epidemiology and Comorbidities of Psychodermatologic Conditions: A Population-Based Analysis

Parsa Abdi¹, Tarek Turk², Zaim Haq³, Michael J. Diaz⁴, Marlene Dytoc⁵

¹Faculty of Medicine, Memorial University of Newfoundland, St. John’s, NL, ²Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, ³Warren Alpert Medical School, Brown University, Providence, RI, ⁴College of Medicine, University of Florida, Gainesville, FL, ⁵Division of Dermatology, Department of Medicine, University of Alberta, Edmonton, AB

Introduction: Psychodermatologic conditions include primary psychodermatologic disorders (PPDs), psychological conditions manifesting with dermatologic symptoms, and psychophysiological disorders, dermatologic conditions influenced by psychological stress. Despite their clinical significance and considerable impact on quality of life, the comprehensive epidemiology and neuropsychiatric comorbidity profiles of these disorders remain limited.

Methods, Results: A nested, case-control study was conducted using data from the All of Us Research Program, a NIH initiative containing clinical data from historically underrepresented groups. From 287,011 eligible participants, 984 patients with PPDs (trichotillomania, skin picking disorder, dermatitis artefacta, body dysmorphic disorder, delusions of parasitosis) and 40,535 patients with psychophysiological disorders (psoriasis, atopic dermatitis, acne vulgaris, hidradenitis suppurativa, vulvodynia) were identified using ICD-10-CM codes. Each patient was paired with four controls based on age, sex, and race/ethnicity using nearest-neighbor propensity score matching. Multivariable logistic regression calculated adjusted odds ratios (aOR) and 95% confidence intervals to evaluate associations with various neuropsychiatric comorbidities.PPDs showed low point prevalences (Range: ≤0.01-0.17%) but demonstrated markedly higher odds of neuropsychiatric comorbidities, including depressive disorders (Range: aOR, 5.72–13.94), anxiety disorders (Range: aOR, 5.96–8.40), and personality disorders (Range: aOR, 8.67–13.56 Psychophysiological disorders had higher prevalence rates (Range: 0.14%–5.72%) but showed more moderate associations, including depressive disorders (Range: aOR, 2.24–3.13), neurodevelopmental disorders (Range: aOR, 1.20–2.36), somatoform disorders (Range: aOR, 1.99–6.13) and sleep-wake disorders (Range: aOR, 2.25–3.95). Across both groups, psychiatric comorbidities were prominent, indicating a strong interplay between psychological factors and skin disease.

Conclusions: This study highlights the substantial neuropsychiatric burden associated with psychodermatologic conditions and underscores the importance of integrated dermatological and psychiatric care. Findings reveal distinct but overlapping comorbidity profiles between PPDs and psychophysiological disorders, emphasizing the need for tailored interventions that address the psychosocial and biological complexities of these conditions.

Learning Objectives

Takeaway Message

Psychodermatologic conditions frequently coexist with diverse neuropsychiatric disorders, emphasizing the need for integrated dermatological and mental health care to improve patient outcomes.

Adherence to RECORD Reporting Guidance Among Observational Studies Using Routinely Collected Health Data Published in General Medical Journals

Heather J. Zhao¹, Inna Ushcatz², Megan S. Lowe³, Chantel Walwyn⁴, Kevin Kim⁵, Eric Benchimol⁶, Sinead Langan⁷, Aaron M. Drucker⁴

¹University of Toronto, Toronto, ON, ²Univeristy of Toronto, Toronto, ON, ³Queens Univrsity, Kingston, ON, ⁴Women’s College Hospital, Toronto, ON, ⁵McMaster University, Hamilton, ON, ⁶The Hospital for Sick Children, Toronto, ON, ⁷London School of Hygiene and Tropical Medicine, London, UK

Introduction: The REporting of studies Conducted using Observational Routinely Collected Data (RECORD) tool was developed to address gaps in reporting studies using routinely collected health data. Much dermatological research uses routinely collected datasets, highlighting the need to assess routinely collected health data reporting. The objective of this study was to assess adherence to RECORD in medical journals and to evaluate its correlation with study quality.

Methods, Results: We searched PubMed using a validated filter to identify studies using routinely collected health data published in eight high impact medical journals between 2016-2023. Four journals endorsed RECORD, while four did not. For each journal, 24 articles were randomly selected, with three studies per year. Study characteristics, RECORD and quality assessments were completed in duplicate and described using proportions and means with standard deviations. Linear regression was used to estimate the association between journal and study characteristics with adherence to RECORD items.

Studies reported a mean of 70.7% (SD 1.8) of RECORD items. Adherence in RECORD-endorsing journals did not differ significantly between RECORD-endorsing compared to non-RECORD endorsing journals (1.8 percent lower adherence; 95% CI: - 5.8, 2.2). Adherence of > 80% was reported for RECORD items 1.1, 1.2, 6.1, 7.1, 19.1 and 22.1.

Conclusions: Studies using routinely collected data that were published in medical journals had moderate adherence to RECORD, with no association between endorsement of RECORD and reporting completeness. RECORD endorsement is insufficient to improve reporting completeness. Authors and journals should be aware of and adhere to items required for RECORD reporting to improve the reproducibility of research.

Learning Objectives

Takeaway Message

Adherence to the RECORD reporting guideline in medical journals is moderate and not influenced by RECORD endorsement, highlighting the need for authors and journals to follow RECORD items to improve research reproducibility.

Evaluating UV Exposure and Skin Cancer Preventive Behaviours in Canada: A National Population Based Cross-sectional Study

Amina Moustaqim-Barrette¹, Hibo Rijal², Santina Conte¹, Mahan Maazi³, Johnny Hanna⁴, Alexandra S.V. Kelly⁵, Alicia Belaiche¹, Alyson McKenna⁶, Sandra Peleaz¹, Francois Lagace¹, Ivan V. Litvinov¹

¹McGill University, Montreal, QC, ²Queens University, Kingston, ON, ³University of British Columbia, Vancouver, BC, ⁴Université Laval, Québec, QC, ⁵University of Ottawa, Ottawa, ON, ⁶Université de Montréal, Montréal, QC

Introduction: Cutaneous melanoma (CM) incidence is increasing in Canada and globally. Sun-protective behaviours are crucial in addressing rising incidence and are responsive to public health intervention. This study sought to assess trends in sun protective behaviours and UV exposure in Canada.

Methods, Results: Using data from the Statistics Canada (SC), we analysed sun-protective behaviours and UV exposure data on over 77,000 individuals aged 18 and above from 2011-2018. We used multivariable logistic regression to understand differences in ten UV exposure and sun protective behaviour outcome variables of interest by several independent demographic factors including age, sex, income, race, Indigeneity, immigration status, and sexual orientation. Age-, gender-, and race-adjusted odds ratios are reported, and all results were weighted using SC weights. We further evaluated temporal trends in UV exposure and sun protection from 2007-2018.

One third (33.3%) of respondents reported having had a sunburn in the past 12 months, and most reported irregular or never use of sunscreen on their body (64.3%) and face (58.1%). Women had significantly higher odds of using sunscreen on their bodies and faces compares to men (OR = 2.85, 95% CI 2.68–3.03 and OR = 4.22, 95% CI 3.96–4.49, respectively). Individuals in the highest income quintile similarly were more likely to use sunscreen on their bodies and faces than those in the lowest income quintile (OR= 1.78, 95% CI 1.55–2.04 and OR= 2.45 (95% CI 2.10–2.86, respectively). Temporal trends showed increasing prevalence of spending 2 hours or more in the sun and a decreasing trend in the use of any sunscreen on the body and face.

Conclusions: Our study highlights significant differences in sun protection and UV exposure across key demographic groups and may help develop targeted public health strategies to enhance sun-protective behaviours and reduce melanoma incidence in Canada.

Learning Objectives

Takeaway Message

Our study used data from over 77000 survey respondents, with a weighted sample representing over 21 million Canadians. We reveal concerning trends in UV exposure and sun protective behaviors across major demographic and socioeconomic groups in Canadian society. We found that most Canadians spend time outdoors on their summer days off, with one-third of Canadians experiencing a sunburn in the past year. For most Canadians, sunscreen use was irregular or absent (64.3% and 58.1% irregular/absent use on the body and face, respectively). Alarmingly, temporal trends indicate an increase in prolonged sun exposure and a decline in sunscreen use among both men and women.

Significant disparities in UV exposure and sun protection practices were identified across demographic variables such as race, sex, age, income, marital status, education, Indigeneity, immigrant status, and sexual orientation. Despite increased awareness of melanoma risks, trends indicate a troubling rise in sun exposure over the years, coupled with inconsistent sunscreen use. These findings underscore a need for targeted public health interventions and policies to promote effective sun safety behaviours, particularly among high-risk populations. Enhanced education and accessible prevention strategies could substantially mitigate the increasing burden of skin cancers, emphasizing the critical role of primary prevention in cancer control. Future efforts must focus on bridging these behavioural gaps to foster a more equitable approach to skin cancer prevention in Canada and beyond.

Exploring What Constitutes a Quality Referral for a Potentially Malignant Skin Lesion: A Scoping Review and Modified Delphi Consensus

Kristina Nazzicone¹, Bethany Wilken², Erin Dahlke^1,3,4, Linden Head¹, Sonja Molin^1,5, Thomas Herzinger^1,5, Lourdes Ramírez Hobak¹, Yuanshen Huang¹, Glykeria Martou¹, Menelaos Konstantinidis^3,6,7, Yuka Asai¹

¹Queen’s University, Kingston, ON, ²Western University, London, ON, ³University of Toronto, Toronto, ON, ⁴St. Joseph’s Health Centre, Toronto, ON, ⁵Charité – Universitätsmedizin Berlin, Germany, ⁶Li K. Shing Knowledge Institute, Toronto, ON, ⁷Institute of Health Policy, Management and Evaluation, Toronto, ON

Introduction: Every medical question to a specialist involves a referral. Referrals for potentially malignant skin lesions are an area of necessary quality improvement. This study aims to achieve consensus on the content of referral letters for potentially malignant skin lesions according to experts who regularly receive these referrals at our institution.

Methods, Results: A scoping review of referral quality literature was conducted. Sources from Embase, MEDLINE, Web of Science, and CADTH Grey Matters were screened independently and in duplicate following PRISMA-ScR guidelines. Data was charted and synthesized using thematic analysis to generate a list of referral components that might be relevant for a skin cancer referral. The scoping review highlighted 77 referral components, synthesized from 47 sources published between 1964 and 2023. Findings suggest cutaneous referrals might include details related to the referral itself (e.g., reason, urgency), referee (e.g., name, specialty), patient (e.g., demographics, contact details), and clinical information (e.g., lesion characteristics, medical history, biopsy results). Next, 9 experts spanning dermatology, plastic surgery, and otolaryngology participated in a two-round modified Delphi process (64% response rate). Panelists scored items using a 5-point Likert scale where a median score of 4-5 out of 5 was considered positive consensus and a score of 1-2 indicated negative consensus. A total of 80 components achieved positive consensus, 11 items achieved negative consensus, and 16 lacked consensus despite two rounds.

Conclusions: Items obtaining positive consensus are considered necessary for quality referrals for skin cancer according to experts that regularly receive these referrals. Items lacking consensus are included as potentially relevant components, however are not considered necessary. Necessary components will be used to inform best practices regarding the content of referral letters for skin cancer and serve as a rubric to assess referral quality at our institution.

Learning Objectives

Takeaway Message

Expert consensus highlights the components necessary for high-quality referrals for potentially malignant skin lesions, providing a framework for assessing referral quality and guiding improvements in clinical practice.

Artificial Intelligence in Acne Diagnosis, Management, and Treatment

Kanwarpreet Karwal¹, Kaitlyn Ramsay², Samiha Mohsen², Ilya Mukovozov^3,4

¹Western University, London, ON, ²University of Toronto, Toronto, ON, ³Toronto Dermatology Centre, Toronto, ON, ⁴Division of Dermatology, Women’s College Hospital, Toronto, ON

Introduction: Acne, a common dermatological condition, poses significant physical and psychological challenges, including scarring and reduced self-esteem. Despite advancements in dermatological therapies, personalized and effective acne management remains an unmet need. Artificial intelligence (AI), encompassing machine learning (ML) and deep learning (DL), has revolutionized dermatology by enhancing diagnostic precision and enabling personalized treatment strategies. AI’s application in acne management includes automated diagnosis, severity classification, treatment customization, and real-time monitoring, advancing the field toward individualized and accessible care.

Methods, Results: A scoping review was conducted using PubMed, MEDLINE, Scopus, and Web of Science to evaluate the integration and implications of AI in acne management. Keywords included "artificial intelligence," "machine learning," "acne management," and "dermatology." Articles addressing AI’s role in diagnostic accuracy, therapeutic personalization, ethical considerations, and clinical integration were analyzed. AI models, particularly Convolutional Neural Networks (CNNs), accurately classify acne types and severities. AI-driven algorithms customize treatment plans based on patient data, such as clinical history and genetic factors, and predict therapeutic outcomes. These innovations facilitate improved access to dermatological care through telemedicine, empowering patients with education and self-monitoring tools. However, challenges such as data privacy, algorithmic bias, and integration into clinical workflows persist.

Conclusions: AI has emerged as a transformative tool in acne management, offering enhanced diagnostic accuracy, personalized treatments, and improved accessibility to dermatological care. While AI-driven solutions address long-standing challenges in acne treatment, their integration into clinical practice requires addressing ethical considerations, data privacy, and system biases. Future advancements will focus on refining AI algorithms, fostering interdisciplinary collaboration, and developing regulatory frameworks to ensure equitable, patient-centered care. As AI continues to evolve, it promises to redefine dermatological care by enabling innovative, precise, and adaptive approaches to acne management.

Learning Objectives

Takeaway Message

The integration of artificial intelligence (AI) into acne management marks a transformative leap in dermatology, addressing longstanding challenges of diagnostic accuracy, personalized treatment, and accessibility. AI technologies, particularly machine learning (ML) and deep learning (DL), offer precise diagnostic capabilities and the ability to classify acne types and severities with accuracy comparable to dermatologists. By leveraging diverse datasets such as clinical images and patient histories, AI tools enable personalized treatment plans that optimize therapeutic outcomes and reduce trial-and-error approaches.

In addition to improving care quality, AI enhances accessibility to dermatological services through telemedicine and remote monitoring tools, empowering patients with education and self-management capabilities. However, the adoption of AI is not without challenges. Ethical considerations, such as data privacy and algorithmic bias, along with integration hurdles in clinical workflows, require careful navigation to ensure equitable and effective implementation.

