Fournier's gangrene (FG) is a rapidly progressive, life-threatening necrotising soft tissue infection of the perineum and external genitalia that remains a surgical emergency with a high mortality despite advances in critical care. Once considered idiopathic, contemporary evidence demonstrates that FG most often arises from identifiable anorectal, urogenital, or cutaneous sources in patients with significant comorbidities, particularly diabetes mellitus and other states of immunocompromise. Mortality remains substantial, typically in the range of 20-30% and is strongly influenced by delays in diagnosis and definitive surgical intervention. This review updates and expands the previous 1998 review (Smith et al.) synthesising recent literature on the epidemiology, pathophysiology, microbiology, clinical presentation, diagnostic principles, management strategies, and outcomes of FG. Emphasis is placed on FG as a primarily clinical diagnosis requiring a high index of suspicion in patients presenting with rapidly progressive perineal pain and infection disproportionate to the physical findings. Prompt and aggressive surgical debridement remains the cornerstone of management, supported by broad-spectrum antimicrobial therapy, intensive supportive care, and a multidisciplinary approach, while the role of adjunctive therapies such as hyperbaric oxygen therapy and negative pressure wound therapy is critically appraised. Despite improvements in recognition and treatment, FG continues to carry significant morbidity and mortality, underscoring the importance of early diagnosis, immediate pathogen control, and coordinated multidisciplinary care to optimise patient outcomes.
In the United Kingdom (UK), 89.1% of patients with moderate-to-severe psoriasis are overweight or obese, and 53.2% have at least one comorbidity. However, real-world data on biologic-treated patients with psoriasis and comorbidities remains limited. Objectives were to compare 36-month drug survival of guselkumab in patients across weight and body mass index (BMI) categories, and in those with or without specific comorbidities. This retrospective cohort study used data from the British Association of Dermatologists Biologics and Immunomodulators Register (BADBIR), collected from January 2018 to July 2024. Co-primary outcomes were overall drug survival, and drug survival stratified by weight and BMI categories, over 36 months, for guselkumab-treated patients. Secondary outcomes included 36-month drug survival among guselkumab-treated patients with and without specific comorbidities, including but not limited to, metabolic syndrome, hypertension, anxiety and/or depression. Kaplan-Meier methodology was used to estimate probabilities for time-to-treatment discontinuation across all patient groups analysed. Among the 482 participants included in this analysis who initiated guselkumab treatment, 36-month drug survival was generally high, with an overall drug survival rate of 0.75 (95% CI, 0.71-0.79). Stratified by weight, drug survival rates were 0.71 (95% CI, 0.59-0.86) for patients <80 kg, 0.79 (95% CI, 0.71-0.87) for those 80-<90 kg, 0.74 (95% CI, 0.68-0.82) for those 90-<100 kg, and 0.74 (95% CI, 0.66-0.82) for those ≥100 kg. Drug survival by BMI category was 0.78 (95% CI, 0.71-0.86) for patients <30 kg/m2 and 0.73 (95% CI, 0.69-0.79) for those ≥30 kg/m2. Across all comorbidities analysed, drug survival at 36 months remained ≥0.69, with no significant differences observed in patients with comorbidities compared to those without. In this UK real-world analysis, drug survival rates for guselkumab over 36 months were consistent across patients with psoriasis in different weight and BMI categories, and were not adversely affected by the presence of comorbidities. This analysis has limitations due to the high proportion of missing weight and BMI data at baseline. Nonetheless, these findings support guselkumab use as a durable treatment option in routine practice, for patients with obesity and other common comorbidities.
Skin cancer incidence is rising in the UK, and with an increasingly aging population, so is frailty. Frailty scoring is not routinely utilised in skin cancer multi-disciplinary team decisions but may have the potential to enhance and personalise clinical management. The aim of this narrative review is to evaluate the literature on clinical tools used to assess frailty, guide management of people with skin cancer (melanoma and keratinocyte cancer) and identify the best frailty score to be used in skin cancer multi-disciplinary team management decisions in the UK. A literature search was conducted using MEDLINE and the results were screened for relevance to the clinical question. From the literature, we identified 12 different scoring tools studied in the management of skin cancer, across 15 papers, which we sub-categorised into 'comorbidity' and 'frailty' assessment tools. Of these, the Geriatric-8, Charlson Comorbidity Index and Adult Comorbidity Evaluation-27 were identified to be the most effective at identifying and stratifying frailty. However, the Rockwood Clinical Frailty Score is currently recommended by the British Geriatric Society and British Association of Dermatology. Notwithstanding the limitations of this critical appraisal (small cohort sizes, single-centre bias and overlapping or similar patient populations) we conclude that frailty scoring should be used in skin cancer multi-disciplinary teams so that patient related factors and tumour related factors are considered when managing skin cancer in older patients. Frailty scoring helps identify patients with limited life-expectancy and greater risk of complications, who may not benefit from 'gold-standard' treatments.
