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CDA Abstracts Oral Presentations Takeaway Message: Varying opinions exist as to how dysplastic nevi are managed amongst Canadian dermatologists. This article provides valuable insight into how colleagues across the country are managing this lesion. O.01 Dysplastic nevus: management by Canadian dermatologists O.02 Canadian acne clinical practice guidelines Priya Sapra1 Charles W. Lynde2 Cheryl Rosen3 Sanjay Siddha3 Yuka Asai2 A Baibergenova3 M Dutil4 S Humphrey5 P Hull6 C Lynde4 Y Poulin7 N Shear4 Jerry Tan1 J Toole8 C Zip9 1. Royal College of Surgeons in Ireland, Dublin, Ireland; 2. Lynde Center for Dermatology, Markham, ON; 3. University of Toronto,Toronto, ON 1. University of Western Ontario,Windsor, ON; 2. McGill University, Montreal, QC; 3. Private practice, Richmond Hill, ON; 4. University of Toronto,Toronto, ON; 5. University of British Columbia,Vancouver, BC; 6. University of Saskatchewan, Saskatoon, SK; 7. University of Laval, Laval, QC; 8. University of Manitoba, Winnipeg, MB; 9. University of Calgary, Calgary, AB Background: The term “dysplastic nevus” (DN) and the management of DN remains controversial. There are no studies about their management by Canadian dermatologists. Methods/Results: To assess the current practice of Canadian dermatologists regarding the terminology and treatment of DN, a survey of 25 questions was emailed to 613 members of the Canadian Dermatology Association, in French and English. Introduction: Acne, a globally burdensome disease, is estimated to affect 4.5 million Canadians. While a variety of treatments exist, there are no prior Canadian evidence-based acne clinical practice guidelines. 179 responses were received. The numbers of participants who completed each individual question varied. 53% of participants had been practicing dermatology for greater than 20 years (not including residency training). 47% of respondents make a diagnosis of DN using only clinical criteria. 49% use complete surgical excision to remove DN; 45% of respondents use 1-2 mm margins for excision. In addition, 69% of respondents indicated they rarely or never re-excise lesions with mild atypia when the margins are reported as positive. 46% of respondents indicated they follow patients with multiple DN more closely. Similarly, 53% indicated they follow DN patients with a family history of melanoma more rigorously than if there was no family history. 78% of participants indicated they perform a total skin examination in patients with DN; 72% also recommend skin self-examination for DN patients. However only 17% of respondents advise skin self-examinations in first-degree relatives of DN patients. Additionally, 46% indicated they follow- their DN patients every 12 months. 66% of respondents believe that a melanoma is more likely to arise de novo rather than in a pre-existing DN. 65% of the surveyed dermatologists do not want the term “dysplastic nevus” to be abandoned. Objective: To develop evidence-based acne clinical practice guidelines adapted to the Canadian health care environment. Methods: Quality evaluation, using a standardized instrument, of evidence-based acne clinical practice guidelines was performed to identify those of highest methodological quality and best suited to adaptation. Methodology for adaptation was congruent with established recommendations. Updated systematic literature search and critical evaluation of studies fulfilling selection criteria of prospective trials in acne was undertaken for treatments available in Canada. Study grading and overall levels of evidence were established by 2 independent raters. Recommendation levels for treatment were established by expert panel voting using an online Delphi process for comedonal, mild-moderate inflammatory and severe inflammatory acne. Results: Based on quality appraisal, the European S3 Acne guidelines were used as the primary adaptation source. Systematic search results for this adaptation found 40 articles updating topical therapies, 67 were found to meet inclusion criterias; of 10 articles on systemic therapies, 5 articles were deemed eligible for inclusion. A search for alternative therapies such as diet found 10 studies, of which 3 were included; 7 of 14 articles on physical therapies were deemed eligible. The highest recommendations were: topical retinoids, benzoyl peroxide (BPO), fixed dose clindamycin/ BPO and adapalene/ BPO for comedonal acne; fixed dose clindamycin/ BPO and adapalene/BPO for mild-moderate inflammatory acne along with consideration of systemic antibiotics and oral contraceptives for more extensive involvement; and oral isotretinoin monotherapy for severe acne. Conclusions: Canadian dermatologists continue to use the term “dysplastic nevus”. There is no apparent consensus on making a diagnosis of DN on clinical features only, and on the various aspects of the treatment of DN. Learning Objective: Results will aid in providing dermatologists with the opinions of their Canadian colleagues, so as to eventually reach a consensus on the management of dysplastic nevi. A1 CDA Abstracts Conclusion: Evidence-based recommendations for acne management were developed by adaptation, following established methodological recommendations, of a previous high quality guideline. This adaptation included updating of systematic searches from the latter and including treatments available in Canada. Conclusion: These results will aid in providing Canadian dermatologists with better treatment of Hidradenitis Suppurativa. Learning Objective: To review successes and challenges that Canadian dermatologists are experiencing in treating patients with Hidradenitis Suppurativa. Takeaway Message: Hidradenitis Suppurativa is a chronic inflammatory skin disorder that Canadian dermatologists find frustrating to treat. Newer agents will hopefully provide better outcomes for our patients. Learning Objective: 1. for comedonal acne, highest recommendations were for topical retinoids, benzoyl peroxide (BPO), fixed dose clindamycin/ BPO and adapalene/BPO 2. for mild-moderate inflammatory acne, highest recommendations were for fixed dose clindamycin/ BPO and adapalene/BPO for mild-moderate inflammatory acne along with consideration of systemic antibiotics and oral contraceptives for more extensive involvement; 3. for severe acne, highest recommendations were for oral isotretinoin Takeaway Message: O.04 Doxycycline and the rare side effect of acute pancreatitis - a case study and literature review Hadal El-Hadi; Karen Holfeld; Andre Grobler University of Saskatchewan, Saskatoon, SK 1. Canadian acne clinical practice guidelines are evidencebased and developed by adaptation 2. High quality evidence can guide recommendations for acne treatment 3. Strength of recommendations are provided for each of comedonal, mild-moderate inflammatory and severe acne. Introduction: Doxycycline is used very commonly to treat skin conditions such as acne and rosacea by dermatologists. However, many dermatologists are unaware of the very rare side effect of pancreatitis from the administration of doxycycline. Although uncommon for pancreatitis to occur, the frequent prescription of doxycycline by dermatologists warrants a case study and literature review of the rare side effect of pancreatitis, given the severity of the disease. O.03 Methods, Results: A patient had perioral dermatitis in which doxycycline was prescribed to treat her condition. Within a week of doxycycline use, the patient was admitted to the emergency department with a raised amylase compatible with a pancreatitis. Ruling out other causes of acute pancreatitis, it was concluded that the patient had doxycycline-induced pancreatitis. Follow-up visit post discharge revealed complete resolution of previous symptoms. A literature review of doxycycline-induced pancreatitis shows that it is thought to be caused either by a hypersensitivity reaction or by the generation of a toxic metabolite. It is not always clear which of these mechanisms is operative. Hidradenitis suppurativa: Canadian dermatologists perspective Ambika Gupta2 Charles W. Lynde1 Sanjay Siddha1 John N. Kraft1 1. University of Toronto,Toronto, ON; 2. University of Ottawa, Ottawa, ON Background: Hidradenitis Suppurativa (HS) is a chronic inflammatory skin disease with a relapsing course. There is a lack of evidence-based guidelines for appropriate treatment which is very frustrating for both dermatologists and patients. Objective: A survey is being conducted to determine if Canadian dermatologists believe that there is an unmet need in treating patients with HS. Information is being collected on dermatologists’ goals, level of satisfaction and challenges in treating patients, along with therapies that dermatologists are using. Conclusions: Pancreatitis is a rare side effect of doxycycline use and patients and dermatologists should be cognizant of this side effect. While medicines are regarded as a common cause of acute pancreatitis, doxycycline induced pancreatitis is rarely reported. Prescribers should have a high index of suspicion for doxycycline-induced pancreatitis in patients with acute pancreatitis without an obvious cause, particularly if it is recurrent. Where doxycycline has been implicated in the aetiology of a patient’s acute pancreatitis, the patient should not be re-exposed to that medication. Methods: Using survey monkey technology. A survey of Canadian dermatologists is being conducted to determine if they have used biologics in treating patients with HS and if so, whether or not they have noticed an improvement in symptoms and patients’ quality of life. Results: The results of the survey will be presented and discussed. A2 CDA Abstracts Conclusion: The risk of developing PsA in patients with psoriasis appears to be greater in those with a higher PASI score, nail disease and a higher BMI. Learning Objective: • acute pancreatitis is a rare side effect of doxycycline use • patients and dermatologists should be cognizant of this side effect Takeaway Message: Learning Objective: To understand the risk factors for developing psoriatic arthritis in patients with psoriasis Takeaway Message: The risk of developing PsA in patients with psoriasis appears to be greater in those with a higher PASI score, nail disease and a higher BMI. • the use of doxycycline can have the rare side effect of acute pancreatitis • f doxycycline has been implicated in the aetiology of a patient’s acute pancreatitis, the patient should not be reexposed to it O.06 Differentiating arteriovenous malformation from infantile hemangioma of the lip O.05 Michele Ramien1, 2 Jérôme Coulombe1 Afshin Hatami1 Julie Powell1 Risk factors for new onset