The future of AI in dermatology is promising, with advancements expected in predictive analytics, genomics integration, and real-time therapy adjustments. Collaborative efforts among clinicians, computer scientists, and policymakers will be critical to refining AI technologies and addressing ethical concerns. Ultimately, AI is poised to redefine acne management and broader dermatological care, offering innovative, patient-centered solutions that elevate both outcomes and the standard of care.

Real-World Effectiveness of Risankizumab in the Multi-Country Post-Marketing VALUE Study: 148-Week Interim Analysis

Diamant Thaçi¹, Mamitaro Ohtsuki², Julia-Tatjana Maul³, Andrea Szegedi⁴, Paula C. Luna⁵, Charles W. Lynde⁶, Hongwei Wang⁷, Ahmed M. Soliman⁷, Doug Ashley⁷, Simone Rubant⁷, Kim A. Papp^8,9

¹Institute and Comprehensive Center Inflammation Medicine, University of Lübeck, Lübeck, Germany, ²Department of Dermatology, Jichi Medical University, Shimotsuke, Japan, ³Department of Dermatology, University Hospital Zurich and Faculty of Medicine, University of Zurich, Zurich, Switzerland, ⁴Department of Dermatology, Faculty of Medicine, University of Debrecen, Debrecen, Hajdu-Bihar, Hungary. ⁵Servicio de Dermatología, Hospital Alemán, Ciudad Autónoma de Buenos Aires, Argentina, ⁶Lynde Institute for Dermatology & Lynderm Research Inc, and Probity Medical Research, Markham, ON, ⁷AbbVie Inc., North Chicago, IL, ⁸K Papp Clinical Research and Probity Medical Research, Waterloo, ON, ⁹University of Toronto, Toronto, ON

Introduction: Risankizumab (RZB) is an IL-23 inhibitor approved for the treatment of moderate-to-severe plaque psoriasis, psoriatic arthritis, and Crohn’s disease. We assessed the long-term effectiveness of RZB versus other commonly used biologics (OtherBios) in the VALUE post-marketing study through Week 148.

Methods, Results: VALUE is a multi-country, prospective observational study in adult patients with moderate-to-severe psoriasis treated with RZB or OtherBios, per local label, in a 2:1 ratio (database lock: 7-Dec-2023). Effectiveness assessment included Psoriasis Area and Severity Index (PASI), Dermatology Life Quality Index (DLQI), and Treatment Satisfaction Questionnaire for Medication (TSQM). Patients who switched or discontinued initial biologics due to ineffectiveness/intolerability were considered treatment failures for subsequent visits (modified non-responder imputation). Propensity score match (PSM) with 1:1 ratio was employed to account for imbalance between treatment groups. Baseline demographics and characteristics were mostly comparable among 1765 (RZB) and 874 (OtherBios) patients. Patients using RZB had a higher baseline PASI (15.0 vs 13.9; P=0.004), fewer had history of psoriatic arthritis (14.7% vs 26.7%; P<0.0001), and more were bio-experienced (49.3% vs 37.1%; P<0.0001). More patients using RZB maintained PASI90 response from Week 16 to 148 (45.4% vs 29.6%; P=0.0002) and fewer changed treatment (10.9% vs 24.2%; P<0.0001) compared to OtherBios. At Week 148, patients using RZB achieved significantly lower absolute PASI (1.4 vs 3.6; P<0.0001) and a higher proportion achieved PASI90/100 (67.2% vs 45.3%/55.2% vs 34.6%; P<0.0001) compared to OtherBios. Patients using RZB had lower DLQI (2.5 vs 5.2; P<0.0001) and higher TSQM global satisfaction scores (86.1 vs 75.5; P<0.0001). PSM confirmed these results. Safety for RZB was consistent with previous studies.

Conclusions: This updated analysis from the VALUE study demonstrates that patients treated with RZB achieve higher durable clinical responses in real-world practice compared to OtherBios. This study is ongoing and not all patients have reached Week 148.

Learning Objectives

Takeaway Message

Safety and Tolerability of Roflumilast Cream from INTEGUMENT-1/2 Trials of Patients with Atopic Dermatitis and Prior Failure of Topical Treatments

Eric L. Simpson¹, Lawrence F. Eichenfield², Melinda Gooderham³, H. Chih-ho Hong⁴, Kim A. Papp^5,6, Adelaide A. Hebert⁷, David Krupa⁸, Scott Snyder⁸, Patrick Burnett⁸, David R. Berk⁸, David H. Chu⁸

¹Oregon Health & Science University, Portland, OR, ²University of California San Diego, La Jolla, CA, ³SKiN Centre for Dermatology, Probity Medical Research, and Queen’s University, Peterborough, ON, ⁴Probity Medical Research, University of British Columbia, Department of Dermatology and Skin Science, Surrey, BC, ⁵Probity Medical Research and Alliance Clinical Trials, Waterloo, ON, ⁶Division of Dermatology, Temerty School of Medicine and University of Toronto, Toronto, ON, ⁷UTHealth Houston McGovern Medical School, Houston, TX, ⁸Arcutis Biotherapeutics, Inc., Westlake Village, CA

Introduction: Roflumilast cream 0.15% is a novel, once-daily, highly potent phosphodiesterase 4 inhibitor approved for treatment of mild-to-moderate atopic dermatitis (AD) in patients aged ≥6 years. Primary treatments for AD include topical corticosteroids (TCS), topical calcineurin inhibitors (TCIs), and crisaborole, but their use may be limited by safety and tolerability concerns. This abstract presents safety and local tolerability of roflumilast cream 0.15% from replicate, 4-week, phase 3 trials (INTEGUMENT-1/2: NCT04773587/NCT04773600) in patients with prior inadequate response, intolerance, and/or contraindications to (ie, failure) TCS, TCI, or crisaborole.

Methods, Results: Patients aged ≥6 years with AD, Eczema Area and Severity Index ≥5, and Validated Investigator Global Assessment for AD (vIGA-AD) of Mild or Moderate were randomized 2:1 to once-daily roflumilast cream 0.15% or vehicle for 4 weeks. Safety and local tolerability were assessed through adverse events and investigator- and patient-rated local tolerability scales. Of 1137 patients in this pooled analysis (884 roflumilast, 453 vehicle), 60.8% reported prior TCS failure, 18.0% TCI failure, and 7.3% crisaborole failure. Application site pain was reported for 1.5% (roflumilast) and 0.7% (vehicle) of patients with TCS failure, 1.8% and 2.5% with TCI failure, and 1.4% and 0% with crisaborole failure. No application site TEAEs were reported for patients who had previously discontinued crisaborole because of stinging, burning, and/or poor tolerability (n=34 and 13, respectively). Investigator-rated and patient-reported local tolerability were comparable with the overall pooled trial results. Overall, ≥98.1% of patients with TCS failure, ≥97.0% with TCI failure, and ≥95.6% with crisaborole failure had no evidence of or minimal irritation on investigator-rated tolerability at all timepoints. For patient-reported tolerability, across all timepoints, ≤3.3% reported hot, tingling, stinging sensations that caused definite discomfort.

Conclusions: Roflumilast cream 0.15% was well tolerated in patients with AD, including those with prior TCS, TCI, and/or crisaborole failure.

Learning Objectives

Takeaway Message

Roflumilast cream 0.15% was well tolerated in patients with atopic dermatitis and prior failure of topical treatments in two phase 3 clinical trials.

Patient-Reported Outcomes and Family Impact with Roflumilast Cream in Atopic Dermatitis: Pooled Results from Phase 3 INTEGUMENT-1 and INTEGUMENT-2 Trials

Eric L. Simpson¹, Mark Boguniewicz², Lawrence F. Eichenfield³, Bob Geng³, Vimal H. Prajapati⁴, Sheila Fallon Friedlander⁵, David R. Berk⁶, David H. Chu⁶

¹Oregon Health & Science University, Portland, OR, ²National Jewish Health, Denver, CO, ³Rady’s Children’s Hospital-San Diego, University of California, San Diego, CA, ⁴Dermatology Research Institute, Probity Medical Research, Skin Health & Wellness Centre, and University of Calgary, Calgary, AB, ⁵Scripps Health, San Diego, CA, ⁶Arcutis Biotherapeutics, Inc., Westlake Village, CA

Introduction: Roflumilast, a potent phosphodiesterase 4 inhibitor, is approved as a once-daily 0.15% cream for patients aged ≥6 years with atopic dermatitis (AD). The objective of this trial was to evaluate the impact of roflumilast cream 0.15% on patient-reported outcomes (including family impact) in patients aged ≥6 years with AD using pooled data from identically designed Phase 3 randomized controlled trials (INTEGUMENT-1: NCT04773587; INTEGUMENT-2: NCT04773600).

Methods, Results: Patients aged ≥6 years with AD, Eczema Area and Severity Index ≥5, and Validated Investigator Global Assessment for AD (vIGA-AD) of Mild or Moderate were randomized 2:1 to once-daily roflumilast cream 0.15% or vehicle for 4 weeks. The primary endpoint was vIGA-AD Success (Clear or Almost Clear with ≥2-grade improvement from baseline) at Week 4. Other outcome measures included Dermatitis Family Impact (DFI; patients aged ≤17 years; minimally important difference: not established), SCORing AD (SCORAD) total score (−8.7), and Patient-Oriented Eczema Measure (POEM; −3.4). Safety and tolerability were also assessed. Among 884 and 453 patients who received roflumilast and vehicle, respectively, a significantly greater proportion of those treated with roflumilast achieved vIGA-AD Success at Week 4 (31.3% vs 14.1%; P<0.0001). Patients treated with roflumilast versus vehicle also had greater mean percent improvement in SCORAD total score (46.2% vs 26.6%, P<0.0001) and least squares mean improvements in POEM (7.5 vs 3.9, P<0.0001) and DFI (3.12 vs 1.74, P<0.0001) at Week 4. Roflumilast and vehicle were associated with low incidences of treatment-emergent adverse events (TEAEs; 21.9% and 14.4%) and TEAEs leading to discontinuation of the trial/trial drug (1.6% and 1.1%).

Conclusions: In two Phase 3 trials of patients with AD aged ≥6 years, once-daily roflumilast cream 0.15% improved signs of AD, patient-reported outcomes, and family impact.

Learning Objectives

Takeaway Message

Roflumilast cream 0.15% provided greater efficacy and improvement in patient-reported outcomes, including family impact, than vehicle in adults and children with atopic dermatitis.

Safety and Pigmentation Changes from a Phase 3 Trial of Roflumilast Foam 0.3% in Patients with Seborrheic Dermatitis (STRATUM)

Andrew F. Alexis¹, Andrew Blauvelt², Seth B. Forman³, Lawrence Green⁴, Edward Lain⁵, Tory Sullivan⁶, David Krupa⁷, David R. Berk⁷, Patrick Burnett⁷, Saori Kato⁷, David H. Chu⁷

¹Weill Cornell Medicine, New York, NY, ²Oregon Medical Research Center, Portland, OR, ³ForCare Medical Center, Tampa, FL, ⁴George Washington University School of Medicine, Rockville, MD, ⁵Sanova Dermatology, Austin, TX, ⁶Sullivan Dermatology, Ft. Lauderdale, FL, ⁷Arcutis Biotherapeutics, Inc., Westlake Village, CA

Introduction: Seborrheic dermatitis (SD) can present with hypopigmentation or hyperpigmentation, especially in patients with skin of color. In a phase 3 randomized, double-blind trial of roflumilast foam 0.3% (a selective phosphodiesterase 4 inhibitor) in patients with SD (STRATUM; NCT04973228), the primary/secondary efficacy endpoints were met; safety, local tolerability, and pigmentation results from this trial are presented here.

Methods, Results: The trial enrolled patients aged ≥9 years with at least moderate SD. Patients were randomized 2:1 to apply once-daily roflumilast foam 0.3% or vehicle for 8 weeks. Safety was assessed through adverse events (AEs), local tolerability, and pigmentation changes. Pigmentation changes were scored on 4-point scales (0 [None] to 3 [Severe]). Overall, 304 patients received roflumilast foam and 153 received vehicle. Incidences of treatment-emergent AEs (TEAE), SAEs, and TEAEs leading to discontinuation were low for both roflumilast and vehicle. Roflumilast and vehicle were well tolerated, with ≥99.3% of patients having no evidence of irritation at Weeks 4 and 8 on investigator-rated assessments and ≥92.3% of patients reporting no sensation or slight warm, tingling sensation that was not really bothersome after application. Most patients (≥95.8%) had no hyper- or hypopigmentation at any study visit. At baseline, hypopigmentation was more common in non-White (10/101; 9.9%) than White patients (9/356; 2.5%). Similarly, baseline hyperpigmentation was more common in non-White (10/101; 9.9%) than White patients (6/356; 1.7%). In both groups, baseline pigmentary findings improved during the study. At Week 8, 64.7% (11/17) of patients with baseline hypopigmentation and 46.2% (6/13) of patients with baseline hyperpigmentation experienced full resolution of pigmentary findings. At Week 8, new instances of hypopigmentation (n=1) and hyperpigmentation (n=6) were uncommon.

Conclusions: Safety (including pigmentation results) and local tolerability profiles were favorable across treatment groups following vehicle and roflumilast foam 0.3% application for 8 weeks in patients with SD.

Learning Objectives

Takeaway Message

Safety and local tolerability profiles were favorable in the STRATUM trial of roflumilast foam 0.3%; patients with hypo- or hyperpigmentation at baseline experienced improvements in pigmentary findings over the trial.

Effectiveness of Upadacitinib in Canadian Adults and Adolescents With Atopic Dermatitis: 6-Month Interim Analysis of the Real-World Multicountry AD-VISE Study

Hermenio Lima^1,2, Jennifer Beecker^3,4,5, Irina Turchin^5,6,7, Michael Cecchini⁸, Parbeer Grewal^9,10, Angélique Gagné-Henley¹¹, Michael Lane¹², Cristina Sancho¹³, Carly Sterling¹⁴, Julie Charbonneau¹⁴, David Préfontaine¹⁴, Charles W. Lynde^5,15,16, Melinda Gooderham^17,18,19

¹LEADER Research Inc., Hamilton, ON, ²Faculty of Health Sciences, McMaster University, Hamilton, ON, ³Division of Dermatology, University of Ottawa, Ottawa, ON, ⁴Ottawa Hospital Research Institute (OHRI), Ottawa, ON, ⁵Probity Medical Research Inc., Waterloo, ON, ⁶Brunswick Dermatology Center, Fredericton, NB, ⁷Dalhousie University, Halifax, NS, ⁸York Dermatology Clinic & Research Centre, Richmond Hill, ON, ⁹Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, ¹⁰Rejuvenation Dermatology, Edmonton, AB, ¹¹Dre Angélique Gagné-Henley MD Inc., St-Jérôme, QC, ¹²AbbVie Inc., North Chicago, IL, ¹³AbbVie, Madrid, Spain, ¹⁴AbbVie Corporation, Saint-Laurent, Qc, ¹⁵The Lynde Institute for Dermatology & Lynderm Research Inc., Markham, ON, ¹⁶Division of Dermatology, Termerty Faculty of Medicine, University of Toronto, Toronto, ON, ¹⁷SKiN Centre for Dermatology, Peterborough, ON, ¹⁸Queen’s University, Kingston, ON, ¹⁹Probity Medical Research, Peterborough, ON

Introduction: The approval of upadacitinib (UPA) for treatment of moderate to severe atopic dermatitis (AD) is supported by several clinical efficacy/safety studies. Real-world data on UPA use in Canada however remain limited.