A 29-year-old man presented with a one-year history of recurrent palpable purpura affecting the lower limbs, occurring most reproducibly within hours of beer consumption. He also reported occasional cold-associated flares, which were considered a possible cofactor rather than a confirmed independent trigger. Skin biopsy showed leukocytoclastic vasculitis and direct immunofluorescence demonstrated IgA vessel-wall immunoreactivity. Investigations did not identify systemic involvement or an alternative cause. The findings support alcohol-triggered cutaneous IgA vasculitis. This case highlights the importance of exposure history, avoidance advice and renal surveillance in adult IgA vasculitis.
This correspondence estimates the hidden operational and financial cost of repeated isotretinoin regulatory change across UK dermatology services following the Medicines and Healthcare products Regulatory Agency’s 2023 and 2026 guidance cycles. Using transparent, conservative assumptions, it argues that substantial clinical, governance and organizational resources were diverted from patient care and that future regulatory interventions should be evaluated not only for safety intent, but also for implementation burden and opportunity cost.
A 3-year-old Pakistani boy has had persistent facial and auricular erosions, periungual inflammation, granulation tissue, and progressive nail dystrophy affecting fingers and toes. He later developed recurrent laryngeal obstruction with persistent hoarseness requiring repeated microlaryngoscopy and serial dilatations, alongside ocular irritation and a granulomatous lateral canthal lesion. Examination showed crusted facial erosions, scarring nail dystrophy, periungual granulation tissue, and thickened dystrophic toenails. Apart from microcytic iron deficiency anaemia, he was otherwise systemically well. Molecular testing identified a homozygous pathogenic LAMA3 variant, consistent with junctional epidermolysis bullosa.
Folliculitis decalvans (FD) is a primary cicatricial alopecia characterised by recurrent pustulation, tufting and progressive scarring hair loss. Familial clustering is rarely reported, limiting understanding of potential genetic susceptibility. We describe five cases of FD occurring in two unrelated families: three sisters with adolescent-onset disease and a mother-daughter pair with adult-onset disease, with a possible history in a preceding generation. Clinical and histopathological findings were consistent with FD in all cases. Staphylococcus aureus was identified in three of the affected individuals. Compared with previously reported familial cases, which predominantly involve male relatives or twins, this series represents the largest female-predominant familial cluster and the first clear mother-daughter occurrence. These findings support a potential heritable component in FD and highlight the need for further genomic and mechanistic studies.
This patient perspective explores the profound physical and psychosocial burden of Erythropoietic Protoporphyria (EPP), characterized by agonizing phototoxic reactions described as "millions of superheated needles". Through a personal account of diagnostic delays and the life-changing impact of a clinical trial for afamelanotide, this submission highlights the urgent need for equitable pediatric access to emerging therapies to mitigate the lifelong "invisible" burden of this disease.
Cutaneous lymphatic carcinomatosis from lung adenocarcinoma is exceedingly rare, and its inflammatory appearance can closely mimic dermatitis or drug-related eruptions, leading to diagnostic delay. We report a case presenting with carcinoma en cuirasse–like morphology—diffuse indurated erythematous plaques with lymphangitic distribution—confirmed on biopsy to represent intralymphatic tumour emboli from metastatic lung adenocarcinoma.
Adagrasib is a selective KRAS G12C inhibitor increasingly used in advanced malignancies and is associated with a range of cutaneous adverse effects. However, pigmentary changes remain rarely reported. We report a patient with recurrent KRAS G12C–mutant non–small cell lung cancer who developed photodistributed hyperpigmentation with associated nail matrix changes following adagrasib therapy.
Abstract This case report describes a 31-year-old patient with gender incongruence who developed Trigeminal Trophic Syndrome (TTS), presenting as non-healing scalp ulcerations in the V1 distribution, following facial feminization surgery. This is the first reported case of TTS after gender affirming surgery and is unique because the ulceration occurring on the scalp (V1 distribution) and was transient, resolving completely with return of normal sensation to the affected area.
An 81-year-old man presented with a persistent, erythematous plaque on the posterior left thigh. The eruption began on the face following use of an over-the-counter emollient and rapidly progressed to the trunk and limbs.