of psoriatic arthritis in a prospective cohort with psoriasis 1. CHU Sainte-Justine, Université de Montréal, Montréal, QC; 2. Division of Dermatology, University of Ottawa, Ottawa, ON Cheryl F. Rosen; Lihi Eder; Arane Thavaneswaran;Vinod Chandran; Amir Haddad; Dafna D. Gladman The International Society for the Study of Vascular Anomalies divides vascular birthmarks into tumors and malformations. Malformations are present from birth and neither proliferate rapidly nor resolve spontaneously. They are further divided into slow and fast flow. The lip has high background vascularity, making it difficult to differentiate a high flow arteriovenous malformation (AVM) from proliferating infantile hemangioma (IH) on the basis of imaging. Toronto Western Hospital,Toronto, ON Background: To study patients with new onset of psoriatic arthritis (PsA), the Toronto Psoriasis Cohort (TPC) was established in 2006. Methods/Results: Patients with psoriasis without inflammatory arthritis or spondyloarthritis (PsC), as determined by a rheumatologist, are enrolled and assessed annually for the development of PsA. 593 patients are enrolled in the TPC; 40 have developed PsA. To compare these patients to those without arthritis, a 1:2 match was carried out. New onset PsA patients were matched by duration of psoriasis at latest assessment, with 2 patients from the TPC without arthritis. The Wilcoxon test was used for continuous variables and the McNemar test was used for categorical variables. The groups had similar percentages of men (new onset PsA: 57.5% vs. PsC: 66.3%). Median (IQR) age at diagnosis of PsC was the same in both groups (new onset PsA: 26 (26) vs. PsC: 25 (19) p=0.39). The percentage who ever smoked was the same (65.8%), with similar numbers having diabetes (5.1% vs. 5.0%) and a history of heart disease or hypertension (38.2%, new onset PsA vs. 25% in PsC ). There was no statistically significant difference in the use of DMARDs or biologics. There was a statistically significant difference in the most recent PASI score, with a higher median (IQR) PASI score in those who developed PsA; 4 (9.2) for those with new onset PsA and 3.5 (4.5) for those with PsC (p=0.02). More patients with new onset PsA had nail involvement, 72.5% compared to 53.8% of those with PsC, p <0.0001. The median (IQR) BMI was greater in those who developed PsA, 29.7 (9.7) vs. 27.1 (5.5) in those with PsC alone. We present 2 cases of AVM of the lip in whom accurate diagnosis was delayed as a result of imaging (ultrasound with Doppler, MRI) favoring the diagnosis of IH. Our two patients exhibited a strikingly similar initial presentation (stage I/dormant), with large geographic well-demarcated red-violaceous patches involving the lower lip that evolved into thick plaques with lip eversion by 4 months of age (stage 2/expansion). Both patients had involvement of the inferior alveolar gingiva and experienced significant bleeding with eruption of anterior primary teeth. Retrospective revision of the initial imaging studies revealed features that could have supported an earlier diagnosis of AVM. When a hemangioma behaves atypically, alternative diagnoses should be considered. We discuss in detail the clinical and radiologic features of our cases to promote recognition, diagnosis, and appropriate management of AVM of the lip. A3 CDA Abstracts but recent research has found a V600E BRAF mutation in about 50% of cases, which could lead to new therapeutic options. We report a case of this unusual disease. Methods/Results: A 65 year old female patient was sent to us by her hepatologist for severe pruritus due to sclerosing cholangitis with hepatic failure rapidly evolving over 7 months. A thorough investigation which included a PET-scan was previously done and revealed a bilateral perirenal infiltration and hypermetabolic bone lesions. A perirenal biopsy showed a histiocytic infiltration with positive immunostaining for CD68 and negative for CD1a. The diagnosis of a non-Langerhans cell histiocytosis with multiorgan infiltration was made. Upon skin examination of the patient, 10 small purple to brown, asymptomatic, slightly hyperkeratotic, papules were noticed on her torso. A biopsy was done and revealed a dermal infiltration of foamy histiocytes with positive immunostaining for CD68 which confirmed a skin manifestation of the same disease. Unfortunately, the patient died 1 month later from hepatic complications and massive abdominal bleeding from ruptured varicose veins due to portal hypertension. Conclusion: Given the rarity of this disease, the diagnosis requires a high level of clinical suspicion. It is therefore important for the dermatologist to be aware of such rare skin manifestations which usually present as xanthoma-like papules. Unfortunately, the prognosis is usually poor with a 5 year survival rate of 68%, and there is no curative treatment. The response to the first line agent interferon-alpha seems to be the most prominent in the cutaneous foci with encouraging results regarding the targeting of interleukin-1 as well as BRAF inhibitors. Learning Objective: To highlight clinical and radiologic features that suggest the diagnosis of an AVM over an IH in the lip area. Learning Objective: Review the manifestations of the Erdheim-Chester Disease and the new advances in treatment options. Takeaway Message: In highly vascularized areas, it is difficult to distinguish AVM from IH on the basis of imaging alone; clinical progression plays an important role in accurate diagnosis. Takeaway Message: 1. Erdheim-Chester disease is a rare form of systemic nonLangerhans cell histiocytosis which classically presents itself with bone pain secondary to histiocytic infiltration. 2. Cutaneous manifestations are rare and consist of xanthoma-like papules. 3. Treatment options are limited; Interferon-alpha remains the first line therapy. Treatment strategies targeting interleukin-1 as well as BRAF inhibitors seem promising. O.07 An interesting case of non-Langerhans cell histiocytosis with skin manifestations: Erdheim-Chester Disease Sophie Vadeboncoeur; Benoît Côté; Annie Belisle Université de Montréal, Montréal, QC Introduction: Erdheim-Chester disease is a very rare form of progressive non-Langerhans cell histiocytosis which classically presents itself with bone pain secondary to histiocytic infiltration. Extraosseous involvement is frequent and can affect almost every organ with a predilection for the lungs, liver, kidneys, heart and central nervous system with skin being an exceptional site of involvement. The etiology is still unknown A4 CDA Abstracts O.08 Primary systemic (AL) amyloidosis masquerading as pseudoxanthoma elasticum: recognizing a novel clinicopathological pattern Heidi Wat; Douglas Wu; Muhammad Mahmood; Alain Brassard University of Alberta, Edmonton, AB Background: Primary systemic (AL) amyloidosis has a variety of cutaneous manifestations. In this case, we present a novel clinicopathological pattern of AL amyloidosis. Observations: A 57 year old woman with a history of AL amyloidosis manifesting as macroglossia and bilateral carpal tunnel syndrome presented with skin-colored to yellow cobblestoned plaques to the neck and bilateral antecubital fossa. Although clinically similar to pseudoxanthoma elasticum (PXE), the skin changes were found to be due to amyloid deposition primarily around the pilosebaceous unit but also within the papillary and reticular dermis based on multiple skin biopsies. There was no amyloid deposition around elastic fibers on both light and electron microscopy. Retinal examination did not demonstrate presence of angioid streaks and cardiac magnetic resonance imaging (MRI) was unremarkable. Previous reports of PXE-like plaques in AL amyloidosis have been reported as part of a rare entity termed amyloid elastosis, which is characterized by the pathological finding of amyloid encasing elastic fibers. However, our case demonstrates several important clinical and pathological differences from this entity. Most notably, there was no dermal elastic fiber involvement, limited cutaneous and systemic involvement and a fairly indolent course with better response to therapy. Conclusions and Relevance: Identification of this atypical presentation of AL amyloidosis has important implications for early detection and rapid treatment of a potentially aggressive and fatal disease. The lack of elastic fiber involvement establishes the uniqueness of this case and further study may be required to determine if this histological finding has prognostic significance. Learning Objective: The objective of this study is to identify a novel clinicopathological entity that may aid in the early detection of primary systemic amyloidosis. Takeaway Message: • The cutaneous manifestations of AL amyloidosis are varied, and being aware of atypical dermatological presentations may lead to earlier diagnosis and treatment. • This entity is distinct from amyloid elastosis, notably due to the absence of amyloid encasing elastic fibres. • Patients presenting with lesions mimicking PXE may be distinguished based on skin biopsy (and electron microscopy), lack of oral lesions, and ophthalmologic examination. A5 CDA Abstracts O.09 YI.01 Clinical recognition of melanoma by dermatologists and non-dermatologists Melanoma and non-melanoma skin cancer detection based on polarization mapping of speckle images - an in-vivo noninvasive technique Michal Martinka1, 3 Richard I. Crawford1, 4 Shannon Humphrey1, 2 1. University of British Columbia,Vancouver, BC; 2. Department of Dermatology and Skin Science,Vancouver, BC; 3. Faculty of Medicine, University of British Columbia,Vancouver, BC; 4. Department of Pathology and Laboratory Medicine, Vancouver, BC Bahman Sotoodian University of Alberta, Edmonton, AB PGY1 Dermatology Resident, University of Alberta Background: The incidence of melanoma is increasing annually in Canada. Consequently there has been a rise in the number of patients presenting with pigmented skin lesions to dermatologists and non-dermatologists. Objective: Clinically distinguishing melanoma from other pigmented skin lesions could be challenging. The current gold standard for diagnosis of melanoma is biopsy. Our study objective is to demonstrate that different skin lesions, malignant vs. benign, could be distinguished using a novel in-vivo noninvasive optical method. Objective: This retrospective study is designed to assess the ability of physicians of different specialties to accurately recognize melanoma. Material & Methods: When a laser beam illuminates a skin lesion, an interference pattern, known as a speckle image, is formed. We simultaneously captured the speckle images using two cameras, each