Methods, Results: AD-VISE (NCT05081557) is an ongoing 2-year observational multicountry study assessing usage of UPA in clinical practice in adults and adolescents with AD. Key effectiveness outcome measures included validated Investigator Global Assessment for Atopic Dermatitis (vIGA-AD), Eczema Area and Severity Index (EASI), and Worst Pruritus Numeric Rating Scale (WP-NRS). This interim analysis (data cutoff 14-Dec-2023) reports baseline, 2-, 4-, and 6-month effectiveness data for Canadian patients (N=193). The proportions of patients with moderate and severe AD (vIGA-AD score of 3/4) at baseline were 47.3% and 48.2%, respectively. The most common reason for initiating UPA on 15 mg was attempting lowest possible effective dose (45.9%) and on 30 mg, high disease burden/severity of skin symptoms (49.2%). More patients starting UPA 30 vs 15 mg were between 18 to <65 years old and had severe AD (vIGA-AD score of 4). At Month 2, 4, and 6, 54.7%, 58.7%, and 55.2% of patients achieved vIGA-AD score of 0/1, 73.3%/49.9%, 80.7%/57.3%, and 74.9%/54.9% achieved 75%/90% improvement in EASI score from baseline (EASI 75/90), while 40.4%, 45.6%, and 44.9% reported no or almost no itch (WP-NRS 0/1), respectively. Similar trends were seen across results on additional patient-reported outcomes (Table).

Conclusions: These effectiveness findings suggest over half of Canadian patients with moderate-to-severe AD treated with UPA achieved clear/almost clear skin and many reported no or almost no itch by Month 6 and often as early as Month 2. Real-world use of UPA 15 and 30 mg was respectively based on use of lowest effective dose and high disease burden, thereby reflecting the dosage and administration recommendations per Canadian label.

Learning Objectives

Takeaway Message

Impact of Treatment Duration on Response Durability: Post-Hoc Analysis of the TRuE-V Long-Term Extension Study of Ruxolitinib Cream in Vitiligo

David Rosmarin¹, Thierry Passeron^2,3, José L. López-Estebaranz⁴, Haobo Ren⁵, Abdelhak Amara Korba⁵, Janel Torsiello⁵, John E. Harris⁶

¹Indiana University School of Medicine, Indianapolis, IN, ²Centre Hospitalier Universitaire de Nice, Université Côte d’Azur, Nice, France, ³INSERM U1065, C3M, Université Côte d’Azur, Nice, France, ⁴University Hospital Fundación Alcorcón, Madrid, Spain, ⁵Incyte Corporation, Wilmington, DE, ⁶University of Massachusetts Chan Medical School, Worcester, MA

Introduction: Ruxolitinib cream (JAK1/JAK2 inhibitor) demonstrated statistically superior repigmentation vs vehicle at Week 24, with continued improvement through Week 52 in TRuE-V1/TRuE-V2 phase 3 studies.

Methods, Results: This analysis included patients who achieved near-complete facial repigmentation (≥90% improvement in facial Vitiligo Area Scoring Index [F-VASI90]) in TRuE-V1/TRuE-V2 (NCT04052425/NCT04057573) and withdrew from ruxolitinib cream treatment in the rollover TRuE-V long-term extension (NCT04530344). Patients were stratified into 3 groups: vehicle crossover to ruxolitinib cream after Week 24 (VEH-RUX) and ruxolitinib cream throughout who achieved F-VASI90 before/at Week 24 (RUX-RUX-early) or after Week 24 (RUX-RUX-later). F-VASI90 response durability was assessed as time to response loss.

Fifty-seven patients were included (VEH-RUX, n=12; RUX-RUX-early, n=25; RUX-RUX-later, n=20). Following ruxolitinib cream withdrawal, median (range) F-VASI90 response was more durable in patients with longer vs shorter treatment duration (RUX-RUX-early, 365 [120–not estimable (NE)] days vs VEH-RUX, 91 [58–NE] days; HR [95% CI], 0.45 [0.17, 1.18]) and for earlier vs later F-VASI90 response attainment (RUX-RUX-early, 365 [120–NE] days vs RUX-RUX-later, 136 [85–NE] days; HR [95% CI], 0.61 [0.27, 1.37]). F-VASI90 response was maintained for ≥180 days in significantly more patients with longer treatment duration (RUX-RUX-early, 60.0% [15/25] vs VEH-RUX, 18.2% [2/11]; P<0.05) and numerically more patients with earlier F-VASI90 response (RUX-RUX-early, 60.0% [15/25] vs RUX-RUX-later, 35.0% [7/20]). Treatment-emergent adverse events (TEAEs) occurred in 58.3% (7/12; VEH-RUX) and 60.0% (27/45; RUX-RUX); application site reactions occurred in 25.0% and 22.2%, respectively. Treatment-related TEAEs (none serious) occurred in 8.3% (1/12; skin papilloma) and 24.4% (11/45; mainly application site reactions: acne [n=4]; erythema, exfoliation, and pruritus [each n=2]).

Conclusions: Ruxolitinib cream application for longer duration (ie, 52 vs 28 weeks) was associated with more durable F-VASI90 response after treatment withdrawal, suggesting continued application beyond achieving complete/near-complete facial repigmentation may be beneficial for prolonged maintenance of effect.

Learning Objectives

Takeaway Message

Patients who achieved near-complete facial repigmentation (≥90% improvement in facial Vitiligo Area Scoring Index [F-VASI90]) with ruxolitinib cream twice daily treatment were able to maintain a durable F-VASI90 response after stopping treatment, especially those who were treated with ruxolitinib cream for a longer duration (52 weeks vs 28 weeks) and those who attained F-VASI90 response earlier (within vs after 6 months). This suggests that patients should continue applying ruxolitinib cream twice daily for additional time beyond complete/near-complete repigmentation for prolonged maintenance of effect.

A Randomized-Controlled Trial Evaluating the Use of a Dermocosmetic Versus a Topical Antimicrobial as Adjunctive Therapies for Post-Procedural Dermatological Wounds

Charles W. Lynde¹, Sandra Skotnicki², S. Nigen³, Tristan Laforest⁴, Nour Dayeh⁴, Lyn Guenther⁵

¹Lynderm Research, Markham, ON, ²Bay Dermatology Centre, Toronto, ON, ³Hopital Maisonneuve-Rosemont, Montréal, QC, ⁴L’Oréal Canada, Montréal, QC, ⁵Guenther Dermatology Research Center, London, ON

Introduction: Actinic keratoses (AKs) are pre-cancerous, intraepidermal malignancies that exists on a continuum with squamous cell carcinoma. Cryotherapy using liquid nitrogen freezing is the most common method for treating AKs. Following cryotherapy, wound care often involves antimicrobial ointments as prophylactics against infection. However, given the rise in antibacterial resistance, equivalent alternatives should be identified. Evaluate post-procedural wound healing of AK lesions, when using either a topical antibiotic (PSO), or a cream containing panthenol, madecassoside, and metal salts (CB5).

Methods, Results: A multicenter, intra-individual, randomized control trial was conducted. A total of sixty participants with at least three AK lesions on each arm were enrolled. Following cryotherapy, three lesions were selected on both arms for study and control treatment. Allocation of treatment to the right or left arm was randomly assigned to either the control group (PSO) or the investigational group (CB5). At each visit, the physician assessed the skin condition (erythema, oozing/crusting) and adverse events, and subject satisfaction was recorded. There were no clinically significant differences in time to lesion healing, erythema, or oozing/crusting between groups. On Day 21, 100% of patients agreed that their lesions had improved. There were no serious adverse events or adverse events related to the study products reported throughout the trial.

Conclusions: Post-procedural treatment with CB5 and PSO demonstrated equivalent wound healing in participants undergoing liquid nitrogen cryotherapy for AKs. These results support the hypothesis that antibiotics are not necessary for safe and effective healing of superficial wounds created secondary to dermatologic procedures.

Learning Objectives

Evaluate post-procedural wound healing of AK lesions

Evaluating the safety of using a dermocosmetic emollient versus a topical antimicrobial

Evaluating the efficacy of using a dermocosmetic emollient versus a topical antimicrobial

Takeaway Message

Post-procedural treatment with CB5 and PSO demonstrated equivalent wound healing in participants undergoing liquid nitrogen cryotherapy for AKs.

Modified Delphi Consensus on Interventions for Radiation Dermatitis in Breast Cancer: A Canadian Expert Perspective

Jeffrey Cao¹, Michael Yassa², Edward Chow³, Jean-Marc Bourque², Danielle Rodin³, Erica Wiebe⁴, Natalie Logie¹, H.M. Dahn⁵, J.M. Caudrelier⁶, Iwa Kong⁷, Valerie Theberge⁸, P. Wright⁹, V. Panet-Raymond¹, B. Bashir¹⁰, Carmen Avella Bolivar¹¹, S. Marchuk⁷, Maxwell Sauder³, Joël Claveau¹², Nour Dayeh¹³, Tarek Hijal¹¹

¹University of Calgary, Calgary, AB, ²Université de Montréal, Montréal, QC, ³University of Toronto Scarborough, Toronto, ON, ⁴University of Alberta, Edmonton, AB, ⁵Dalhousie University, Halifax, NS, ⁶University of Ottawa, Ottawa, ON, ⁷University of British Columbia, Vancouver, BC, ⁸Jewish General Hospital, Montréal, QC, ⁹University of Saskatchewan, Saskatoon, SK, ¹⁰University of Manitoba, Winnipeg, MB, ¹¹McGill University, Montreal, QC, ¹²Université Laval, Québec, QC, ¹³L’Oréal Canada, Montréal, QC

Introduction: Acute radiation dermatitis (ARD) is a prevalent adverse effect of radiotherapy in patients with breast cancer, and there is a lack of high-quality data regarding its prevention and management. This study employs a modified Delphi consensus process to compile the perspectives of Canadian dermatology and breast cancer radiation oncology experts, aiming to establish consensus-based recommendations for the prevention and management of ARD in breast cancer patients.

Methods, Results: A four-round modified Delphi consensus process was organized with the participation of 19 Canadian experts. The process involved a systematic review of existing literature on the prevention and treatment of ARD in breast cancer, from January 1946 to July 2023. After review of the literature, participants provided their opinions on the strength and quality of the evidence for the identified interventions. A second round assessed the degree to which the intervention would be recommended in either low- or high-risk settings. Two more rounds consolidated consensus.

After the first round, consensus for evidence of recommendation or suggestion in support of use of a product was reached for 4 prevention interventions. With regards to the management of ARD, there was consensus about the strength of evidence for 1 product. After the fourth round, consensus for recommendation was reached for 3 prevention interventions in both low- and high-risk patients: washing, moisturizing, and prevention education. For high-risk settings, 3 additional prevention interventions reached consensus: barrier films, betamethasone and mometasone. With regards to the management of ARD, there was consensus for recommendation of: foam dressings, betamethasone and mometasone.

Conclusions: This pan-Canadian modified Delphi consensus initiative provides expert-reviewed and evidence-based recommendations for interventions to prevent and manage ARD in breast cancer patients. The endorsed interventions offer valuable guidance for clinicians, highlighting areas where consensus among experts has been achieved.

Learning Objectives

Identify gaps in evidence and underscore the imperative for continued research efforts to refine the standard of care for acute radiation dermatitis in breast cancer patients undergoing radiotherapy.

Establish consensus-based recommendations for the prevention and management of ARD in breast cancer patients.

Valuable guidance for clinicians, highlighting areas where consensus among experts has been achieved.

Takeaway Message

This pan-Canadian modified Delphi consensus initiative provides expert-reviewed and evidence-based recommendations for interventions to prevent and manage ARD in breast cancer patients.

Real-World Effectiveness of Tralokinumab in Adults with Atopic Dermatitis: Physician-Assessed Severity After up to 9 Months in the TRACE Study

Elena Pezzolo^1,2, Michael Cork^3,4, Jennifer Beecker⁵, Adrian Rodriguez⁶, Niels Bennike⁷, Teodora Festini⁷, Ulla Ivens⁷, Diamant Thaçi⁸

¹Department of Dermatology, San Bortolo Hospital, Vicenza, Italy, ²A Study Centre of the Italian Group for the Epidemiologic Research in Dermatology (GISED), Bergamo, Italy, ³Sheffield Children’s Hospital, Sheffield, UK, ⁴Sheffield Dermatology Research, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK, ⁵Division of Dermatology, The Ottawa Hospital, The Ottawa Hospital Research Institute, Ottawa, ON, ⁶Nashville Skin, Nashville, TN, ⁷LEO Pharma A/S, Ballerup, Denmark, ⁸Institute and Comprehensive Center for Inflammation Medicine, University of Lübeck, Lübeck, Germany

Introduction: Phase 3 clinical trials have established the efficacy, safety, and tolerability of tralokinumab, a monoclonal antibody specifically targeting interleukin-13, in adults with moderate-to-severe atopic dermatitis (AD). The present analysis compliments the results of phase 3 trials by reporting on the effectiveness of tralokinumab in real-world practice, including patients who previously received treatment with dupilumab.

Methods, Results: TRACE is a prospective, non-interventional, international, single-cohort study of adults treated with tralokinumab for moderate-to-severe AD. Enrolment occurred between November 2021 and July 2023 (the cut-off date for this analysis was October 15th, 2023). Patients were assessed according to usual practice at each investigative site.