A 37-year-old male (Fitzpatrick skin type III) presented with a 10-month history of an enlarging nodule on the right parietal scalp. There was a paternal history of melanoma, but no family history of similar skin lesions. Physical examination revealed an ill-defined, pink, round, non-tender, mobile nodule measuring 15 x 15 mm. A second similar papule measuring 6 x 5 mm was found at the right scalp apex.
We describe a rare case of cryptococcoid neutrophilic dermatosis following exposure to radiocontrast dye in a patient with renal insufficiency. The complex histopathological findings and clinical context made it difficult to differentiate from iododerma, emphasizing the importance of prompt recognition and treatment for this condition.
Subcutaneous sarcoidosis (Darier–Roussy disease) is an uncommon form of cutaneous sarcoidosis that predominantly affects the extremities. Facial involvement is rare and may represent a diagnostic challenge. We describe a woman presenting with nodules of the cheek and lips, whose histopathological and radiological findings led to the diagnosis of systemic sarcoidosis. This case expands the clinical spectrum of subcutaneous sarcoidosis and emphasizes the need to consider sarcoidosis in the differential diagnosis of granulomatous panniculitis affecting the face.
INTRODUCTION:Cutaneous T-cell lymphomas (CTCL) comprise a clinically, histologically, and molecularly heterogeneous group of subtypes. They fulfil aspects of both chronic and malignant skin conditions and may thus affect health-related quality of life (HRQL) in various ways. To date, there is little information known about the topology of CTCL patients in routine care. OBJECTIVES:This study aims to characterize the frequency and distribution of body sites affected by CTCL in routine care and to analyze the impact on HRQL. METHODS:Cross-sectional survey study as part of the routine care at a University Medical Center. Topical distribution was identified with a detailed grid scheme filled by the patient and the affected body surface area (BSA) was recorded by the physician. Skindex-29 measured HRQL. RESULTS:153 patients with CTCL were included, with a mean age of 59.5 ± 16.5 years and a majority of male patients (61.4%). The mean number of grids marked was 129.2, corresponding to 12.7% of the BSA, and the most frequently affected body areas were thighs, back, and lower legs. Skindex-29 revealed that HRQL in CTCL patients is impaired on a mild level, with a mean of 27.5 ± 21.3. Patients with involvement of the visible or genital area showed a significantly poorer HRQL. Overall, 70% of patients reported relevant pruritus (NRS ≥3), which was strongly associated with worse HRQL, independent of localization. Linear regression analysis revealed a significant correlation between an increased impairment of HRQL and a higher BSA, a manifestation in visible areas, and a higher itching intensity. CONCLUSION:This analysis provides data on the distribution of CTCL in routine care. Our study highlights the importance of specific areas, such as visible body areas or the genital area, as determinants for the reduction of HRQL. This knowledge can help to improve patient-centered healthcare in CTCL.
Cost comparisons of psoriasis biologics rely on list prices, but confidential rebates can substantially alter real costs—often hidden even from prescribers. Ireland's Framework Agreement mandates a transparent 37% price cut plus 12.5% rebate once a biosimilar enters the market, but deeper discounts for Best Value Biologics stay confidential. European tendering data show actual discounts of 80–90% off list price, meaning cost-minimisation analyses using list prices alone risk misleading clinicians. This letter proposes an approach similar to that in Scotland or Denmark - sharing relative net-cost rankings with prescribers without disclosing confidential absolute prices.
We report a 9-year-old South Asian boy diagnosed with childhood granulomatous periorificial dermatitis (CGPD) following periorbital papules in the context of vitiligo treated with Ayurvedic and Unani preparations. This case describes an atypical periocular distribution in a child of South Asian heritage and, to our knowledge, the first reported association between CGPD and Ayurvedic and Unani topical preparations. Clinicopathological correlation confirmed the diagnosis and topical metronidazole resulted in marked improvement, highlighting the importance of considering traditional remedy use as a potential disease trigger.
A 79-year-old male presented to dermatology with a solitary, painless nodular lesion on the chest that had been present for over 20 years with gradual enlargement over the last 6 years. His past medical history included a mild IgM lambda paraproteinemia, chronic kidney disease, hypertension and COPD.
The rapid expansion of teledermatology has resulted in skin lesion photography being undertaken by an increasingly diverse workforce, leading to substantial variation in technical image quality. We describe the development and evaluation of the Dundee Image Grading Scale (DIGS), a brief, numeral-based, image quality assessment tool designed specifically for macroscopic lesion photography. The tool demonstrates reliable performance across users with varied clinical and technical backgrounds, while remaining intuitive and efficient to use. We anticipate that this will support future quality assurance activities across services that are dependant on high-quality image capture, such as; teledermatology and the emerging AI applications for skin cancer diagnosis.