with a polarizer oriented to the coand cross-polarization direction of the laser source. Through a pixel-by-pixel registration between the two polarized images, we constructed a degree of linear polarization (DOLP) map. The distribution of the DOLP map reveals that tissues respond at different polarization directions. We hypothesize that the distribution of a DOLP map, expressed statistically as mathematic moments, could be used as a diagnostic parameter for skin lesions. Methods: Pathology reports of biopsies submitted to Vancouver Coastal Health with a clinical diagnosis of melanoma were reviewed (January - July 2013). The clinical diagnoses made by dermatologists, general practitioners and family physicians (GP/FP), and all other specialists were correlated with the final histopathological diagnosis. Results: The dermatologists, GP/FP’s and all other specialists achieved diagnostic accuracies of 24.75% (50 of 205), 3.52% (9 of 240) and 12.75% (14 of 107), respectively. Dermatologists diagnosed the most melanoma (50) and had the highest diagnostic accuracy (24.75%). The clinical diagnosis rendered by GP/FP’s matched the histopathological diagnosis in only 3.52% of biopsies. GP/FP’s also diagnosed the lowest number of melanomas (9) and biopsied the most skin lesions (240). All other specialists performed better than GP/FP’s in accuracy (12.75%) but only performed half as well as dermatologists. Results: We examined 22 MM, 76 SK, 44 nevi, 27 BCC, and 11 SCC skin lesions under two light sources. All malignant cases were confirmed by biopsy. The DOLP maps for these skin lesions were constructed. The first 4 mathematical moments were calculated from the DOLP maps, and we found the 3rd and 4th order moments of the red & blue lasers showed significant differences between the mean of some benign pigmented and malignant lesions. The initial ROC analysis for MM vs. SK, 4th moment from blue laser, resulted in an AUC = 0.838 with p = 0.0001. The similar comparison using red laser resulted in AUC = 0.856 with p=0.0001. Conclusion: Although the diagnostic accuracy of dermatologists was significantly better than the other groups, the majority of patients with suspicious skin lesions present to a family or general practitioner first. Thus, there is considerable value in providing more training and education to non-dermatologists as it can have a meaningful impact on patient care. Conclusion: Our innovative approach towards skin cancer had demonstrated great promise in influencing the diagnosis of melanoma and other skin lesions. Our method would substantially assist dermatologists in deciding whether to biopsy the lesions or not. Learning Objective: Generate awareness of the importance of adequate dermatology training of non-dermatologists in accurate pigmented lesion diagnosis to improve patient care. Takeaway Message: 1. Dermatologists have significantly better clinical accuracy in recognizing melanoma when compared to non-dermatologists. 2. There is value in providing more training and education in accurate diagnosis of melanoma to non-dermatologists as it can have a meaningful impact on patient care. A6 CDA Abstracts SYCP1, cTAGE1 and GTSF1 were expressed in CTCL, but not in normal skin or benign inflammatory dermatoses. Learning Objective: Characterizing skin lesions through the statistical moments of the depolarization mapping of speckle images Learning Objective: Understand how ectopic expression of Cancer Testis (CT) antigens can be used as novel diagnostic/ prognostic markers or as novel targets for immunotherapy in CTCL. Takeaway Message: 1. Polarization of light could be used to differentiate different types of skin lesions 2. The statistical moment of depolarization maps can potentially differentiate malignant from benign lesions Takeaway Message: A number of CT antigens are ectopically expressed in CTCL patients and patient-derived cell lines. Aberrant histone acetylation may explain the mechanism behind the ectopic expression of these genes. These genes can be used as diagnostic/prognostic molecular markers or as novel targets for immunotherapy in CTCL. YI.02 Ectopic expression of cancer testis antigens in Cutaneous T-Cell Lymphoma (CTCL) patients YI.03 Leflunomide in dermatology and use in pemphigus vulgaris Ivan V. Litvinov1 Brendan Cordeiro 1 Hanieh Zargham 1 Yuanshen Huang 2 Kevin Pehr 1 Marc-Andre Doré 3 Martin Gilbert3 Youwen Zhou2 Thomas S. Kupper4 Denis Sasseville 1 Nazli Ghiasi1 Scott Walsh1 1. McGill University, Montreal, QC; 2. University of British Columbia,Vancouver, BC; 3. Laval University, Quebec City, QC; 4. Harvard University, Boston, MA, USA. 1. University of Toronto,Toronto, ON; 2. Sunnybrook Health Sciences Centre, Toronto, ON The pathogenesis of CTCL remains only partially understood. A number of recent studies attempted to identify novel diagnostic markers and future therapeutic targets. One group of antigens, cancer-testis (CT) antigens, normally present solely in testicular germ cells, can be ectopically expressed in a variety of cancers. Based on previous studies a number of CT antigens were reported to be ectopically expressed in CTCL patients. In the current work we test the expression of a subset of CT genes by RT-PCR in a cohort of CTCL patients, normal skin samples, lesional skin from benign inflammatory dermatoses and in 11 patient-derived CTCL cell lines. We correlate such expression with the p53 status and explore the molecular mechanisms behind their ectopic expression in these cells. Our findings demonstrate that SYCP1, SYCP3, REC8, SPO11 and GTSF1 genes are heterogeneously expressed in CTCL patients and patient-derived cell lines, while cTAGE1 was found to be robustly expressed in both. Mutated p53 status did not appear to be a requirement for the ectopic expression of CT antigens. While T cell stimulation resulted in a significant upregulation of STAT3 and JUNB expression, it did not significantly alter the expression of CT antigens. Treatment of cells with Vorinostat or Romidepsin Histone Deacetylase (HDAC) inhibitors resulted in a significant dose-dependent upregulation of expression of SYCP1, cTAGE1, REC8 and SPO11 mRNA, but not protein, in CTCL cell lines, while treatment of cells with Histone Acetyltransferase (HAT) inhibitor (Anacardic Acid) significantly downregulated the baseline expression of SCP1 and SPO11 mRNA. Comparison of expression between CTCL and non-malignant skin samples demonstrated that Leflunomide is a weak immunosuppressant which was first FDA approved for the treatment of rheumatoid arthritis. Although its use in dermatology has been limited, there is good evidence to support efficiency in the treatment of psoriasis as well as psoriatic arthritis. There is one previous report of use in bullous pemphigoid in the literature and no reports of use in pemphigus vulgaris to date. We present a case series involving 7 patients with refractory pemphigus vulgaris treated with Leflunomide as a novel therapy. Subjects were identified though a retrospective chart review of all patients with a confirmed diagnosis of pemphigus vulgaris seen between Jan 2002- Jun 2013 at the Sunnybrook Health Sciences Centre. Subjects had received Leflunomide at a loading dose of 100 mg daily for 3 days followed by 10 or 20 mg daily. Data collected include duration and severity of disease, previous treatments and response to Leflumonide therapy. All patients were monitored with weekly blood work for the first month and monthly thereafter. Follow up was done at 6 weeks for 5 patients, all of whom had some improvement clinically. All subjects received follow up at 6 months and 100% of participants had significant improvement clinically with 4 patients achieving complete remission. Beyond the 6 month point, 5/6 patients experienced mild flares responding to a course of low dose prednisone. Leflunomide was generally well tolerated and no adverse events were reported. The most common side effect was gastrointestinal symptoms and thrombocytopenia, not significant enough to lead to termination of therapy. We conclude that Leflunomide A7 CDA Abstracts is a promising novel therapy for pemphigus vulgaris with a favorable efficacy to side effect profile. Learning Objective: To learn about the evidence for Leflunomide in dermatology and in particular it’s efficacy as a novel treatment for pemohigus vulgaris. Takeaway Message: Leflunomide is a disease modifying agent with a favourable efficacy to toxicity ratio which can be used as a third-line agent in the treatment of pemphigus vulgaris. YI.04 Treatment of nail psoriasis with intralesional triamcinolone acetonide using a needle-free jet-injector Mélissa Nantel-Battista;Vincent Richer; Isabelle Marcil; Antranik Benohanian Conclusion: Treatment with triamcinolone acetonide delivered by Med-Jet MBX® is a safe, minimally painful and effective treatment for nail psoriasis. Université de Montréal, Montreal, QC Background: Treating nail psoriasis is challenging. Corticosteroid matrix injection with needle is a conventional treatment but pain is often a limitation. Learning Objective: • Becoming more familiar with the NAPSI score for grading nail psoriasis severity • Learning about different treatment options for nail psoriasis • Getting to know better the needle-free injector and their different clinical applications, especially for the treatment of nail psoriasis Takeaway Message: Objective: Evaluate efficacy and safety of triamcinolone acetonide needle-free injection with the Med-Jet MBX® in psoriatic fingernail. Methods: Seventeen patients were enrolled between January 2012 and January 2013. Four treatments sessions were scheduled every 4 ± 1 weeks. Clinical efficacy was evaluated with NAPSI score of target nail differences before and after the treatment. • Treatment of nail psoriasis with triamcinolone acetonide delivered the Med-Jet needle-free injector has shown to be efficient and minimally painful • Safety of the local treatment of nail psoriasis with triamcinolone acetonide has been demonstrated in our study using the Med-Jet • Before prescribing a systemic treatment for nail psoriasis, consider the option of the needle-free injector for delivering local treatment Results: Mean baseline NAPSI score was 6.5 on an 8 points scale (95% CI 5.652; 7.348) and mean final NAPSI score was 2.8 on an 8 points scale (95% CI 1.859; 3.741), demonstrating statistically significant treatment efficacy (p-value = 0.0007). NAPSI score for target nail from baseline to end of treatment was decreased by 46.25%. A8 CDA Abstracts Learning Objective: To evaluate the histological and clinical outcomes of the contoured staged surgical excision technique for lentigo maligna of the head and