At baseline, the mean age was 44.1 years, mean AD duration was 18.9 years, 52.2% of patients were male. Over half (57.3%) had received systemic treatments including 23.9% who had received dupilumab. Reported outcomes are based on observed data at baseline (n=824), 3 months (n=668), 6 months (n=331), 9 months (n=143). At baseline, 34.0% of patients had an IGA of 4 (severe), the mean EASI score was 20.1, and BSA was 28.5%. At months 3, 6, and 9, EASI scores decreased to 6.4, 5.4, 3.6 while BSA improved to 12.1%, 9.3% and 7.6%. At months 3, 6, and 9, the proportion of patients with EASI ≤7 was 72%, 77% and 80% while the proportion with an IGA of 4 was 4.6%, 2.7% and 2.5%. Improvements were similar in dupilumab-experienced patients, with mean EASI scores decreasing from 16.9 (baseline) to 6.8, 5.9 and 3.8 while the proportion of patients with EASI ≤7 increased from 26% (baseline) to 70%, 76% and 80%.

Conclusions: These results compliment those from phase 3 trials supporting the real-world effectiveness of tralokinumab in treating adults with moderate-to-severe AD. Improvements were progressive over 9 months even among those with previous dupilumab experience.

Learning Objectives

To understand physician-assessed effectiveness of tralokinumab for treating moderate-to-severe atopic dermatitis in real-world clinical practice.

To evaluate the potential for progressive improvements in atopic dermatitis for patients treated over time.

To evaluate changes the severity of atopic dermatitis in patients with, or without, previous experience with an anti-IL-4 biologic.

Takeaway Message

When used in real-world practice, tralokinumab improved physician-assessed disease severity in patients with moderate-to-severe atopic dermatitis. Progressive improvements were observed over the 9-month follow-up period, including in patients with prior exposure to dupilumab.

Real-World Effectiveness of Tralokinumab for Head and Neck Atopic Dermatitis After up to 9 Months Treatment in the TRACE Study

April Armstrong¹, Ahmed Ameen², Jerry Bagel³, Irina Turchin^4,5, Teodora Festini⁶, Ulla Ivens⁶, Ida Vittrup⁶, Andrew Pink⁷

¹University of California Los Angeles, Los Angeles, CA, ²NMC Speciality Hospital, Abu Dhabi, UAE, ³Windsor Dermatology, East Windsor, NJ, ⁴Brunswick Dermatology Center, Fredericton, NB, ⁵Probity Medical Research, Waterloo, ON, ⁶LEO Pharma A/S, Ballerup, Denmark, ⁷St John’s Institute of Dermatology, Guy’s and St Thomas’ Hospitals, London, UK

Introduction: Atopic dermatitis (AD) frequently involves the head and neck (H&N) region causing embarrassment, stigmatization, and diminished quality of life. Consequently, understanding treatment outcomes for patients with H&N involvement may inform real-world treatment decisions. In clinical trials, tralokinumab was effective and well-tolerated for moderate-to-severe atopic dermatitis (AD). The present analysis was undertaken to assess the real-world impact of tralokinumab for patients with H&N AD.

Methods, Results: TRACE is an international, non-interventional, prospective, single-cohort study of adult patients treated with tralokinumab for AD. Patients were enrolled between November 2021 and July 2023 (the cut-off date for this interim analysis was October 15th, 2023). Patients were assessed according to usual practice at each investigative site; reported outcomes are based on observed data at each timepoint.

At baseline, 79.5% of enrolled patients had H&N AD (n=655/824). The percentage of patients with an Investigator’s Global Assessment (IGA) rating of 0/1 after 3, 6, and 9 months of tralokinumab treatment was 33.6%, 48.4%, and 57.4%, respectively. Among those with a baseline IGA ≥2, improvement of at least 2 points was achieved after 3, 6, and months by 46.4% (220/474), 59.1% (140/237), and 71.6% of patients, respectively. The percentage of patients reporting H&N AD decreased to 67.2% and 52.1% after 3 and 6 months. Most patients with Dermatology Life Quality Index (DLQI) scores ≥6 at baseline achieved ≥6-point reduction with tralokinumab: 57.9%, 63.6%, and 74.4% at 3, 6 and 9 months, respectively. Improvements were achieved for Mean Peak Pruritus Numeric Rating Scale (PP-NRS) and mean Sleep-NRS scores. Similar improvements were observed across all endpoints in dupilumab-naïve and dupilumab-experienced patients.

Conclusions: Up to 9 months of tralokinumab treatment improved disease severity and quality of life in patients with AD in the difficult to treat H&N area, regardless of prior dupilumab use.

Learning Objectives

To understand the real-world effectiveness of tralokinumab treatment on the signs of AD with head and neck involvement, as measured by physician-rated scales.

To understand the real-world impact of tralokinumab on the symptoms of AD with head and neck involvement, as measured by patient-rated outcomes.

To understand real-world outcomes of tralokinumab treatment for AD with head and neck involvement in patients with, or without, prior treatment with an anti-IL4 biologic (dupilumab).

Takeaway Message

When used in real-world practice, tralokinumab reduced H&N involvement in adult patients with moderate-to-severe AD. Treatment for up to 9 months improved physician-rated disease severity, patient-rated symptoms, and quality of life, regardless of prior dupilumab use.

Real-World Effectiveness of Tralokinumab for Atopic Dermatitis with Genital Involvement: Outcomes After 3 Months of Treatment in the TRACE Study

Esther Serra-Baldrich¹, April Armstrong², Teodora Festini³, Ulla Ivens³, Ida Vittrup³, Marni Wiseman⁴

¹Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona Autonoma de Barcelona, Barcelona, Spain, ²David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, ³LEO Pharma A/S, Ballerup, Denmark, ⁴SKiNWISE DERMATOLOGY, Winnipeg, MB

Introduction: Genital involvement in atopic dermatitis (AD) might be overlooked due to limited routine examination or patients’ reluctance to discuss this with clinicians. This analysis was undertaken to assess the real-world impact of tralokinumab for AD in patients with genital involvement.

Methods, Results: TRACE is a prospective, non-interventional, international, single-cohort study of adults treated with tralokinumab for moderate-to-severe AD. Patients were enrolled between November 2021 and July 2023; the cut-off date for this interim analysis was October 15th, 2023. Patients were assessed according to usual practice at each investigative site; reported outcomes are based on observed data at each timepoint. Outcomes are reported after 3 months treatment with tralokinumab.

Compared to the total population (n=824), patients with genital involvement (n=123, 14.9%) were more likely to have Investigator’s Global Assessment (IGA) ratings of 4 (49.2% vs 34.0%), higher Dermatology Life Quality Index (DLQI) scores (15.8 vs 12.8) and sleep numerical rating scale (NRS) scores (6.2 vs 5.0). After 3 months, clear skin on the genitals was reported by 67/100 patients for whom assessments were available. IGA ratings were available for 94/123 patients, of whom 32% were IGA 0/1 (clear or almost clear) after 3 months. For 90 patients with both an IGA ≥2 at baseline and an IGA rating at 3 months, 44 (48.9%) achieved a ≥2-point improvement. Among patients with DLQI ≥6 at baseline, 63.6% achieved a ≥6-point improvement. Mean sleep NRS decreased from 6.2 to 3.5. Overall, improvements in physician- and patient-reported outcomes were similar between patients with genital involvement and those in the full study cohort.

Conclusions: Awareness of the impact of genital involvement in AD and the effectiveness of available treatments are crucial for making informed decisions. These 3-month results demonstrate real world effectiveness of tralokinumab in AD patients with genital involvement.

Learning Objectives

To understand the extent and impact of genital involvement in AD.

To understand the real-world effectiveness of tralokinumab treatment on the signs of AD with genital involvement, as measured by physician-rated scales.

To understand the real-world impact of tralokinumab on the symptoms of AD with genital involvement, as measured by patient-rated outcomes.

Takeaway Message

When used in real-world clinical practice, 3 months of treatment with tralokinumab improved physician-rated and patient-reported outcomes in patients with AD on the genitals.

52-Week Safety and Disease Control with Ruxolitinib Cream in Children Aged 2 to 11 Years with Atopic Dermatitis (TRuE-AD3 Study)

Lawrence F. Eichenfield¹, Linda F. Stein Gold², Eric L. Simpson³, Andrea L. Zaenglein⁴, April W. Armstrong⁵, Megha M. Tollefson⁶, Weily Soong⁷, Lara Wine Lee⁸, Alim R. Devani⁹, Seth B. Forman¹⁰, Dareen D. Siri¹¹, Howard Kallender¹², Brett Angel¹², Qian Li¹², Amy S. Paller¹³

¹University of California San Diego School of Medicine, La Jolla, CA, ²Henry Ford Health System, Detroit, MI, ³Oregon Health & Science University, Portland, OR, ⁴Penn State/Hershey Medical Center, Hershey, PA, ⁵David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, CA, ⁶Mayo Clinic, Rochester, MN, ⁷AllerVie Health, Birmingham, AL, ⁸Medical University of South Carolina, Charleston, SC, ⁹Dermatology Research Institute, Calgary, AB, ¹⁰ForCare Clinical Research, Tampa, FL, ¹¹Midwest Allergy Sinus Asthma SC, Normal, IL, ¹²Incyte Corporation, Wilmington, DE, ¹³Northwestern University Feinberg School of Medicine, Chicago, IL

Introduction: We report safety and disease control with as-needed ruxolitinib (Janus kinase [JAK]1/JAK2 inhibitor) cream use in children aged 2–11 years with mild to moderate atopic dermatitis (AD) from the TRuE-AD3 study.

Methods, Results: TRuE-AD3 included children aged 2–11 years with AD, an Investigator’s Global Assessment (IGA) score of 2/3, and 3%–20% affected body surface area (BSA). Patients were randomized 2:2:1 to apply twice-daily 0.75% ruxolitinib cream, 1.5% ruxolitinib cream, or vehicle for 8 weeks. At Week 8, patients initially randomized to ruxolitinib cream continued their regimen for an additional 44-week long-term safety (LTS) period (n=282 evaluated) but only treated lesions as needed; patients initially randomized to vehicle were rerandomized 1:1 (blinded) to either ruxolitinib cream regimen. Over the full 52-week study, both strengths of ruxolitinib cream were similarly well tolerated, with no new safety signals in the LTS period. Patients on ruxolitinib cream throughout the 52-week study (either strength; n=264) had a low incidence of application site reactions (5.3%). The most common treatment-emergent adverse events (TEAEs) were upper respiratory tract infection (14.8%) and nasopharyngitis (9.1%). There were no TEAEs suggestive of systemic JAK inhibition, consistent with generally low ruxolitinib plasma concentrations. At Week 8, IGA 0/1 was achieved by substantially more patients who applied 0.75%/1.5% ruxolitinib cream vs vehicle cream (50.0%/72.4% vs 24.5%, respectively). Improvements were maintained or further improved to Week 52 (0.75%/1.5% ruxolitinib cream, 79.5%/72.3%). Affected absolute BSA was substantially lower with 0.75%/1.5% ruxolitinib cream vs vehicle at Week 8 (4.3%/2.9% vs 7.2%, respectively), with maintained or lower values in the LTS period (Week 52, 0.75%/1.5% ruxolitinib cream, 2.0%/1.9%).

Conclusions: Both 0.75% and 1.5% ruxolitinib cream were well tolerated in children with AD over the entire 52-week study and resulted in effective disease control in the 44-week, as-needed treatment period.

Learning Objectives

Takeaway Message

68-Week Safety Results of Amlitelimab in Participants with Moderate-to-Severe Atopic Dermatitis from STREAM-AD Phase 2b Dose-Ranging and Withdrawal Study

Stephan Weidinger¹, Linda Stein Gold², Yoko Kataoka³, Yanzhen Wu⁴, John T. O’Malley⁵, Charlotte Bernigaud⁶, Samuel Adelman⁵

¹Department of Dermatology and Allergy, University Hospital Schleswig-Holstein, Kiel, Germany, ²Department of Dermatology, Henry Ford Hospital, Detroit, MI, Michigan, ³Osaka Habikino Medical Center, Habikino, Japan, ⁴Sanofi, Beijing, China, ⁵Sanofi, Cambridge, Massachusetts, ⁶Sanofi, Paris, France

Introduction: Amlitelimab is a fully human, non-depleting, anti-OX40 Ligand (OX40L) antibody that modulates the immune system via OX40L inhibition. The safety results over 68 weeks from the Phase 2b STREAM-AD trial in participants with moderate-to-severe AD are presented here.

Methods, Results: STREAM-AD (NCT05131477) was 2-part, Phase 2b, randomized, double-blind, placebo-controlled trial of amlitelimab in adults with moderate-to-severe AD. Part 1 involved 24-week treatment period of 388 participants with subcutaneous amlitelimab (250 mg with 500 mg loading dose [250mg +LD], n=77; 250mg, n=78; 125mg, n=77; 62.5mg, n=78) or placebo (n=78) every 4 weeks. Part 2 involved 28-week maintenance/withdrawal and 16-week safety follow-up. Participants achieving Eczema Area and Severity Index-75 and/or Investigator Global Assessment 0/1 at 24-week in Part 1 (clinical responders) entered Part 2; 190 clinical responders were re-randomized 3:1 to placebo (withdrawal group) or to continue the pre-Week 24 Q4W amlitelimab dose. Participants (n=186) were treated with 250mg+LD, n=34 (withdrawal)/n=13 (continuing); 250mg, n=28/n=11; 125mg, n=32/n=12; 62.5mg, n=34/n=7; placebo responders continuing placebo (n=15).

No dose-dependent relationship was observed in total incidence of treatment-emergent adverse events (TEAEs), serious adverse events (SAEs), or adverse events of special interest. Pooled data from Week 0-68 are presented: continued amlitelimab, (n=43); withdrawn, (n=128); continued placebo, (n=15). Incidence of TEAEs was (83.7%, 92.2%, and 93.3%), respectively. Majority of TEAEs were mild or moderate in severity. Incidence of SAEs was (4.7%, 2.3%, and 0), respectively; with 1 (0.8%) considered related to treatment in the withdrawn group. One participant (continued-125mg) had 4 TEAEs leading to treatment discontinuation which were not related to treatment. No other TEAEs leading to treatment discontinuation were reported. There were no deaths during study.

Conclusions: In the STREAM-AD Phase 2b trial, amlitelimab was well tolerated and demonstrated an acceptable safety profile in the Part 2 (responder) population up to 68 weeks.

Learning Objectives

Takeaway Message

Amlitelimab was well tolerated with acceptable safety profile, with relationship observed between amlitelimab dose and incidence of TEAEs, SEAs.

Impact of Amlitelimab on Lichenification in Atopic Dermatitis: Post-hoc Results from the STREAM-AD Phase 2b Study of Moderate-to-Severe Atopic Dermatitis

April Armstrong¹, Andrew Blauvelt², Charles W. Lynde³, Xinghua Gao⁴, Koji Masuda⁵, Kassim Rahawi⁶, Charlotte Bernigaud⁷

¹University of California, Los Angeles, CA, ²Blauvelt Consulting, LLC, Portland, OR, ³University of Toronto, Markham, ON, ⁴Department of Dermatology, The First Hospital of China Medical University, Shenyang, China, ⁵Department of Dermatology, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan, ⁶Sanofi, Cambridge, MA, ⁷Sanofi, Paris, France

Introduction: Atopic dermatitis (AD), a chronic inflammatory disease, is marked by skin lichenification resulting from constant scratching and rubbing. This analysis evaluates effect of amlitelimab, a fully human non-depleting anti-OX40 ligand (OX40L) monoclonal antibody, on skin lichenification.

Methods, Results: STREAM-AD (NCT05131477), a randomized, double-blinded, placebo-controlled, phase 2b trial, included a 24-week treatment period (Part 1), a 28-week maintenance/withdrawal period (Part 2), and a 16-week safety follow-up. In Part 1, adult participants with moderate-to-severe AD were randomized 1:1:1:1:1 to subcutaneous amlitelimab (250 mg with 500-mg loading dose [250 mg+LD], n=77; 250 mg, n=78; 125 mg, n=77; 62.5 mg, n=79) or placebo every 4 weeks (n=79). Primary endpoint was percent change in Eczema Area and Severity Index (EASI) from baseline at Week 16. A key secondary endpoint was percent change in EASI from baseline at Week 24. This post hoc analysis evaluated the least-squares (LS) mean percent change from baseline to Week 24 in EASI lichenification subscores in 4 body regions. Data on or after treatment discontinuation or use of rescue/prohibited medications impacting efficacy was imputed by worst observation carried forward.

Baseline EASI lichenification subscores were similar across treatment groups. At Week 24, all amlitelimab doses improved percent change in EASI lichenification region subscores from baseline vs placebo, with highest response seen with 250 mg+LD. The LS mean percent changes in lichenification subscores from baseline at Week 24 were: head and neck (-64.2, -53.0, -53.6, -46.2, and -19.9), upper extremities (-53.6, -40.5, -38.1, -34.1, and -22.7), trunk (-62.0, -44.5, -49.3, -40.9, and -22.2), and lower extremities (-60.8, -48.1, -49.9, -46.6, -27.0) for 250 mg+LD, 250mg, 125mg, 62.5mg and placebo, respectively.

Conclusions: At Week 24, amlitelimab improved EASI lichenification scores across all body regions. Amlitelimab may be an effective future treatment for moderate-to-severe AD characterized by lichenification.

Learning Objectives

Takeaway Message

Amlitelimab significantly improves EASI Lichenification subscore in specific body regions (head and neck, upper extremities, trunk and lower exterimities) at Week 24, compared to placebo, suggesting its potential as a future treatment option for atopic dermatitis characterised by lichenification.

Here Comes the Sun! A Study on Sun Exposure and Associated Risks in the Canadian Population

Thierry Passeron^1,2, Henry Lim³, Jean Krutmann⁴, Brigitte Dreno⁵, Sonya Abdulla⁶, Patricia Ting⁷, Monica K. Li⁸, Delphine Kerob⁹, Caroline Le Floch⁹, Tristan Laforest¹⁰, Nour Dayeh¹⁰

¹University Côte d’Azur, CHU Nice, Department of Dermatology, Nice, France, ²University Côte d’Azur. INSERM U1065, C3M, Nice, France, ³Department of Dermatology, Henry Ford Health System, Detroit, MI, ⁴IUF Leibniz Research Institute for Environmental Medicine, Dusseldorf, Germany, ⁵Nantes Université, INSERM, CNRS, Immunology and New Concepts in ImmunoTherapy, INCIT, UMR 1302/EMR6001, Nantes, France, ⁶Division of Dermatology, University of Toronto, Toronto, ON, ⁷Department of Medicine - Division of Dermatology, University of Calgary, Calgary, AB, ⁸Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, ⁹La Roche-Posay Laboratoire Dermatologique, L’Oreal, Levallois-Peret, France, ¹⁰La Roche-Posay Laboratoire Dermatologique, L’Oreal Canada, Montreal, QC

Introduction: To evaluate the awareness and attitudes towards various aspects of sun exposure risks and protection methods among Canadians.

Methods, Results: An online survey conducted from 28 September to 18 October 2021 included 3,540,000 panellists aged 18 years and above from 17 countries across five continents – the data presented is that of the Canadian subset population. The survey focused on demographics, sun exposure habits, comprehension of risks, and knowledge of photoprotection. The results were analyzed using descriptive statistics to identify prevalent trends and discrepancies in sun protection behaviours among Canadians.

The majority of Canadian respondents (93%) acknowledged the health risks associated with sun exposure. While 81% of Canadians reported using some form of sun protection, only 10% systematically implemented all recommended protective measures, highlighting a gap in knowledge translation. Misconceptions regarding the safety of tanned skin and the effectiveness of sunscreens were widespread, particularly in younger demographics and in individuals with darker skin phototypes. Knowledge and preventive behaviours were markedly better among individuals who regularly consult dermatologists.

Conclusions: This study highlights general awareness of sun protective behaviours but a lack of universal and comprehensive implementation among Canadians. Given the knowledge gaps in younger demographics and darker skin phototypes, targeted educational initiatives are essential to correct prevalent misconceptions about sun exposure and tanned skin. Dermatologists and other health care professionals can play a pivotal role in education and primary prevention strategies for skin cancer and other sun-related comorbidities.

Learning Objectives

Takeaway Message

There is a complex landscape of sun-related behaviours and attitudes amongst Canadians. While there is a general awareness of the risks associated with sun exposure, significant gaps exist in knowledge, attitudes, and practices related to sun protection.

Safety & Persistence of Brodalumab for Plaque Psoriasis in the Canadian Real-World Setting: 6-Month Follow-up Interim Results from the CARE Study

Marni Wiseman^1,2, Mohammed Bawazir³, Virginie Kelly^4,5, Michael Cecchini⁶, Charles F. Lortie⁷, Lyne Giroux^8,9, Andrei Metelitsa^10,11, Sunil Kalia^12,13, Véronique Gaudet¹⁴, Martin Barbeau¹⁴, Maxime Barakat¹⁴, Maria Eberg¹⁵, Calum S. Neish¹⁵, Shoshannah Kalson-Ray¹⁵, Sabitha Rajaruban¹⁵

¹Section of Dermatology, Department of Medicine, University of Manitoba, Winnipeg, MB, ²SKiNWISE Dermatology and Wiseman Dermatology Research, Winnipeg, MB, ³Falls Dermatology Centre, Niagara Falls, ON, ⁴Clinique Médicale Saint-Louis, Québec, QC, ⁵Centre de recherche Saint-Louis, Québec, QC, ⁶York Dermatology Clinic & Research Centre, Richmond Hill, ON, ⁷Park Dermatology, Sherwood Park, AB, ⁸Sudbury Skin Clinique, Sudbury, ON, ⁹Northern Ontario School of Medicine University, Sudbury, ON, ¹⁰Beacon Dermatology, Calgary, AB, ¹¹Section of Dermatology, Department of Medicine, University of Calgary, Calgary, AB, ¹²Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, ¹³Photomedicine Institute and Clinical Centre for Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, ¹⁴Bausch Health, Canada Inc., Laval, QC, ¹⁵IQVIA Inc., Kirkland, QC

Introduction: CARE is a prospective, 12-month, Canadian multi-center, observational study in adult patients with plaque psoriasis (PsO) initiating brodalumab as part of routine clinical care. This interim analysis describes the safety profile and treatment persistence of brodalumab up to 6 months post-initiation.

Methods, Results: Safety and persistence were evaluated with rates of adverse events (AEs) and serious adverse events (SAEs), and the number of patients who remained on treatment. All study data was evaluated descriptively.

A total of 351 patients (58.4% male; 74.0% Caucasian; mean age: 51.1 years, SD: 14.0) with 6-month follow-up visit (M6) data were included. At baseline, 56.4% of patients had a PsO disease duration of 10 years or greater, and 83.2% were biologic-naïve. Two-thirds (66.7%) reported at least one comorbidity of interest, including hypertension (25.6%), psoriatic arthritis (14.8%), or type 2 diabetes mellitus (14.0%). The mean PASI score was 14.1 (SD: 9.1) at baseline.

Most patients received one or more concomitant medications (CMs) of interest at the time of brodalumab initiation (72.6%, 255/351) and at M6 (70.7%, 244/345). The most prevalent psoriasis-related CM of interest at M6 was topical corticosteroids (24.6%, 85/345).

From baseline to M6, 44.4% (156/351) of patients reported any AE, and 2.0% (7/351) reported any SAE (Table 1). Most AEs were mild (57.4%, 167/291) or moderate (40.2%, 117/291). Furthermore, 58.1% (169/291) of AEs were assessed as not related to brodalumab. Of the 11 SAEs, 10 were deemed not related, and 1 as unlikely to be related to brodalumab.

At M6, 95.4% of patients (334/350) persisted with brodalumab treatment. Of the 16 patients who discontinued, 6 were due to AEs, 5 due to patient decision, 4 due to lack of efficacy, and 1 due to a comorbidity.

Conclusions: Brodalumab showed high treatment persistence and was well tolerated during the 6-month follow-up period.

Learning Objectives

Takeaway Message

Brodalumab showed high treatment persistence and was well tolerated in adult patients with plaque psoriasis during the 6-month follow-up period.

Guselkumab Demonstrates Consistent Complete Clearance at Week 16 Across Special Sites in Participants with Low Body Surface Area, Moderate Psoriasis

Brad P. Glick¹, Jennifer Beecker^2,3,4, Javier Alonso-Llamazares⁵, Angela Moore^6,7,8, Theodore Alkousakis⁹, Kush Shah⁹, Olivia Choi⁹, Daphne Chan¹⁰, Laura Park-Wyllie¹¹, Jenny Jeyarajah¹², Katelyn Rowland⁹, Geeta Yadav¹³, H. Chih-ho Hong^14,15

¹Larkin Community Hospital, Palm Springs Campus, Miami, FL, ²University of Ottawa, Ottawa, ON, ³The Ottawa Hospital Research Institute, Ottawa, ON, ⁴JRB Research Inc, Ottawa, ON, ⁵Driven Research LLC, Driven Research International LLC, Coral Gables, FL, ⁶Baylor University Medical Center, Dallas, TX, ⁷Arlington Research Center, Arlington, TX, ⁸Arlington Center for Dermatology, Arlington, TX, ⁹Johnson & Johnson Inc., Horsham, PA, ¹⁰Johnson & Johnson (Canada) Inc., Horsham, PA, ¹¹Johnson & Johnson (Canada) Inc., Toronto, ON, ¹²Janssen Research & Development, LLC, Spring House, PA, ¹³FACET Dermatology, Toronto, ON, ¹⁴University of British Columbia, Department of Dermatology and Skin Science, Vancouver, BC, ¹⁵Probity Medical Research, Surrey, BC

Introduction: Patients with low body surface area (BSA) psoriasis (PsO) with special site involvement are difficult to treat and are frequently left untreated or undertreated, despite qualifying for systemic treatment. SPECTREM is an ongoing Phase 3b, multicenter, randomized, double-blind, placebo (PBO)-controlled study evaluating guselkumab (GUS) efficacy in participants with low BSA (2-15%), moderate PsO (Investigator’s Global Assessment [IGA] score=3) involving 1 special site (scalp, face, intertriginous, genital).

Methods, Results: 338 participants were randomized 2:1 to GUS 100mg (N=225) or PBO (N=113) at Week (W)0, W4, then every 8 weeks. W16 assessments included percent improvement from baseline in Psoriasis Area Severity Index (PASI) score and BSA, and complete skin clearance (IGA=0).

At baseline, mean BSA was 7.6%, mean disease duration was 17 years, and 13.7% participants had received prior systemic therapy. At W16, the least squares (LS) mean percent improvement from baseline in PASI score was 82.6% for GUS-treated participants vs 13.7% for PBO. The LS mean percent improvement in BSA was 80.6% for GUS-treated participants vs 6.1% PBO. Overall, complete skin clearance (IGA=0) was achieved by 40.4% of GUS-treated patients vs 3.5% PBO. Complete clearance of each special site was achieved in the majority of GUS-treated participants vs PBO (all comparisons p<0.001); Scalp (60.3% vs 9.3%); Face (75.7% vs 23.9%); Intertriginous (76.6% vs 24.2%); and Genital (72.7% vs 32.7%). Rates of adverse events (AEs) and serious AEs (SAEs) were generally balanced between guselkumab and placebo groups (AEs: 37.8% vs 39.8%; SAEs: 1.3% vs 0.9%, respectively). No guselkumab-treated participants experienced an AE leading to discontinuation vs 3.5% with placebo. No new safety signals were identified.

Conclusions: Among these undertreated, low BSA PsO patients with >1 special site involved, majority achieved complete special site clearance after just 3 guselkumab doses. Overall safety was consistent with the established GUS safety profile.

Learning Objectives

Takeaway Message

Among these undertreated, low BSA PsO patients with >1 special site involved in the SPECTREM trial, the majority achieved complete special site (scalp, face, intertriginous, genital) clearance after just 3 guselkumab doses. Overall safety was consistent with the established GUS safety profile.

Maintenance of Povorcitinib Response in Patients with Hidradenitis Suppurativa: Efficacy During the Open-Label Extension Period of a Phase 2 Study

Falk G. Bechara^1,2, Susan Poelman³, Martin M. Okun⁴, Afsaneh Alavi^2,5, Joslyn S. Kirby⁶, Christos C. Zouboulis^2,7, Kurt Brown⁶, Leandro L. Santos⁶, Zhenyi Xue⁶, Martina L. Porter⁸

¹Ruhr-University Bochum, Bochum, Germany, ²European Hidradenitis Suppurativa Foundation (EHSF), Dessau, Germany, ³Beacon Dermatology, Calgary, AB, ⁴Fort Memorial Hospital, Fort Atkinson, WI, ⁵Mayo Clinic, Rochester, MN, ⁶Incyte Corporation, Wilmington, DE, ⁷Staedtisches Klinikum Dessau, Brandenburg Medical School Theodor Fontane and Faculty of Health Sciences Brandenburg, Dessau, Germany, ⁸Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA

Introduction: Novel therapies for hidradenitis suppurativa (HS), a chronic recurrent disease marked by periodic flares, should provide sustained disease control. Povorcitinib (oral, JAK1-selective inhibitor) demonstrated dose-dependent efficacy at Week 16 in a phase 2 study (NCT04476043).