neck, including the optimal surgical margin required for complete tumor clearance. We propose that a surgical margin larger than the current standard guideline of 0.5cm is required for complete tumor clearance of Lentigo Maligna of the head and neck. YI.05 Outcomes of contoured staged surgical excision for Lentigo Maligna of the head and neck Alexis A. Botkin1 Annie Liu1 An-Wen Chan1, 2, 3 Christian Murray1, 3 Nowell Solish1, 3 Takeaway Message: Our cohort of patients demonstrate that margins larger than the current surgical guideline of 0.5cm may be required to obtain complete tumor clearance for lentigo maligna of the head and neck. 1. University of Toronto,Toronto, ON; 2.Women’s College Research Institute, Toronto, ON; 3.Women’s College Hospital,Toronto, ON Introduction: The Lentigo Maligna (LM) subtype of melanoma in situ commonly arises on the head and neck with subclinical peripheral extension, introducing functional, cosmetic, and reconstructive challenges in surgical treatment. Traditional wide excision with a margin of 0.5cm remains the standard of care based on consensus recommendations. However, case series suggest that over half of patients require a larger than 0.5cm surgical margin for tumor clearance. Contoured staged surgical excision (CSE) is a novel type of staged excision that ensures 100% margin control with tissue processing under permanent section. YI.06 The quality of life impairment in patients with Hidradenitis Suppurativa: A Canadian study Niloofar Anooshirvani; R Gary Sibbald; Afsaneh Alavi University of Toronto,Toronto, ON Introduction: Hidradenitis Suppurativa (HS) is a chronic, debilitating disease of apocrine gland bearing skin involving the axilla, groin, perianal and perineal skin. The clinical picture includes solitary nodules, diffuse, painful abscesses, malodorous drainage, sinus tract formation and scarring. The adverse affect of this disease on quality of life is imaginable but not extensively studied, especially in the Canadian population. Methods: A retrospective chart review and survey were completed for patients who underwent CSE for LM of the head and neck at Women’s College Hospital in Toronto, from July 2010 to March 2013. We recorded the total surgical margin size required for complete histological clearance, as well as post-operative infection and tumor recurrence. Results: Among 105 patients the surgical margins required for clearance of LM ranged from 0.3 to 2.5cm. 21% (22/105) of patients required a margin greater than 0.5cm and 10% needed 1.5cm or greater margins. Of the 79 survey responders (75% response rate) 1.2% reported a recurrence. Method: A prospective and retrospective chart review study, which employed qualitative questionnaires. 31 Patients with a diagnosis of HS were identified and contacted via telephone to participate in the study. Once consented 2 Surveys were filled out over the phone or during the patient visit including DLQI, SF36V2. Harley score documented based on the patients’ physical exam documented in the chart. Discussion: Although consensus guidelines currently recommend a 0.5cm surgical margin for lentigo maligna, our data suggest that a fifth of patients require a larger margin for complete tumor clearance. Contoured staged excision provides a safe technique for achieving high cure rates for this challenging tumor. Results: Mean ± SD DLQI score was 9.1 ± 9 equating to a moderate effect on patient’s life. There was a positive, significant correlation between Hurley’s staging and DLQI scores. (rs = 0.51 P=0.003). SF 36V2 determined that the domains significantly affected by HS are: • Bodily pain (45.1 ±12.3 P=0.04) • General health (45 ±12.1 P=0.03) • Social functioning (44.4 ±11.2 P=0.01) Conclusions: There is a significant impairment in quality of life in patients with HS. There is a direct relationship between the severity of the disease and quality of life impairment. When comparing physical and mental components of overall health, this study showed that HS patients have greater impairment in the physical health component. A9 CDA Abstracts Learning Objective: Learning Objective: Determine and quantify quality of life impairment in patients with HS and assess the correlation of disease severity (based on Hurley’s staging) to quality of life. 1) To understand the risk of malignancy associated with the different types of myositis. 2) To recognize the subset of patients with the highest risk of cancer and the change in risk over time. Takeaway Message: Both Dermatomyositis and to lesser extent polymyositis are associated with an increase malignancy risk. The risk extends for several years after diagnosis. Periodic malignancy screening is recommended in this high risk group. Takeaway Message: Hidradenitis supprativa is a cutaneous disease that involves young to middle age individuals and predominantly females. Dermatologists need to consider the significant quality of life impairment in patients with HS to outline the management plan accordingly. YI.07 Risk of malignancy in patients with dermatomyositis and polymyositis: metaanalysis of population-based studies YI.08 Raed Alhusayen; Akerke Baibergenova The frequency of malignant wounds in leg ulcer patients referred to wound care clinic at Women’s College Hospital Sunnybrook Health Sciences Centre,Toronto, ON Niloofar Anooshirvani2 Farhad Ghassemi1 Afsaneh Alavi1 Background: there is a wide variation in the literature about the risk of malignancy in dermatomyositis (DM) patients. 1. University of Toronto,Toronto, ON; 2. Universty of Ireland, Dublin, Ireland Objective: to assess the risk of malignancy among patients with DM and polymyositis (PM) using population-based studies. Methods: we searched MEDLINE and EMBASE databases for population-based studies published in English up to May 2013. The primary outcome was the observed to expected ratio of malignancy among patients with DM expressed as standardized incidence ratio (SIR). The risk of malignancy in PM was a secondary outcome. We also conducted subgroup analyses to assess the risk among DM patients by gender, time since diagnosis, age group, and by specific cancer type. Results: Five studies involving 4802 patients were included. The pooled SIR for the risk of cancer among DM patients was 4.39 (95% CI, 3.22 - 5.99). PM was associated with a lower but statistically significant risk of malignancy (SIR 1.75; 95% CI, 1.37 - 2.25). Among DM patients, the risk was higher for men (SIR 5.29; 95% CI, 3.49 – 8.04) than women (SIR 4.56; 95% CI, 2.97 – 7.02). Similarly, the risk was highest in the 1st year after DM diagnosis (SIR 17.29; 95% CI, 11.08 – 26.99) then decreased for 1-5 and more than 5 year periods to (SIR 2.7; 95% CI, 1.96 – 3.72) and (SIR 1.37; 95% CI, 1.27 – 1.48), respectively. In European studies, the highest relative risk increase was in ovarian cancer (SIR 10.36; 95% CI, 6.17 – 17.39) while the most commonly observed cancers were: Lung, colorectal, and Breast. Conversely, nasopharyngeal cancer was the most commonly observed malignancy in Taiwan and had the highest increase in relative risk ( SIR 139.9; 95% CI, 137.8 – 148.1). Conclusion: DM is associated with a 4-fold increase in the risk of cancer with men having slightly higher risk than women. The risk is highest in the 1st year after diagnosis but remains elevated even beyond 5 years. Introduction: Chronic wounds are slow to heal with an increased risk of transforming into malignancy over time. Skin cancers can present either primarily as an ulcer or as a secondary malignancy from chronic inflammation within a longstanding wound. Methodology: A retrospective cross-sectional study of patients who were referred to the wound clinic at WCH, with leg ulcers from 2011-2013 were performed. Those who received a biopsy of their ulcer were identified and a standard questionnaire regarding the details of the wound and biopsy was completed. The rate of the malignancy, patient demographics, wound characteristics and associated disease were documented. Results: A total of 1189 patients’ files with leg ulcer were reviewed. Of this population, 151 patients had received a biopsy of their ulcer. 13.2% (20) of the biopsied ulcer was cancerous (BCC, SCC, Sarcoma and Melanoma). The average age of patients with malignant ulcers was 81 years old with female predominance(75% ). The average duration of a malignant ulcer was 2.9 years with average ulcer size at 14.1 cm2. Overall 12% of all the files reviewed were biopsied and only 1.7% of all the total files reviewed were malignant wounds. Conclusion: The prevalence of malignancy in chronic leg ulcer series varies from 5 to 15 % depending on the frequency of skin biopsies and the patient population has been reported. In our study the prevalence of cancer in the wound biopies reported 13.2%. While malignancy is a rare complication of leg ulcers, early and correct diagnosis will reduce the morbidity of the disease. A10 CDA Abstracts Learning Objective: Takeaway Message: 1) Determine the prevalence of malignant leg ulcers in the patients referred to a wound clinic 2) Identify the risk factors associated with malignant ulcers 3) Evaluate the characteristics of a malignant ulcer Takeaway Message: Any ulcer that is not healing at the expected rate or has atypical presentations should be biopsied to rule out malignancy. Treating the underlying cause is the mainstay of optimal wound care. • Patients with a personal or family history of atopy are at increased risk of cutaneous delayed-type hypersensitivity reactions to common topical consumer product ingredients and medicaments. • Intermittent exposure to common topical consumer product ingredients and medicaments poses a higher risk for the development of cutaneous delayed-type hypersensitivity reactions. SS.01 Cutaneous delayed-type hypersensitivity to topical consumer product ingredients and medicaments and atopy SS.02 Pyoderma gangrenosum associated with alitretinoin therapy Jonathan Levy; Alain Brassard University of Alberta, Edmonton, AB Mark Kirchhof1 Gillian C. de Gannes1, 2 1. Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC; 2. Division of Dermatology, Department of Medicine, St. Paul’s Hospital,Vancouver, BC Background: A rare side effect of isotretinoin is the development of pyoderma gangrenosum (PG). Here we describe a case of PG associated with alitretinoin therapy. Atopy is a genetic predisposition to the development of allergic reactions and the increased production of IgE upon exposure to environmental antigens. Allergic contact dermatitis (ACD) is a T-cell mediated cutaneous delayed-type hypersensitivity (CDTH) reaction to topical allergens. We hypothesized that patients with a personal or family history of atopy would be at increased risk of developing ACD to topical consumer products and medicaments. Case: A 45 year old woman with a long-standing history of bilateral hand and foot eczema was treated with alitretinoin after failing topical corticosteroid therapy. She was started on alitretinoin (30mg once daily) and the dermatitis significantly improved. However, 5 months following initiation of therapy she developed a painful ulcer on her left shin. Treatment with multiple courses of intravenous antibiotics was not effective. The patient was then referred to our dermatology clinic while still taking alitretinoin. For this study, we reviewed the patch test database of the UBC Contact Dermatitis Clinic from 2008 to 2013. A personal or family history of atopy was noted. A total of 1515 patients were included in this study. Our data show that patients with a personal or family history of atopy are most likely to react to fragrances, botanicals or cosmeceuticals. They are also at increased risk of reacting to topical antibiotics, topical steroids and preservatives. Interestingly we found that a history of atopy was protective to developing CDTH to vehicle ingredients like propylene glycol. Our data show that patients with atopy are at increased risk of developing CDTH to topical consumer product ingredients and medicaments. An interesting observation from our study is that topicals used less frequently have an increased risk of CDTH compared to topicals that are used more frequently. Learning Objective: Assess the risk of cutaneous delayedtype hypersensitivity reactions to common topical consumer product ingredients and medicaments in patients with a personal or family history of atopy. Physical examination revealed two discrete ulcers with violaceous, undermined borders on her left lower leg. Punch biopsy revealed nonspecific inflammation and ulceration. Superficial and deep skin cultures were negative for bacteria, fungi, and mycobacteria. Other investigations including complete blood count, liver enzymes, and urinalysis were within normal limits, while hepatitis B surface antigen and antibody to hepatitis C were negative. Her past medical history is relevant for eczema, type 2 diabetes mellitus, gastroesophageal reflux disease, and hypercholesterolemia. PG was clinically diagnosed and the patient was treated with tacrolimus 0.1% ointment twice daily. Alitretinoin was stopped and the ulcer healed within 2 months of discontinuation. Discussion: To our knowledge this is the first reported case of PG secondary to treatment with alitretinoin. Only five cases of PG associated with isotretinoin therapy have been reported, but PG associated with alitretinoin or any of the other retinoids has never been reported. The mechanism of PG resulting from retinoid use is unknown, but has been suggested to be A11 CDA Abstracts related to altered neutrophil chemotaxis, increased skin fragility, and/or vascular proliferation. Learning Objective: To present the first reported case of pyoderma gangrenosum associated with alitretinoin therapy. Takeaway Message: In addition to isotretinoin, alitretinoin can also be rarely associated with pyoderma gangrenosum. SS.03 • Outline an approach to patient with contact dermatitis to wound products Takeaway Message: Allergic and irritant contact dermatitis to wound products or ulcer exudate is a common occurrence. Clinicians should be cognizant of the allergens in these products and the potential for sensitization. Once contact dermatitis develops, investigations should be ordered to determine the etiology or cause, and the dermatitis should be appropriately treated. Wound related allergic/irritant contact dermatitis SS.04 Afsaneh Alavi Sandy Skotnicki R Gary Sibbald Howard Maibach2 1 1 1 Dominant dystrophic epidermolysis bullosa treated with minocycline – a case report 1. University of Toronto,Toronto, ON; 2. UCSF School of Medicine, San Francisco, CA, USA Jordan Leung1 Paul Kuzel2 Alain Brassard2 1. Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB; 2. Division of Dermatology and Cutaneous Sciences, Department of Medicine, University of Alberta, Edmonton, AB Introduction: Contact dermatitis is a common, but underdiagnosed condition associated with chronic wounds. Forty to eighty percentage of patients with venous leg ulcers have one or more positive patch test reactions, with most of the identified allergens relating to previous allergen exposure or a history of contact dermatitis. Incidence of contact allergic dermatitis in persons with leg ulcers is high related to allergenic properties of commonly utilized wound care products, long term exposure to the identified allergens under occlusion, and the impaired barrier function of the ulcerated skin. Methodology and results: A literature search on the irritant and allergic contact dermatitis ( 1994-2014) was performed and combined with the expert opinion. The common reported irritants /allergens ingredient in wound products identified and the articles reported the allergies to these products were outlined. The recommendations for the replacement products and avoidance of allergens outlined. Conclusion: Clinically, contact dermatitis in patients with chronic wounds may present with localized itching, increased pain, discrete or diffuse periwound dermatitis of varying severity or worsening of the wound base and margin despite treatment, early diagnosis is critical to decrease patient suffering, avoid antibiotic overuse and optimize healing environment. Common allergens should be avoided including fragrances, propylene glycol, colophony, and topical antibiotics. Both allergic and irritant contact dermatitis occur in patients with wounds, particularly patients with chronic wounds such as leg ulcers. Epidermolysis bullosa (EB) is an inherited illness characterized by fragile skin and spontaneous formation, or formation upon minor trauma, of vesicles/bullae on various parts of the body. EB can first be subdivided into one of: EB simplex, junctional EB, dystrophic EB, and mixed type EB (Kindler syndrome). Each subtype has mutations in different genes. Dystrophic EB (DEB) results due to a mutation in the COL7A1 gene. Collagen VII is critical for the secure attachment of the epidermis to the dermis at a level deep to the basement membrane’s lamina densa. As a result, mutated collagen VII in DEB is the foundation for the clinical features seen with this illness. DEB can be further subdivided into autosomal dominant and autosomal recessive categories. One of the main focuses in treatment of epidermolysis bullosa is prevention of vesicle/bulla formation. Case reports have described treatment of DEB, with varying effectiveness, using topical camostat mesylate, minocycline, phenytoin, cyclosporine, topical corticosteroids, high dose tocopherol acetate, a combination of oral prednisone and DL-alphatocopheryl acetate, topical tacrolimus, and thalidomide. This case report describes the successful treatment of a 57-year-old male with dominant DEB (DDEB) using oral minocycline. Learning Objective: Recognize the use of minocycline as a potential treatment option for patients with dominant dystrophic epidermolysis bullosa. Learning Objective: • Identify the common allergens in wound products • Consider contact dermatitis as a cause of non healing ulcers Takeaway Message: Oral minocycline has been successfully used in the treatment and prevention of wounds for a 57-year-old male with dominant dystrophic epidermolysis bullosa. A12 CDA Abstracts SS.05 Persistence of IL-17A+ T lymphocytes and IL-17A expression in psoriatic plaques refractory to ustekinumab therapy C Jack1, 3 S. Mashiko2 N. Arbour2 R. Bissonnette3 M. Sarfati2 1. McGill University, Montreal, QC; 2. Université de Montréal, CRCHUM, Montreal, QC; 3. Innovaderm Research, Montreal, QC Ustekinumab targets the shared IL-12/-23 p40 subunit, thereby impairing Th1 and Th17 responses. Most patients with psoriasis treated with ustekinumab improve but do not achieve complete clearance and present with refractory plaques. We investigated the mechanisms underlying refractory skin lesions by examining pro-inflammatory cytokine expression in such plaques. Cells were isolated from skin biopsies of patients treated with ustekinumab (n=9) and from untreated patients (n=9) using a novel and rapid (6hrs) experimental approach. This method combines enzymatic and mechanical digestion of skin followed by cytokine analysis by flow cytometry of cutaneous leukocytes in the absence of in vitro stimulation. We found that patients treated with ustekinumab have the same proportion of CD45+ leukocytes, CD3+ T cells and CD3+ IL-17A+ cells in their plaques as untreated patients. Real-time PCR confirmed significantly elevated IL-17A mRNA expression in plaques in both cohorts of patients relative to non-lesional skin. Unexpectedly, we detected a significant increase in the proportion of IL-17A+ CD3- CD45+ cells in plaques of ustekinumab-treated, as compared to non-treated, patients (0.21 and 1.43% respectively, p<0.009). We conclude that refractory plaques are infiltrated by IL-17A+ hematopoietic CD45+ cells, whose lineage remains to be defined, and exhibit elevated levels of IL-17A despite targeting of IL-23 by ustekinumab. SS.06 Chronic Spontaneous Urticaria – an evaluation of an indirect immunofluorescence method for detecting anti-mast cell IgG antibodies Bahar Bahrani; Natasha Gattey; Peter Hull University of Saskatchewan, Saskatoon, SK An autoimmune basis is believed to be responsible for about half of all cases of chronic spontaneous urticaria (CSU) with specific IgG antibodies directed at the high affinity receptor sites for IgE on the mast cell. The autologous serum skin test (ASST) is used to identify this autoimmune form of CSU. Currently, basophil histamine release assay and basophil activation test (BAT) have been used as an alternative to the ASST. We have developed an indirect immunofluorescence method to demonstrate the presence of anti-mast cell antibodies using skin sections from a patient with severe bullous mastocytosis. Sections from paraffin embedded blocks of skin biopsied infant with bullous mastocytosis and cord-blood derived mast cells were used as substrates. Serum patients with CSU was used, and fluorescein conjugated human IgG was used to label fixed antibody. Amongst the bullous mastocytosis slides, positive indirect immunofluorescence was found in 35 (46.05%) of the patients (n=76). There was a positive indirect immunofluorescence in 17 (50%) patients who had a positive ASST (n=34), 49.09% of non-IVIG treated CSU patients (n=55), and in 61.09% of IVIG treated patients (n=21). Amongst the cord-blood derived mast cell cytospin slides, positive indirect immunofluorescence was found in 29 (41.43%) of the patients (n=70). Positive indirect immunofluorescence was found in 14 (45.16%) patients who had a positive ASST (n=31), 46% of non-IVIG treated CSU patients (n=50), and in 60% of IVIG treated patients (n=20). It is possible to detect anti-mast cell IgG antibodies by indirect immunofluorescence. IgG autoantibodies could be detected in about half of CSU cases examined. Indirect immunofluorescence should be considered a more direct and credible indicator of the autoimmune form of CSU. Learning Objective: An indirect immunofluorescence method can be used to identify anti-mast cell IgG auto-antibodies. Takeaway Message: Indirect immunofluorescence should be considered a more direct and credible indicator of the autoimmune form of CSU. SS.07 Indoor tanning policies and their implementation across Canada Pavandeep Gill1 Sunil Kalia2 1. Faculty of Medicine, University of British Columbia,Vancouver, BC; 2. Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC Skin cancer is the most common type of cancer affecting Canadians today. Ultraviolet radiation (UVR) from tanning beds is a known carcinogen and exposure to indoor tanning before age 35 can increase the risk of melanoma – the deadliest form of skin cancer – by 75%. The World Health Organization, Canadian Cancer Society, and the Canadian Dermatology Association all recommend that the use of tanning beds for non-medical purposes be restricted in individuals under age 18. Health Canada also agrees that minors should not use indoor tanning but policies and regulations surrounding tanning bed usage by minors remain under the control of provincial A13 CDA Abstracts governments. We review the current provincial public health policies surrounding indoor tanning. After contacting governing provincial health bodies, we also discuss how these policies and regulations, if any, are being implemented and enforced in each province across Canada. Learning Objective: To review the current status of indoor tanning policies across Canada and what efforts, if any, are being implemented to enforce them Seasonal and geographic trends in tanning Bez Toosi; Sunil Kalia Department of Dermatology and Skin Science, University of British Columbia, and Photomedicine Institute,Vancouver General Hospital.,Vancouver, BC Background: The incidence of skin cancer remains high and continues to rise. Tanning has been linked to causing skin cancer. Although tanning practices are assumed to be seasonal, seasonal patterns in tanning have not been systematically evaluated. This study explores seasonal and geographic trends in tanning practices in order to better understand tanning behaviors and to design timely intervention and harm reduction strategies. It utilizes internet search query data from Google Trends to test the hypothesis that tanning varies by season and contrary to general understanding peaks before the active months (June to August) of summer. Conclusion: Currently the Canadian educational campaigns that educate people about the hazards of tanning begin in May or June. This study suggests interest in tanning practices to be • Interest in tanning salons is seasonal and is highest in the months preceding summer. • The Canadian educational campaigns which attempt to educate people about the hazards of tanning currently start in May or June after the interest and potential use of tanning salons have peaked. • Results support initiation of educational campaigns earlier during the year. SS.09 Analysis of STAT4 expression in cutaneous T-cell lymphoma (CTCL) patients and patient-derived cell lines Ivan V. Litvinov1 Brendan Cordeiro 1 Simon Fredholm2 Niels Odum2 Yuanshen Huang 3 Youwen Zhou3 Thomas S. Kupper4 Anders Woetmann2 Denis Sasseville 1 Objective: To determine the seasonal and geographic effects on tanning and tanning salons search queries. Results: Time series revealed peaks in NSV’s in March-April and troughs in October-November in Canada and the United States. The peaks and troughs in NSV’s from Australian data were out of phase by 6 month as compared to the northern hemisphere counterparts, consistent with a seasonal pattern. Cosinar analysis revealed statistically significant seasonal effects on NSV’s in all countries. The magnitude of seasonal increase in NSV’s was similar between Canada, United States and Australia. The analysis of variance showed no significant difference between the three countries. Learning Objective: Appreciate the seasonality and trends in tanning. Takeaway Message: SS.08 Methods: Internet search query data were obtained from Google Trends. Monthly normalized search volumes (NSV’s) were determined for the term “tanning” and “tanning salons”, from January 2004 to December 2013. Using cosinor analysis, and Kruskal-Wallis one-way analysis of variance, seasonal and geographic effects were tested for data from Canada, United States and Australia. highest in the months preceding summer and prior to the onset of these campaigns. Further studies are needed to confirm these findings, but these results support having educational campaigns being initiated earlier during the year. 1. Division of Dermatology, McGill University Health Centre, Montréal, QC; 2. Department of International Health, Immunology, and Microbiology, University of Copenhagen, Copenhagen, Denmark; 3. Department of Dermatology and Skin Science, University of British Columbia,Vancouver, BC; 4. Harvard Skin Disease Research Center, Department of Dermatology, Brigham and Women’s Hospital, Harvard University, Boston, MA, USA Introduction: Deregulation of STAT signaling has been implicated in the pathogenesis for a variety of cancers, including CTCL. Recent reports indicate that loss of STAT4 expression is an important prognostic marker for CTCL progression and is associated with the acquisition of T helper 2 cell phenotype by malignant cells. However, little is known about the molecular mechanism behind the downregulation of STAT4 in this cancer. Methods: In the current work we test the expression of STAT4 and STAT6 via RT-PCR in CTCL lesional skin samples and in immortalized patient-derived cell lines. In these malignant cell lines we correlate the expression of STAT4 and STAT6 with the T helper (Th) phenotype markers and test the effect of Histone Deacetylase (HDAC) inhibitiors and siRNAmediated knock down of miR-155 on STAT4 expression. Results: Our findings demonstrate that STAT4 expression correlates with Th1 phenotype, while STAT6 is associated with A14 CDA Abstracts the Th2 phenotype. Our results further document that STAT4 and STAT6 genes are inversely regulated in CTCL. Treatment with HDAC inhibitors upregulates STAT4 expression, while at the same time decreases STAT6 expression in MyLa cells. Also, siRNA-mediated knock down of miR-155 leads to upregulation in STAT4 expression in MyLa cells. Conclusions: In summary, our results suggest that loss of STAT4 expression and associated switch to Th2 phenotype during CTCL progression may be driven via aberrant histone acetylation and/or upregulation of oncogenic miR-155 microRNA. Learning Objective: Loss of STAT4 in CTCL is associated with progressive disease and concomitant switch from Th1 to Th2 phenotype in malignant T lumphocytes. This molecular change may be medicated through abnormal histone acetylation and/or upregulation of miR-155 oncogenic microRNA. SS.10 Geographic distribution of Cutaneous T-Cell Lymphoma cases in Houston and Texas: a comparison of the MD Anderson and Texas Cancer Registries Results: Our findings, based on the MDACC database document geographic clustering of patients in three communities within the Houston metropolitan area, where CTCL incidence rates were 5-20 times higher than the documented population rate and patients with this rare cancer were residing along the same street/highway. Moreover, Fisher’s exact test analysis of incidence rates in these communities over time suggests a significant increase after ~2005. Analysis of the TCR database defined the CTCL population rate for the state to be 5.77 [95% CI 5.52, 6.03] cases per million individuals per year, confirmed the observations from the MDACC database and further highlighted additional putative areas of geographic clustering for CTCL across Texas. Conclusions: Our study documents geographic clustering of CTCL cases and argues for the existence of yet unknown external triggers for this rare cancer. Identification of additional CTCL clusters around the world will potentially help identify these triggers and will bring us closer to preventing this disease. Learning Objective: Review demographic trends for Cutaneous T-Cell Lymphoma over the past ~15 years and describe recent findings on geographic clustering of CTCL in Houston and Texas. Ivan V. Litvinov1 Michael T. Tetzlaff2 Elham Rahme3 Youssef Habel3 David R. Risser4 Pamela Gangar2 Michelle A. Jennings2 Kevin Pehr 1 Victor G. Prieto2 Denis Sasseville 1 Madeleine Duvic5 SS.11 1. Division of Dermatology, McGill University Health Centre, Montreal, QC; 2. Department of Pathology, Section of Dermatopathology,The University of Texas MD Anderson Cancer Center, Houston,TX, USA; 3. Division of Clinical Epidemiology, McGill University Health Centre, Montreal, QC; 4. Cancer Epidemiology and Surveillance Branch,Texas Cancer Registry, Department of State Health Services, Austin,TX, USA; 5. Department of Dermatology,The University of Texas MD Anderson Cancer Center, Houston,TX, USA Evaluating morbidity and association with autoimmune thyroiditis of chronic urticaria in children Elena Netchiporouk McGill University, Montreal, QC Introduction: The majority of skin cancers are caused by external and sometimes preventable agents including Human Papilloma Virus, Merkel cell polyomavirus or exposure to sun, arsenic or radiation. Reports of occurrence of Mycosis Fungoides in married couples and families raise the possibility that there might be an important environmental trigger for this disease. While it was suggested that Cutaneous T-Cell Lymphoma (CTLC) arises from inappropriate T cell stimulation, currently no definitive preventable trigger has been identified. Methods: In the current work we analyzed by region, zip code, age, sex and ethnicity the demographic data of 1047 patients from Texas, who were seen in a CTCL clinic at the MD Anderson Cancer Center during 2000-2012 (the MDACC database) and 1990 patients that were recorded in the Texas Cancer Registry (TCR database) between 1996-2010. Subsequently data from both databases was cross analyzed and compared. Chronic urticaria (CU) is defined when hives occur for at least 6 weeks. Recent studies suggest that autoimmunity including targeting