Methods, Results: Patients were randomized (1:1:1:1) to once-daily povorcitinib 15/45/75mg or placebo for 16 weeks. Thereafter, patients started the 36-week open-label extension (OLE) and received once-daily povorcitinib 75mg. Maintenance of response during OLE was evaluated in 4 ways: change in International Hidradenitis Suppurativa Severity Score System (IHS4) severity category; percentage of povorcitinib-randomized patients maintaining HS Clinical Response (HiSCR)50/75/90/100 (≥50/75/90/100% decrease from baseline in abscess and inflammatory nodule [AN] count, with no increase in number of abscesses or draining tunnels); percentage of patients with flare (ie, ≥25% increase in AN count [and ≥2 AN increase] relative to baseline); and percentage of patients who received local rescue intervention (incision and drainage or intralesional corticosteroid).

174 patients were treated in the OLE (placebo→75mg, n=42; 15→75mg, n=44; 45→75mg, n=42; 75mg, n=46). Percentages of povorcitinib-randomized patients with mild (score 0–3)/moderate (score 4–10)/severe (score ≥11) disease per IHS4 were: baseline, 0.0%/37.4%/62.6%; Week 16, 35.6%/31.8%/32.6%; Week 52 (povorcitinib 75mg), 50.0%/30.9%/19.1% (Figure). Among Week 16 HiSCR50 (n=72)/HiSCR75 (n=47)/HiSCR90 (n=26)/HiSCR100 (n=21) responders, 73.6%/66.0%/73.1%/71.4% of patients maintained their response through Week 52. Percentages of patients with ≥1 HS flare during OLE were 26.8% (placebo→75mg), 15.9% (15→75mg), 17.1% (45→75mg), and 17.4% (75mg). Percentages of patients requiring local lesional rescue at each visit during OLE ranged from 0.0%–6.9% in placebo→75mg, 0.0%–14.7% in 15→75mg, 0.0%–10.0% in 45→75mg, and 0.0%–3.2% in 75mg group.

Conclusions: A high proportion of patients with HS treated with povorcitinib 75mg can maintain meaningful clinical responses during long-term treatment.

Learning Objectives

Takeaway Message

Patients with hidradenitis suppurativa who were treated with povorcitinib and achieved Week 16 response across stringent clinical outcome thresholds (HiSCR75, HiSCR90, HiSCR100) typically maintained their response with povorcitinib 75mg through Week 52. Disease severity decreased through 52 weeks of treatment and few patients experienced HS flares or needed local lesional rescue. These results demonstrate that many patients treated with povorcitinib 75mg can maintain meaningful clinical response during long-term treatment.

Effectiveness of Risankizumab in Canadian Bio-naïve Patients with Psoriasis Participating in the VALUE Multicountry Observational Study

Charles W. Lynde^1,2,3, Maryam Alam^1,4, David N. Adam^1,3,5, Ronald Vender^6,7, Richard Haydey⁸, A. Sabri Alper⁹, Tshepiso Madihlaba¹⁰, Mélanie Labelle⁹, Kim A. Papp^1,3,11

¹Probity Medical Research Inc., Waterloo, ON, ²The Lynde Institute for Dermatology & Lynderm Research Inc., Markham, ON, ³Division of Dermatology, Termerty Faculty of Medicine, University of Toronto, Toronto, ON, ⁴SimcoMed Health Ltd, Barrie, ON, ⁵Baywood Dermatology & CCA Medical Research, Ajax, ON, ⁶Faculty of Health Sciences, McMaster University, Hamilton, ON, ⁷Dermatrials Research Inc., Hamilton, ON, ⁸The Winnipeg Clinic, Winnipeg, MB, ⁹AbbVie Corporation, Saint-Laurent, QC, ¹⁰AbbVie Inc., North Chicago, IL, USA. ¹¹Alliance Clinical Trials, Waterloo, ON

Introduction: Risankizumab (RZB), a humanized IgG1 monoclonal antibody, inhibits IL-23 by binding its p19 subunit and is approved for moderate-to-severe plaque psoriasis and psoriatic arthritis (PsA). The efficacy outcomes from Canadian bio-naïve patients in the VALUE post-marketing observational study are reported at Month 37.

Methods, Results: VALUE (NCT03982394) is an ongoing global study evaluating real-world durability of response, time to first treatment change, and quality of life compared with other commonly used biologics (2:1 allocation). Patients were treated with RZB or other biologics approved for psoriasis, as prescribed. Psoriasis Area and Severity Index (PASI), static Physician Global Assessment (sPGA), and Dermatology Life Quality Index (DLQI) were collected every 3 months up to 37 months. Descriptive statistics and t-test results are from an interim lock on 07-Dec-2023. Patients who switched to another biologic or discontinued the initiated biologic due to lack of effectiveness/intolerability were treated as treatment failures for subsequent visits. 321 Canadian bio-naïve patients were included in the analysis (217 in RZB and 104 in other biologics groups) and at cutoff, 163 had reached the Month 37 visit. At baseline, demographics were similar between the groups. In the RZB group, fewer patients had history of PsA (20 [9.3%] vs 25 [24.0%], P=0.0004) and more patients had PASI score greater than 10 (149 [68.7%] vs 54 [51.9%], P=0.0036). At 37 months in the RZB group, the PASI (mean [SD] = 1.0 [2.12] vs 2.0 [2.78], P=0.0183) and sPGA (0.7 [1.04] vs 1.3 [1.13]; P=0.0012) scores were lower, and achievement of PASI90 (76.1% vs 50.0%, P=0.0008), PASI100 (60.6% vs 31.5%; P=0.0005), and sPGA 0 (61.5% vs 31.5%, P=0.0003) was higher. Improvements in DLQI were also observed (Table).

Conclusions: Canadian bio-naïve patients treated with RZB demonstrated durable reduction in psoriasis symptoms and achieved significantly higher treatment targets and quality of life improvements.

Learning Objectives

Takeaway Message

G2-PASE and G2-EASE: Development of Rapid, Reliable and Novel Severity Measures for Psoriasis and Atopic Dermatitis

Wayne P. Gulliver^1,2, Om Prakash Yadav², Susanne R. Gulliver², Margaret Cousens², Vimal H. Prajapati^3,4,5,6,7,8, Robert Gniadecki⁹, Wayne Langholff¹⁰, Adriana Calce¹¹

¹Memorial University of Newfoundland, St. John’s, NL, ²NewLab Clinical Research Inc., St. John’s, NL, ³Dermatology Research Institute, Calgary, AB, ⁴Skin Health & Wellness Centre, Calgary, AB, ⁵Probity Medical Research, Calgary, AB, ⁶Division of Dermatology, Department of Medicine, Calgary, AB, ⁷Section of Community Pediatrics, Department of Pediatrics, Calgary, AB, ⁸Section of Pediatric Rheumatology, Department of Pediatrics, Calgary, AB, ⁹Division of Dermatology, Department of Medicine and Dentistry, University of Alberta, Edmonton, AB, ¹⁰Janssen Research & Development, LLC, Spring House, PA, ¹¹Johnson & Johnson (Canada) Inc., Toronto, ON

Introduction: Disease severity measures in psoriasis and atopic dermatitis can be time consuming and burdensome for every day clinical use. The Gulliver-Gestalt-Psoriasis Area Severity Estimate (G2-PASE) and Gulliver-Gestalt-Eczema Area Severity Estimate (G2-EASE) were developed to approximate PASI and EASI scores, respectively, using body surface area (BSA) and the Physician Global Assessment (PGA). The objective of this study was to determine the reliability and validity of G2-PASE and G2-EASE compared to PASI and EASI, respectively.

Methods, Results: Baseline disease severity data (PGA, BSA, and PASI) were leveraged from Canadian patients with a history of moderate-to-severe plaque psoriasis enrolled in the first cohort of the Psoriasis Longitudinal Assessment and Registry (PSOLAR 1) to test the reliability and validity of the previously developed G2-PASE algorithm. The G2-PASE was calculated for each patient. G2-EASE was validated with a NewLab Data set.

1803/1896 Canadian patients in PSOLAR 1 had PASI data and were included in this analysis. The average baseline PASI score was 5.52 (SD 6.44, range 0.00-64.30), and the mean calculated G2-PASE score was 8.37 (SD 7.51, range 0.00-45.00). The Pearson’s correlation coefficient was 0.83 (p<0.0001), indicating very strong and significant correlation between PASI and G2-PASE scores. The standardized Cronbach coefficient alpha was 0.91. G2-EASE was calculated similarly utilizing gestalt BSA and PGA data, with a correlation coefficient of 0.95 (p=0.000) and 0.92 (p=0.000) across two samples. Cronbach’s α values of 0.97 and 0.95 indicated excellent reliability for G2-EASE. AUC values are determined to be 1 (p = 0.00) for all data sets utilized in the study, indicating that the newly developed tools are highly reliable.

Conclusions: This study validates G2-PASE and G2-EASE as reliable measures of plaque psoriasis and atopic eczema severity, respectively, when compared to PASI and EASI. Validation for G2-VASE (vitiligo) and G2-HECSE (hand eczema) is ongoing.

Learning Objectives

Takeaway Message

This study validates both G2-PASE and G2-EASE as reliable measures of plaque psoriasis and atopic eczema severity, respectively, when compared to PASI and EASI.

Delgocitinib Cream Leads to Significant Improvements Across All CHE Signs and Region HECSI Subscores in DELTA 1 and 2

Benjamin Ehst¹, H. Chih-ho Hong^2,3, Nina Magnolo⁴, Ketty Peris^5,6, Matthew Zirwas⁷, Keith Baranowski⁸, Douglas Maslin^8,9, Laura Sorensen⁸, Emma Guttman-Yassky¹⁰

¹Oregon Medical Research Centeer, Portland, OR, ²Probity Medical Research Inc., Waterloo, ON, ³University of British Columbia, Vancouver, BC, ⁴University Hospital Münster, Münster, Germany, ⁵Università Cattolica del Sacro Cuore, Rome, Italy, ⁶Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy, ⁷DOCS Dermatology, Columbus, OH, ⁸LEO Pharma A/S, Ballerup, Denmark, ⁹Addenbrooke’s Hospital, Cambridge, UK, ¹⁰Icahn School of Medicine at Mount Sinai, New York, NY

Introduction: In the phase 3 DELTA-1 (NCT04871711) and DELTA-2 (NCT04872101) trials, delgocitinib cream 20 mg/g, a topical Janus kinase inhibitor, demonstrated statistically significant improvement in all primary and secondary efficacy endpoints and was well-tolerated in patients with moderate to severe Chronic Hand Eczema (CHE).

Methods, Results: This pooled post hoc analysis of DELTA-1 and DELTA-2 included 639 adults treated with delgocitinib cream 20 mg/g and 321 with cream vehicle twice daily for 16 weeks. Times to reach 75% improvement on the Hand Eczema Severity Index (HECSI-75) and HECSI score of ≤16 (clear/almost clear), and HECSI sign and hand region subscores were measured.

By Week 16, 67.7% of delgocitinib-treated patients achieved HECSI-75 at least once (vs. 37.1% cream vehicle; P<0.0001) and 69.5% achieved HECSI measure of clear/almost clear skin at least once (vs. 43.5% cream vehicle; P<0.0001)[CC1]. At Week 16, delgocitinib cream treatment improved median HECSI sign subscores from baseline versus cream vehicle (erythema [55.6% vs. 14.3%], fissures [72.7% vs. 33.3%], infiltration/papulation [66.7% vs. 16.7%], edema [83.3% vs. 36.4%], scaling [50.0% vs. 20.0%], and vesicles [100% vs. 50.0%]; all P<0.0001 vs. cream vehicle). Median improvements were observed in all affected areas of the hand (region subscore [delgocitinib cream vs. cream vehicle]: back of hand [100% vs. 50.0%], fingers excluding tips [77.5% vs. 25.0%], fingertip [78.7% vs. 33.3%], palm of hand [75.0% vs. 33.3%], and wrists [100% vs. 54.5%]; all P<0.0001 vs. cream vehicle).

Conclusions: More than 2 out of 3 delgocitinib-treated patients achieved clear or almost clear skin as measured by change from baseline in HECSI score. Statistically significant improvements with delgocitinib cream 20 mg/g over cream vehicle were seen across all signs of CHE (including erythema, scaling, vesicles, and fissures) and all regions of the hand and wrist up to Week 16.

Learning Objectives

Takeaway Message

Delgocitinib cream 20 mg/g was a well-tolerated topical treatment that led to improvements across the key clinical signs of CHE and all affected areas of the hand, throughout the 16-week trials.

Treatment Response of Delgocitinib Cream According to CHE Subtypes: Results from the Phase 3 DELTA-1, -2, and -3 Trials

Robert Bissonnette¹, Sibylle Schliemann², Melinda Gooderham^3,4,5, Irina Turchin^5,6,7, Richard B. Warren^8,9, Marie Louise Schuttelaar¹⁰, Marie-Noëlle Crépy^11,12, Luca Stingeni¹³, Jonathan I. Silverberg¹⁴, Keith Baranowski¹⁵, Marie Louise Oesterdal¹⁵, Ursula Plohberger¹⁵, Laura Soerensen¹⁵, Tove Agner¹⁶

¹Innovaderm Research, Montréal, QC, ²Department of Dermatology, University Hospital Jena, Jena, Germany, ³Department of Dermatology, Queens University, Peterborough, ON, ⁴SKiN Centre for Dermatology, Peterborough, ON, ⁵Probity Medical Research, Peterborough, ON, ⁶Department of Medicine, Dalhousie University, Halifax, NS, ⁷Brunswick Dermatology Center, Fredericton, NB, ⁸8Dermatology Centre, Northern Care Alliance NHS Foundation Trust, Manchester, UK, ⁹9NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK, ¹⁰University Medical Centre Groningen, University of Groningen, Groningen, Netherlands, ¹¹Department of Dermatology, University Hospital of Centre of Paris, Cochin Hospital, AP-HP, Paris, France, ¹²Department of Occupational and Environmental Diseases, University Hospital of Centre of Paris, Hotel-Dieu Hospital, AP-HP, Paris, France, ¹³Dermatology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy, ¹⁴Department of Dermatology, The George Washington University School of Medicine and Health Sciences, Washington, DC, ¹⁵LEO Pharma A/S, Ballerup, Denmark, ¹⁶Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark

Introduction: Chronic Hand Eczema (CHE) presents as several etiological and clinical subtypes. In patients with moderate to severe CHE, delgocitinib cream demonstrated significant improvement in all key efficacy endpoints and was well tolerated versus cream vehicle in the phase 3 DELTA 1 (NCT04871711) and DELTA 2 (NCT04872101) trials and in the open label DELTA 3 trial (NCT04949841) when used long-term as needed.

Methods, Results: This pooled analysis included 638 patients treated with delgocitinib cream 20 mg/g in DELTA-1, - 2 and -3. The primary endpoint of DELTA-1 - 2 was the Investigator’s Global Assessment for CHE (IGA-CHE) treatment success (TS) at Week (W) 16, defined as IGA-CHE score of 0/1 (clear or almost clear, i.e., no/barely perceptible erythema and no other signs), with a ≥2-step improvement from baseline. A key secondary endpoint was ≥75% improvement in Hand Eczema Severity Index (HECSI-75). Data were assessed at W16 and W52, according to main CHE subtype (atopic hand eczema [n=225]; hyperkeratotic hand eczema [n=143]; irritant contact dermatitis [n=123]; allergic contact dermatitis [n=78]; vesicular hand eczema [n=69]).

IGA-CHE TS and HECSI-75 were achieved at W16 by 24.3% and 49.4% of delgocitinib-treated patients, respectively, and at least once during initial 16 weeks of treatment by 42.0% and 66.5%, respectively. The proportion of patients achieving IGA-CHE TS and HECSI-75 increased to 59.9% and 83.5%, respectively, after 52 weeks of treatment. By W52, IGA-CHE TS and HECSI-75 were achieved at least once by 75.7% and 92.5%, respectively (irritant contact dermatitis), 72.5% and 87.7% (vesicular hand eczema), 66.0% and 89.4% (allergic contact dermatitis), 58.9% and 84.7% (atopic hand eczema), and 38.2% and 68.6% (hyperkeratotic hand eczema) of patients treated with delgocitinib cream.

Conclusions: Delgocitinib cream 20 mg/g was effective across all CHE subtypes at W16, with increasing treatment effects observed up to W52 and was well tolerated.

Learning Objectives

Takeaway Message

Delgocitinib cream 20 mg/g was a well-tolerated topical treatment that was effective across all CHE subtypes, with increasing treatment effects observed through 52 weeks of treatment, supporting the long-term benefit of delgocitinib cream in patients with moderate to severe CHE.

Real-World Effectiveness, Retention and Updosing of Secukinumab in Biologic-Naïve and -Experienced Patients with Moderate-to-Severe Plaque Psoriasis: PURE Registry Data

Melinda Gooderham¹, Lorne Albrecht², Jennifer Beecker³, Adriana Lopez-Tello⁴, Charles W. Lynde⁵, Monica Maiolino⁶, Farheen Mussani⁷, Vimal H. Prajapati^8,9,10,11, Carmen Y. Taveras¹², Marie Maguin¹³, Tanya Zappitelli¹³, Kim A. Papp¹⁴

¹SKiN Centre for Dermatology and Probity Medical Research, Peterborough, and Queen’s University, Kingston, ON, ²Enverus Medical Research, University of British Columbia and Probity Medical Research, Surrey, BC, ³Division of Dermatology, University of Ottawa, The Ottawa Hospital, Ottawa Hospital Research Institute and Probity Medical Research, Ottawa, ON, ⁴NEKI Medical Professional Services, Medical Consulting and Clinical Researching Sector, Toluca, Mexico, Mexico. ⁵Lynde Institute for Dermatology, University of Toronto and Probity Medical Research, Toronto, ON, ⁶Consultorios médicos Bouzo, Ciudad autónoma de Buenos Aires, Buenos Aires, Argentina, ⁷Mussani Skin Solutions Dermatology, Stoney Creek, ON and McMaster University, Hamilton, ON, ⁸Skin Health & Wellness Centre, Calgary, AB, ⁹Dermatology Research Institute, Calgary, AB, ¹⁰Probity Medical Research, Calgary, AB, ¹¹Division of Dermatology, Department of Dermatology, Section of Community Pediatrics, Section of Pediatric Rheumatology, Department of Pediatrics, University of Calgary, Calgary, AB, ¹²Jose Maria Cabral y Baez Hospital and Union Medica Clinic Santiago R.D, Santiago de los Caballeros, Dominican Republic, ¹³Novartis Pharmaceuticals Canada Inc., Dorval, QC, ¹⁴Alliance Clinical Trials and Probity Medical Research, Waterloo, ON and Division of Dermatology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON

Introduction: Secukinumab demonstrated sustained efficacy across multiple psoriatic disease manifestations. Here, secukinumab real-world effectiveness, and on-label and post-updosing retention rates were assessed in biologic-naïve and biologic-experienced patients with moderate-to-severe psoriasis over 5 years in the PURE study.

Methods, Results: The PURE registry is an ongoing study involving 2,500 patients with moderate-to-severe plaque psoriasis. Patients with an inadequate response to on-label secukinumab (300 mg Q4W) were updosed based on physician’s judgement. Updosing is defined as a cumulative dose ≥300 mg monthly. Retention rates, Psoriasis Area and Severity Index (PASI) 90 response, and time to updosing were assessed over time, up to 5 years in patients who started on secukinumab.

As of 05-Oct-2023, 1134 secukinumab-treated patients (biologic-naïve=948; biologic-experienced=186) were assessed. Secukinumab retention rates remained high from years 1-5: 82.4%, 70.7%, 63.1%, 58.2%, 53.0%. Rates were higher in biologic-naïve (83.2%, 71.8%, 64.5%, 59.6%, 54.5%) than biologic-experienced patients (78.4%, 65.1%, 55.6%, 50.5%, 45.1%) (Figure). PASI 90 responses at years 1-5 were 54.7%, 56.5%, 61.60%, 65.0%, and 62.7%. At years 1 and 5, PASI 90 responses were 56.1% and 62.6% (biologic-naïve) and 47.1% and 63.3% (biologic-experienced). Overall, 27.0% (n=306) of patients (26.6% [n=252] of biologic-naïve patients, and 29.0% [n=54] of biologic-experienced patients) were updosed. Post-updosing, 50% of patients remained on secukinumab for 23.9 months (median). The mean time to updosing was 13.6, 14.3, and 10.4 months, respectively, in the overall, biologic-naïve and biologic-experienced cohorts.

Conclusions: Secukinumab demonstrated sustained effectiveness over the observation period with higher retention in biologic-naïve than biologic-experienced patients. Retention rates remained high post-updosing, with biologic-naïve patients experiencing longer time to updosing than biologic-experienced patients.

Learning Objectives

Takeaway Message

This analysis from the PURE registry demonstrates the sustained effectiveness of secukinumab over the observation period in treating patients with moderate-to-severe plaque psoriasis, with higher retention rates observed in biologic-naïve patients compared to biologic-experienced patients. Secukinumab updosing was well-tolerated and the retention rates remained high after updosing. Biologic-naïve patients experienced a longer time to updosing than biologic-experienced patients.

A Novel Multidisciplinary Dermatological Care Model for Managing Patients with Acne and Atopic Dermatitis: Consensus Guidance for Pharmacists

Aaron Sihota¹, Ahmad Abouzant², Jen Belcher³, Cameron Bonell¹, Ahmed Chehade⁴, Chris Chiew⁵, Annie Chong⁶, Joël Claveau⁷, Stéphane Côté⁷, Carole Cyr⁸, Raj Dhami⁹, Anil Goorachurn⁶, Mike Kani¹⁰, Lauren Lam¹¹, Angela Law^12,13, Nardine Nakhla^14,15, Oluwatobiloba Obatusin¹⁶, John Papasterigou^17,18, Beverly Salomon^19,20, Stephane Villeneuve²¹, Tristan Laforest²², Nour Dayeh²², Maxwell Sauder^23,24

¹Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, ²Rexall Pharmacy Group, Vancouver, BC, ³Ontario Pharmacists Association, Toronto, ON, ⁴Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton, AB, ⁵London Drugs, Richmond, BC, ⁶London Drugs, Edmonton, AB, ⁷Université Laval, Québec, QC, ⁸Pharmacie Carole Cyr, Montréal, QC, ⁹Shoppers Drug Mart, London, ON, ¹⁰Loblaw, Calgary, AB, ¹¹Beacon Dermatology, Calgary, AB, ¹²Clinic One Three Eight, Vancouver, BC, ¹³Dermapure, Vancouver, BC, ¹⁴MAPflow Inc, Oakville, ON, ¹⁵School of Pharmacy, University of Waterloo, Waterloo, ON, ¹⁶Sobeys, Chilliwack, BC, ¹⁷Shoppers Drug Mart, Toronto, ON, ¹⁸Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, ¹⁹Jean Coutu, Montréal, QC, ²⁰Faculty of Pharmacy, Université de Montréal, Montréal, QC, ²¹Jean Coutu, Québec, QC, ²²L’Oréal Canada, Montréal, QC, ²³Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, ²⁴Princess Margaret Cancer Centre, Toronto, ON

Introduction: Acne and atopic dermatitis (AD) are common dermatological conditions with significant impact on patients’ quality of life. Both conditions require long-term management, often involving a combination of prescription medications, over-the-counter (OTC) products, and lifestyle modifications. Recent legislation has expanded pharmacists role in these conditions. To address care gaps and enhance long-term management, four national panels (in British Columbia, Ontario, Alberta, and Montreal), comprising 22 dermatologists and pharmacists, convened to develop a collaborative framework. Their goal was to formally define how pharmacists can support mild to moderate acne and AD management collaboratively with community dermatologists, ultimately optimizing patient outcomes.

Methods, Results: Key questions were identified based on current patient journey gaps in acne and AD care, focusing on patient initial assessment, follow-up, communication, and multidisciplinary collaboration between the dermatologist and pharmacist. Using the Nominal Group Technique (NGT) in two voting rounds, eight consensus recommendations emerged:

Pharmacists should:

Conclusions: Given the absence of a unified pharmacy framework for dermatological care in Canada, this consensus guidance provides a novel blueprint for multidisciplinary management of acne and AD by the pharmacist in collaboration with the dermatologist, ultimately supporting better patient experiences and outcomes.

Learning Objectives

Takeaway Message

Pharmacists play a pivotal role in the collaborative management of mild to moderate acne and atopic dermatitis (AD). By providing expert guidance on prescription medications, OTC products, and lifestyle modifications, pharmacists can help optimize treatment outcomes and improve patient well-being. This consensus-based framework underscores the importance of comprehensive initial assessments, early identification of drug-drug interactions, and continuous monitoring of patient adherence. Pharmacists are uniquely positioned to counsel on appropriate skincare practices—such as selecting non-comedogenic products, recommending suitable emollients and moisturizers, and advising on sun protection—to support the skin barrier and manage potential side effects. Furthermore, they can address patient concerns about long-term medication use, especially in the context of newer biologic or targeted therapies. Ongoing communication every three to six months with dermatologists and primary care providers helps ensure timely adjustments to treatment plans and fosters a cohesive, multidisciplinary approach to patient care. By unifying best practices and establishing clear guidelines, this novel framework provides valuable direction for pharmacies across Canada, promoting consistent, high-quality dermatological support that ultimately enhances patients’ quality of life.

Real-World Effectiveness of Brodalumab in Canadian Patients with Plaque Psoriasis: CARE Study 6-Month Interim Data

Sunil Kalia^1,2, Danielle Brassard³, David N. Adam^4,5, Wei Jing Loo^6,7, Russell Wong⁸, Marni Wiseman^9,10, Ronald Vender¹¹, Véronique Gaudet¹², Martin Barbeau¹², Maxime Barakat¹², Maria Eberg¹³, Calum S. Neish¹³, Shoshannah Kalson-Ray¹³, Sabitha Rajaruban¹³

¹Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, ²Photomedicine Institute and Clinical Centre for Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, ³Clinique D, Laval, QC ⁴Division of Dermatology, Temerty Department of Medicine, University of Toronto, Toronto, ON, ⁵CCA Medical Research and Probity Medical Research, Ajax, ON, ⁶DermEffects, Probity Medical Research Inc., London, ON, ⁷Western University, London, ON, ⁸Rejuvenation Dermatology Clinic, Edmonton, AB, ⁹Section of Dermatology, Department of Medicine, University of Manitoba, Winnipeg, MB, ¹⁰SKiNWISE Dermatology and Wiseman Dermatology Research, Winnipeg, MB, ¹¹Dermtrials Research Inc., Hamilton, ON, ¹²Bausch Health, Canada Inc., Laval, QC, ¹³IQVIA Inc., Kirkland, QC

Introduction: The effectiveness of brodalumab was evaluated in Canadian patients with plaque psoriasis enrolled in the CARE study up to 6 months post-initiation.

Methods, Results: Effectiveness was assessed using Psoriasis Area and Severity Index (PASI), Static Physician’s Global Assessment (sPGA), and Psoriasis Symptom Inventory (PSI) scores.

This interim analysis included 351 patients with 6-month follow-up (M6) data. At baseline, the mean PASI and PSI scores were 14.1 (SD: 9.1) and 18.5 (SD: 7.2), respectively. The sPGA was moderate (3) for 64.4% of patients, and severe (4) for 30.8%. Most patients (93.2%) had one or more special sites affected by PsO (e.g., face, scalp, hands, feet or genitalia), and 83.2% were biologic-naïve.

At the 3-month follow-up (M3), PASI 75/90/100 were observed in 78.2% (265/339), 64.0% (217/339) and 43.4% (147/339) of patients, respectively. At M6, these proportions were 82.1% (276/336), 72.6% (244/336), and 52.1% (175/336), respectively.

Most patients achieved a sPGA of clear (0) or almost clear (1) at M3 (68.5%; 233/340) and M6 (77.6%; 263/339). Furthermore, most patients observed a ≥2-grade improvement in sPGA at M3 (73.5%; 250/340) and M6 (78.5%; 266/339), compared to baseline. The mean percentage change in PSI was -71.7 % (SD: 33.9%) at M3 and -72.2 % (SD: 34.0%) at M6.

Subgroup analyses at M6 showed that PASI 100 and sPGA of 0/1 were achieved in 50.9% (82/161) and 82.0% (132/161) of patients with 3-5 special sites, 52.6% (81/154) and 72.3% (112/155) with 1-2 special sites, and in 57.1% (12/21) and 82.6% (19/23) with none, respectively. Additionally, the proportion of patients that achieved PASI 100 and sPGA 0/1 at M6 tended to be higher for biologic-naïve patients than for biologic-experienced patients.

Conclusions: Improvements in the signs and symptoms of psoriasis were observed after 3 months of brodalumab therapy and were maintained or further improved after 6 months.

Learning Objectives

Takeaway Message

After 3 months of brodalumab therapy, adult patients with plaque psoriasis observed rapid improvements in psoriasis signs and symptoms that were sustained or further increased after 6 months.