either the mast cell IgE receptor, the IgE molecule or auto-antigens (i.g. thyroid antigens) may account for almost 50 % of spontaneous CU cases. The pathogenesis of CU and its effect on quality of life (QoL) are not well established in children. We aimed to establish a registry of CU in children to assess autoimmunity, QoL and factors affecting QoL. Between January 2013 and 2014, we recruited 35 children. Participants were queried on demographics, clinical history and QoL (CUQ2oL) through a validated questionnaire. In addition, participants filled the urticaria activity score (UAS). Blood tests were drawn to assess basophile activation, thyroid autoimmunity and confirmatory tests were performed when applicable to di- A15 CDA Abstracts agnose inducible forms. The Wilcoxon Rank Sum test and multivariate regression analysis were used to assess autoimmunity and factors associated with impaired QoL respectively. Our findings reveal that the majority of children were males (57%) presenting at a median age of 8 years (IQR: 3.75-12.0). Thyroiditis was reported in 17.1% of family members, but TSH and anti-thyroid peroxidase were normal in all patients. Physical forms occurred in 17.1 % of patients. Mean CD63 expression was 5.3% and was comparable to CD63 levels in controls. The mean weekly quality of life (UAS) score over 3 months was 6.5 on a scale of 42, which indicates a mild disease. Increased age at onset (OR=2.2, 95%CI) was associated with decreased QoL in the functionality domain and higher UAS (OR=2.16) with worse sleep domain. In conclusion, CU in children was not associated with thyroiditis or autoimmunity. Older age of onset and higher UAS may affect the quality of life in pediatric population. Our cohort will be followed for 10 years to study the natural history of CU. Learning Objective: • To understand the role of autoimmunity in the pathogenesis of chronic urticaria in children. T•o determine the impact of CU on the quality of life in pediatric population. • To assess factors affecting the quality of life in children. Takeaway Message: • Compared to adults, the implication of autoimmunity and thyroiditis seems to be less important in pediatric CU. • Most children have a mild disease and good control with anti-histamines only. • Older age of onset and higher urticarial activity score may affect the quality of life in pediatric population. Methods: Commonly presenting dermatologic issues (n=136) were used to determine patterns for changes in colour, shape, and topography. The proportion of each type of presentation was calculated accordingly. Correlations were determined by observing trends within paired characteristics. Results: Colour changes within the studied conditions were due to changes in pigmentation (26.2%) and vascular components (73.8%). Topographically, conditions presented with elevated lesions (58.2%), flat (20.9%), or lacked structure (15.7%). Elevated lesions presented as papules/plaques (61.5%), nodules (17.9%), vesicles (17.9%) or scars (2.6%). Flat lesions presented as macules/patches (85.7%) or scaly lesions (14.3%). Pigmented lesions were histologically in the dermis (48.5%) and epidermis (51.5%) and topographically presented as flat (63.6%), elevated (30.3%), and depressed (6.1%). Pigmented lesions presented as macules/patches (60.1%) and papules/plaques (24.2%).Vascular lesions were histologically found in the dermis (78.5%) and epidermis (21.5%) and presented as elevated (65.6%), lacked structure (22.6%), flat (6.4%), or depressed (5.4%). Lesions with no colour change had equal prevalence in the dermis and epidermis. Conclusion: Lesions tended to present with clusters of traits in a characteristic manner within the commonly presenting skin conditions analyzed. Elevated lesions were more common and usually presented as papules. Flat lesions usually presented as macules. Pigmented lesions tended to be flat and presented almost equally in the dermis and epidermis.Vascular lesions were more often elevated and found within the dermis. Recognition of these visual patterns can be used to elucidate underlying pathomechanisms rapidly. Educational tools can be tailored toward this line of reasoning to fill the paucity in teaching and improve the diagnosis of dermatologic conditions by primary care physicians. SS.12 SS.13 Evaluation of the prevalence of dermatologic clinical presentation visual patterns for the improvement of dermatology education Scurvy in a pediatric leukemia patient presenting as phrynoderma and perifollicular purpura Joseph E. Marinas1 Hermenio Lima2 Jeffery Cowger1 Sydney Harris-Janz2 Donna Johnston2 Jacqueline Halton2 Nordau Kanigsberg1 Carly Kirshen1 1. Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON; 2. Division of Dermatology, Department of Medicine, McMaster University, Hamilton, ON 1. Department of Dermatology, University of Ottawa, Ottawa, ON; 2. Children’s Hospital of Eastern Ontario, Ottawa, ON Introduction: Dermatology is a visual discipline in which specialists diagnose lesions using rapid pattern recognition. Diagnosis of these conditions requires a gestalt of clinical, histological, immunological, genetic, and morphological features which may present in a characteristic pattern. Background: Inadequate energy intake is an undesirable yet frequently observed complication in children with leukemia receiving chemotherapy. Chronic malnutrition in this population may result in depletion of several nutrients. Ascorbic acid (vitamin C) is an antioxidant and essential cofactor in several biological reactions including the synthesis of collagen, prosta- A16 CDA Abstracts glandin metabolism, fatty acid transport, and norepinephrine synthesis. Deficient levels of ascorbic acid, below 11umol/L (0.2 mg/dL), can occur in as little as three months and result in scurvy, a clinical syndrome, largely due to impaired collagen synthesis resulting in disordered connective tissue. Mucocutaneous manifestations of scurvy include follicular keratotic plugging, perifollicular purpura, corkscrew hairs, lower extremity edema with ecchymoses as well as bleeding, swelling and ecchymoses of gingiva and the loss of teeth. SS.14 Teaching dermatology to internal medicine residents: evaluating the effectiveness of an educational intervention Monica K. Li1 Steve Doucette2 Laurie M. Parsons1 1. University of Calgary, Calgary, AB; 2. Research Methods Unit, Capital Health, Halifax, NS Case Description: We report the case of a 10-year-old male with T-Cell ALL in the interim maintenance phase of protocol AALL0434 who presented in hospital with perifollicular purpura and follicular keratotic plugging of the posterolateral aspect of the arms, buttocks, posterior thighs, calves and shins. Prior to initiation of chemotherapy, the patient had a diet that was deficient in fruits and vegetables. Since the initiation of chemotherapy, the patient had consistently poor food intake, specifically limited in fruit and vegetables, that led to a severe weight loss of 18.5% of his baseline body weight. Based on the cutaneous findings a serum ascorbic acid level was ordered and demonstrated a serum concentration of less than 5 umol/L, indicative of deficiency. The patient was started on treatment doses of ascorbic acid at 125 mg three times daily for 7 days, then once daily for a period of 3 months to normalize serum levels of ascorbic acid. Conclusion: Chronic malnutrition in pediatric chemotherapy patients can lead to nutritional deficiencies. Although scurvy is a relatively rare complication, screening for ascorbic acid deficiency through patient physical exam and dietary assessment is an important consideration in this population. Learning Objective: To describe the cutaneous manifestations and treatment of scurvy. Takeaway Message: Chronic malnutrition in pediatric chemotherapy patients can lead to nutritional deficiencies. Although scurvy is a relatively rare complication, screening for ascorbic acid deficiency through patient physical exam and dietary assessment is an important consideration in this population. Background: Internists often encounter dermatologic issues, yet studies have shown that internal medicine trainees perform poorly at diagnosing skin diseases, and have suboptimal education in dermatology. Specifically, there is no published data comparing different educational interventions in dermatology and its impact on long-term knowledge retention in internal medicine residents. Objective: We aim to evaluate the impact of teaching dermatology to internal medicine trainees, and compare different educational methods on long-term knowledge retention. Methods: A prospective, interventional study design was used. Trainees of the Internal Medicine residency program at the University of Calgary were randomized into two groups to receive didactic or group-based education. Dermatology teaching was provided once monthly for three consecutive months, with pre- and post-tests administered for each educational intervention. A final test to evaluate long-term knowledge retention will be administered three months after the last educational intervention. Only test scores of trainees who provided consent to the study were analyzed. Results: Preliminary findings show improvement of scores from pre- to post-test following dermatology education. Near significant difference was found in test scores associated with the first teaching intervention (median pre-test 51% to post-test 55.2%, p-value 0.11, n=13), and a significant increase was found in test scores associated with the second teaching intervention (median pre-test 33.4% to post-test 59.6%, p value 0.03, n=6). No statistical difference in improvement of test scores were observed between didactic teaching and group-based learning methods. Further analysis of demographic factors that may affect the acquisition of knowledge, on test scores for the third teaching intervention, and on knowledge retention will be performed when the data becomes available. Conclusion: Preliminary results of our study support the importance of dermatology education for internal medicine trainees. Further analysis will provide insights that may contribute to the development of effective dermatology curricula for this important group of care providers. A17 CDA Abstracts Learning Objective: To provide insights on the impact of a dermatology educational intervention for internal medicine trainees. Learning Objective: To discuss both the success of the “Case of the Week” blog and the hurdles that have been encountered during its set-up and execution. Takeaway Message: Dermatology education has the potential to directly impact the competence of internal medicine trainees in managing cutaneous problems. Takeaway