Patients with Alopecia Areata on YouTube and TikTok: A Cross-Sectional Analysis

Eric P. McMullen¹, Shahnawaz Towheed², Parsa Abdi³, Dea Metko², Shanti Mehta⁴, Orhan Yilmaz⁵, Jeffrey Donovan^6,7

¹Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, ²Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, ³Faculty of Medicine, Memorial University of Newfoundland, St. John’s, NL, ⁴Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ⁵College of Medicine, University of Saskatchewan, Saskatoon, SK, ⁶Department of Dermatology, University of British Columbia, Vancouver, BC, ⁷Donovan Hair Clinic, Whistler, BC

Introduction: Alopecia areata (AA) is a common hair loss condition and may cause patients to experience increased stress, anxiety, and depression. YouTube and TikTok are online platforms with billions of monthly users. Both serve as a medium for individuals affected by AA to share their personal experiences.

Methods, Results: We cross-sectionally analyzed the top 100 most-viewed respective long-form YouTube videos, YouTube Shorts, and TikTok videos using the keywords “my alopecia areata story” in April and May 2024. The videos were rated using the modified DISCERN instrument and JAMA Benchmark criteria. Video characteristics and clinical characteristics were collected.

A total of 262 videos were included, with most by non-members of the medical community (98.5%), with a small percentage from healthcare workers (1.5%). The ethno-racial composition of the video creators was predominantly White (55.3%), followed by Black (19.8%), East Asian (8.0%), South Asian (6.9%), Hispanic/Latino (3.8%), and Other/Unknown (6.1%). Common AA types were localized AA (83.2%), alopecia universalis (AU) (9.9%), and alopecia totalis (AT) (6.9%). The cohort was majority female (83.6%), and videos from female patients were associated with a higher number of psychological symptoms (>3) compared with male patients (U-statistic=3,801.0; P=0.038). AA severity (i.e., AT/AU vs. less severe forms) was not associated with a higher number of psychological symptoms (F-statistic=1.47; P=0.23), nor was it associated with satisfaction (χ2=0.58, P=0.75).

Conclusions: Limitations include selection bias and an inability to verify the accuracy of AA diagnosis. Due to time constraints, typical AA consultations may overlook important patient concerns such as diet, stress management, complementary therapies, and wigs. The lack of a statistically significant difference in psychological symptoms, treatment considerations, and overall satisfaction across AA severity levels may suggest that AA can be distressing with any severity. Dermatologists should make appropriate referrals to mental health specialists when necessary.

Learning Objectives

1. Understand the role of online platforms like YouTube and TikTok in sharing patient experiences with alopecia areata (AA).

2. Analyze the demographic and clinical characteristics of video creators and their association with psychological symptoms in AA.

3. Evaluate the impact of AA severity on psychological symptoms, treatment satisfaction, and patient concerns.

Takeaway Message

We cross-sectionally analyzed the top 100 most-viewed respective long-form YouTube videos, YouTube Shorts, and TikTok videos using the keywords “my alopecia areata story” and our findings may suggest that AA can be distressing with any severity. Dermatologists should make appropriate referrals to mental health specialists when necessary. 

A Systematic Review and Meta-Analysis of the Risk of Insulin Resistance and Alopecia Areata

Eric P. McMullen¹, Parsa Abdi², Shanti Mehta³, Dea Metko⁴, Jeffrey Donovan^5,6

¹Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, ²Faculty of Medicine, Memorial University of Newfoundland, St. John’s, NL, ³Temerty Faculty of Medicine, University of Toronto, Toronto, ON, ⁴Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, ⁵Department of Dermatology, University of British Columbia, Vancouver, BC, ⁶Donovan Hair Clinic, Whistler, BC

Introduction: Prior research has identified increased odds of metabolic syndrome, hyperinsulinemia, and dyslipidemia in patients with alopecia areata (AA). We investigated whether insulin resistance was more common in patients with AA compared with controls based on full multivariate analysis.

Methods, Results: A systematic review was conducted per PRISMA guidelines. Clinical studies that measured the homeostasis model assessment of insulin resistance (HOMA-IR), along with other metabolic biomarkers including insulin, fasting blood glucose (FBG), C-peptide, and body mass index (BMI) in patients with AA and control subjects were included. Continuous outcomes were assessed using the standardized mean difference (SMD) with 95% confidence intervals employing a random-effects model. Heterogeneity among studies was evaluated using the I² statistic. Five studies totalling n=249 with AA and n=87 controls were included. The specific AA subtypes included multifocal (62.1%), universalis (18.2%), totalis (11.1%), ophiasis (6.6%), and diffuse (2.0%). Compared with controls, patients with AA had higher HOMA-IR values (SMD=0.62; 95%CI, 0.20–0.88; P=0.004) (Figure 1), higher fasting insulin values (SMD=0.54; 95%CI, 0.16–0.93; P=0.006), higher FBG (SMD=0.33; 95%CI, 0.13–0.53; P=0.001), and higher C-peptide (SMD=0.67; 95%CI, 0.40–0.95; P<0.00001). BMI did not differ significantly between groups (SMD=0.01; 95%CI, −0.18–0.20; P=0.89).

Conclusions: AA and insulin resistance may share similar immunopathogenic mechanisms, including elevated cytokines (e.g., IFN-γ, TNF-α, and IL-1) and disrupted insulin receptor signaling. Adiponectin, an adipose tissue-circulating adipokine has effects in promoting insulin sensitivity. Patients with AA have shown lower serum levels of adiponectin than healthy controls, illustrating a potential mechanism for AA pathogenesis. At present, it seems reasonable to consider hemoglobin A1c, FBG, and fasting insulin in addition to their standard blood testing panels in patients with known risk factors for insulin resistance. Involvement of primary care and/or endocrinology will be important for patients with AA with confirmed insulin resistance.

Learning Objectives

1. Evaluate the association between alopecia areata (AA) and metabolic markers of insulin resistance, including HOMA-IR, fasting insulin, FBG, and C-peptide.

2. Understand the potential immunopathogenic mechanisms linking AA and insulin resistance, such as cytokine dysregulation and adiponectin deficiency.

3. Recognize the significance of metabolic screening in AA patients with known risk factors for insulin resistance.

Takeaway Message

In our systematic review, patients with alopecia areata had higher markers of insulin resistance (HOMA-IR, fasting insulin, FBG, and C-peptide) compared to controls, possibly due to shared immunopathogenic mechanisms. Screening for insulin resistance and involving primary care and/or endocrinology in management is important.

Dupilumab as a Treatment for Bullous Pemphigoid in a Liver Transplant Recipient: A Case Report

Sarah S. Rashid¹, P. Régine Mydlarski², Fatemeh Jafarian²

¹Cumming School of Medicine, University of Calgary, Calgary, AB, ²Division of Dermatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB

Introduction: Bullous pemphigoid (BP) is a common subepidermal autoimmune bullous disease that affects the skin and mucous membranes. It is more prevalent in the elderly, often resulting in significant morbidity and mortality. BP is rare in solid organ transplant recipients (SOTRs) but presents unique challenges due to their underlying immunosuppression, which increases the risks of infection and adverse drug reactions. Herein, we present the first reported case of dupilumab successfully treating BP in a liver transplant recipient.

Methods, Results: A 70-year-old female post-liver transplant presented with pruritic and painful blisters. She had multiple comorbidities and was on cyclosporine to prevent graft rejection. Her biopsy revealed subepidermal bullae with an inflammatory infiltrate composed of eosinophils, neutrophils, and lymphocytes. Direct immunofluorescence studies demonstrated a linear band of IgG and C3 at the dermal-epidermal junction. She was started on low-dose prednisone, which was increased to 50 mg due to a flare-up. However, with a gradual taper to 30 mg, she experienced an acute worsening of her BP. Given the severity of her condition and risk of infection, she was admitted to hospital. Up to 60 mg prednisone was required to control her blistering and mycophenolate mofetil 500 mg twice daily was given as a steroid-sparing agent. As her bullous disease was recalcitrant to treatment, dupilumab 300 mg every other week was added. Within two weeks of the new therapy, her condition cleared. Over the following months, she successfully tapered her prednisone to 5 mg, maintaining control of her BP with dupilumab.

Conclusions: Our case demonstrates the potential of dupilumab as a therapeutic option for BP in transplant recipients. These encouraging outcomes support the need for innovative, targeted treatments for SOTRs with skin disease. However, additional research is urgently required to validate the safety and efficacy of biologic therapies in this high-risk patient population.

Learning Objectives

1. Recognize the therapeutic challenges of managing BP in solid organ transplant recipients.

2. Identify the role of dupilumab as a novel treatment option for recalcitrant BP in immunosuppressed transplant patients.

3. Review the clinical decision-making process in adjusting immunosuppressive therapies in patients with BP and other comorbidities.

4. Reflect on the broader clinical and research implications of using dupilumab in the treatment of BP.

Takeaway Message

Dupilumab shows promise as a safe and viable treatment option for recalcitrant bullous pemphigoid in transplant recipients, providing effective disease management when conventional immunosuppressive therapies fail or pose significant risks to the patient.

Concomitant Therapy of Surgical Shave Excision and Intralesional Injections for Ear Keloids: Early Results from a Retrospective Cohort Study

Jennifer V.H. Tran^1,2, Shantel D.J. Lultschik¹, Jessica S.S. Ho¹, Sheetal Sapra¹, Kevin Dong¹, Klaudija Gusic¹

¹Institute of Cosmetic and Laser Surgery, Oakville, ON, ²Schulich School of Medicine and Dentistry, Western University, London, ON

Introduction: Keloids are hypertrophic scars that commonly arise in the ear region. The authors’ objectives were to (1) evaluate effectiveness of surgical shave excision followed by intralesional triamcinolone acetonide and onabotulinumtoxinA injections; and (2) evaluate safety and patient satisfaction.

Methods, Results: This study was a retrospective chart review of patients who received treatment of extralesional surgical shave excision followed by intralesional triamcinolone acetonide and onabotulinumtoxinA injections to treat ear keloids at a single outpatient dermatology clinic. A prospective patient questionnaire was administered to the same patient population to collect recurrence and patient satisfaction.

A total of 45 patients were included, consisting of 84.4% females (n = 38) and 15.6% males (n = 7) with a mean age of 25.5 years. Through retrospective chart review, early recurrence was seen in 6.7% of patients (n = 3), and via the prospective patient questionnaire, 11.1% of patients noted early keloid recurrence (n = 5). Of the patients who expressed their level of satisfaction in-clinic, 96.0% (n = 24) reported being satisfied or very satisfied and 4.0% (n = 1) were dissatisfied. Satisfaction was also assessed through the prospective patient questionnaire; of those who consented to the questionnaire, 100.0% (n = 24) were satisfied or very satisfied. Only 20.0% (n = 9) of all patients reported experiencing side effects, consisting of pruritus (11.1%; n = 5), tenderness (4.4%; n = 2), pain (2.2%; n = 1), and mild atrophy (2.2%; n = 1).

Conclusions: Extralesional surgical shave excision followed by intralesional triamcinolone acetonide and onabotulinumtoxinA injections may represent a promising treatment option for ear keloids.

Learning Objectives

• Evaluate the efficacy of this combined treatment modality by analyzing recurrence rates and patient satisfaction levels reported in the study.

• Identify potential side effects associated with the treatment, such as pruritus, tenderness, pain, and mild atrophy, and discuss strategies to manage these adverse effects.

• Assess patient-reported outcomes and satisfaction following the combined treatment, emphasizing the importance of patient-centered care in dermatological practice.

Takeaway Message

This study demonstrates the early results on the effectiveness of concomitant surgical excision and IL TA and onabotulinumtoxinA injections for ear keloids with a low recurrence rate. The high patient satisfaction, minimal to mild side effects, and great cosmetic results suggest this combination should be considered as a treatment alternative for ear keloids. However, future research involving large-scale studies with comparative designs and long-term follow-up is required to determine the value of this treatment modality for keloid management.

Treatment of Xanthelasma Palpebrarum Using Trichloroacetic Acid 80%

Sheetal Sapra¹, Jennifer V.H. Tran^1,2, Harmeeet Gurm¹, Mackenzie Eleuterio¹

¹Institute of Cosmetic and Laser Surgery, Oakville, ON, ²Schulich School of Medicine and Dentistry, Western University, London, ON

Introduction: We sought to analyze the effectiveness, recurrence, safety, and patient satisfaction rates following xanthelasma palpebrarum (XP) treatment with trichloroacetic acid (TCA) 80%. Although TCA is a commonly used treatment option, the studies investigating TCA application had small sample sizes, used varying concentrations, or had short follow-up times.

Methods, Results: This was a retrospective review of patients treated with TCA 80% for XP between January 2012 and August 2022. A prospective telephone questionnaire was administered to the same patient population to evaluate recurrence, patient satisfaction, and side effects.

In total, 77 patients were included in this retrospective review. Most patients received one treatment (n=38; 49.4%) and had XP located bilaterally (n=59; 76.6%) on either the lower eyelids only (n=18; 23.4%) or both the upper and lower eyelids (n=18; 23.4%). Following treatment, 94.2 percent (n=49) of patients expressed satisfaction and 97.2 percent (n=70) displayed a clinician-reported improvement in XP. In the prospective patient questionnaire, the reoccurrence of XP was self-reported in 24.7 percent (n=19) of all patients. The adverse events, reported by the clinician during the retrospective review and the patient during the prospective questionnaire, included erythema (n=2; 2.6%), hyperpigmentation (n=4; 5.2%), hypopigmentation (n=3; 3.9%), and scarring (n=2; 2.6%). Comparing to

Conclusions: XP has a strong likelihood of recurrence. TCA 80% as a treatment exhibited a high degree of patient satisfaction that was sustained long-term compared to other TCA concentrations. The patients perceived nominal side effects, minimal invasiveness, and reduced risk of further cosmetic disfiguration. TCA 80% for XP management should be considered as a treatment option due to high patient satisfaction, mild side effects, low cost, and long-term cosmetic results.

Learning Objectives

• Evaluate the efficacy of TCA 80% based on clinical outcomes, including lesion clearance rates, recurrence rates, and the time required to achieve optimal results in patients with XP.

• Identify the common side effects and complications associated with TCA 80% treatment for XP, such as erythema, hypopigmentation, scarring, and the strategies to mitigate these risks.

• Analyze patient satisfaction data and quality-of-life improvements following TCA 80% treatment, highlighting the importance of setting realistic expectations and discussing treatment goals with patients.

Takeaway Message

XP has a strong likelihood of recurrence. TCA 80% as a treatment exhibited a high degree of patient satisfaction that was sustained long-term compared to other TCA concentrations. The patients perceived nominal side effects, minimal invasiveness, and reduced risk of further cosmetic disfiguration. TCA 80% for XP management should be considered as a treatment option due to high patient satisfaction, mild side effects, low cost, and long-term cosmetic results.