Message: A blog is an effective web-based tool to augment Dermatology education. SS.15 Evaluation of the “Case of the Week” blog as a web-based education tool for dermatology residents Fiona Lovegrove; Jane Wu; Scott Walsh University of Toronto Dermatology Division,Toronto, ON Online resources have become an increasingly significant component of medical education. In particular the “blogosphere” – the internet’s community of web logs (colloquially known as “blogs”) – continues to expand at a fervent pace. In such a visual specialty as Dermatology, a blog provides an excellent forum for the presentation and discussion of patient cases. The “Case of the Week” blog is a resident-initiated project that was created for use by the Dermatology residents, fellows and teaching faculty at the University of Toronto (UofT). Each post summarizes an interesting case presented at the weekly citywide patient viewing rounds with the patient history, physical examination findings, photographs, and discussion questions. The aim of the blog is to be a study resource for residents as well as to share references and ideas discussed at rounds. From its inception in September 2012, there have been 46 posts of patient cases and 8 “clinical pearls” (short posts that share a specific idea or resource related to a case discussed at rounds). The cases have ranged from common presentations such as lichen planus and tinea corporis, to the more esoteric – e.g. purigo pigmentosa and lipoid proteinosis. In 2013, the website had 5284 page views from 542 visits of an average 5 minute, 47 second duration. Information from the posts has been used for presentations at national conferences as well as material in OSCE stations for UofT dermatology in-training exams. This presentation will further discuss both the success of the “Case of the Week” blog and the hurdles that have been encountered during its set-up and execution. These include technical issues as well as patient consent and privacy concerns. The future of this project is open to possibilities such as expansion to include other medical education resources, however the most important future direction will be to maintain the blog as a valuable educational tool for UofT’s residents and associated dermatologists. A18 CDA Abstracts Poster Presentations utilizing combinations of other light-based and energy systems such as intense pulsed light, ultrasound, radiofrequency, and various injectable treatments, are warranted to further advance the art and science of rejuvenation. P1.01 Efficacy and safety of facial rejuvenation via the sequential combined use of multiple laser modalities Anil Kurian1 Douglas Wu1 William Groff2 Richard E. Fitzpatrick2 1. University of Alberta, Edmonton, AB; 2. Cosmetic Laser Dermatology Goldman, Butterwick, Fitzpatrick, Groff & Fabi, San Diego, CA, USA Background: Facial rejuvenation via ablative resurfacing has the potential to achieve excellent outcomes, but adverse events and downtime can be significant. Conversely, the side effect profile of non-ablative modalities is considerably less, but the clinical efficacy is often also substantially reduced. However, the safety and efficacy of combining multiple rejuvenating laser modalities has yet to be fully explored. Objectives: In this study, we present a novel sequential multi-modal laser protocol that efficiently and selectively targets specific components of the photoaging process while simultaneously producing significant global facial rejuvenation in a single treatment session safely. Conclusions: With excellent results and the requirement for only one treatment session, patients are well-served with a multi-modal approach to facial rejuvenation. Additional studies Takeaway Message: With excellent results, good safety profile and the requirement for only one treatment session, patients are well-served with a multi-modal approach to facial rejuvenation. Additional studies utilizing combinations of other light-based and energy systems such as intense pulsed light, ultrasound, and radiofrequency , and various injectable treatments, are warranted to further advance the art and science of rejuvenation. P1.02 Comparing syringe injectability of triamcinolone acetonide for keloid management Anthony Vo1 Gloria Rockwell1 Marc Doumit2 Methods: A retrospective chart review was performed of patients receiving combination sequential multi-modal laser rejuvenation of the face at our center between January 1, 2010 and January 1, 2013. Fifty patients treated by two independent physicians were selected at random for further analysis. Standardized clinical photographs were obtained of each patient prior to treatment and follow up post-treatment at both short and long term intervals. Clinical criteria were scored from standardized numerical scales and included evaluation of dyspigmentation, rhytides, telangiectasia, and skin texture, overall percentage improvement and healing time. A patient satisfaction survey was conducted to assess perceived overall improvement, lifestyle disruption, pain or discomfort, and overall satisfaction. Results: All measured clinical parameters achieved significant improvement. Overall improvement was measured at a sustained 60% over the long term. Healing time was measured at 9 ± 4 days (mean ± SD) and lifestyle disruption during the week immediately post-treatment was rated at 2.4 out of 4 (mild to moderate). Twenty-eight out of fifty patients responded to the survey, reporting overall patient satisfaction as high, measuring on average 3.1 out of 4. Learning Objective: With excellent results, good safety profile and the requirement for only one treatment session, patients are well-served with a multi-modal approach to facial rejuvenation. 1.The Ottawa Hospital, Ottawa, ON; 2. University of Ottawa, Ottawa, ON Purpose: Injections of triamcinolone acetonide (TA) into a keloid is often difficult and uncomfortable for a physician due to the injection force required. Altering the syringe and needle parameters can help reduce this force, but there are no evidence-based guidelines. The purpose of this study was to investigate the effects of various syringe and needle parameters on the injection force of TA, in order to determine a combination that is ergonomically feasible for keloid injections. Methods: 5 common syringes, ranging from 1 to 5mL in size, and 3 needle gauges(25G, 27G, 30G) varying in lengths(1336mm) were used. A load cell was used to generate and measure the injection force. The effects of syringe size, injection speed(1,3,5mm/sec), needle length and gauge were determined by injecting stock TA suspensions(40mg/ml). The most ergonomic needle-syringe combination was determined and compared to a combination commonly used in practice, by injecting into an excised keloid sample. Intraclass correlation coefficient(ICC) and independent t-test were used to determine reliability and significance respectively. Results: Increasing the speed of the injection, syringe size, needle length and gauge significantly increased the injection force required(p<0.001). 25G needles were less likely to clog with the TA suspensions(failure rate:33%) than 27G/30G(failure rate:85% and 100% respectively)(p<0.001). The 1mL polycarbonate syringe with a 25G 16mm needle re- A19 CDA Abstracts quired the lowest injection force. This combination required a maximum of 25.0N to inject into an excised keloid, compared to the common needle-syringe combination (39.9N). Each experiment was repeated at least four times. ICC for all tests were greater than 0.407. Methods: This was a multi-center, observational study collecting PROs in patients initiating (naïve) or receiving ongoing (maintenance) onabotA treatment. All patients provided baseline demographics. HU was the primary outcome measure obtained from the SF-12® Health Survey using the SF-6D, collected at baseline, week four post-treatment and up to five subsequent injection visits (SV). Mean and 95% confidence interval for baseline and change from baseline HU scores were calculated. The safety cohort included enrolled patients who received ≥1 treatment. Conclusions: The combination of syringe and needle significantly affected the injection force of TA. Increasing the speed of injection, syringe size, needle length and gauge significantly increased the force of injection. The 1 mL polycarbonate syringe with a 25G 16mm needle is an ergonomically feasible combination for keloid injections. Learning Objective: Understand the effects of various needle and syringe parameters on the injection force of triamcinolone acetonide into keloids and to apply this knowledge in order to be more ergonomic and to have a higher chance of injection success. Takeaway Message: 1. Increasing the speed of injection, syringe size, needle length and gauge significantly increases the injection force of triamcinolone acetonide. By adjusting these parameters, a lower injection force required can be achieved. 2. 25G needles are less likely to clog with stock triamcinolone acetonide suspensions(40mg/ml) (injection failure rate:33%) than 27G/30G needles(injection failure rate:85% and 100% respectively) 3. The 1 mL polycarbonate syringe with a 25G 16mm needle is an ergonomically feasible combination for keloid injections. P1.03 Evaluation of the baseline demographics and health utility in adults receiving onabotulinumtoxinA (BOTOX®) for the treatment of hyperhidrosis in a prospective observational cohort study: MOBILITY® Robert Miller2 Meetu Bhogal1 Grace Trentin1 1. Allergan, Inc., Markham, ON; 2. Dalhousie University, Halifax, NS Results: 288 hyperhidrosis patients between 14-81 years old (mean=32.5, SD=11.5) were enrolled, with 33 completing. The majority were female (N=222, 77.1%) and Caucasian (N=265, 92.0%). 151 (52.4%) were naïve and 137 (47.6%) maintenance. Baseline HU scores were similar in naïve (mean=0.782, SD=0.129) and maintenance (mean=0.799, SD=0.115) patients. Improvements in HU scores were observed up to SV3 in naïve (mean change=0.025, SD=0.122) and remained around baseline up to SV2 in maintenance (mean change=0, SD=0.132) patients. Thereafter, HU scores decreased (mean change≤-0.066); however, data was based on a reduced sample size (N=37, 12.8% by SV3). Overall, mean HU scores increased or were maintained at the time of the patients’ last treatment visit. The hyperhidrosis cohort reported 3 non-serious adverse events in 1 patient. Conclusions: The majority of hyperhidrosis patients enrolled in MOBILITY® were female, Caucasian, and naïve to onabotA treatment. Although study completion rate was low, due to variable treatment needs in this population, data indicates that onabotA treatment can improve or maintain HU in hyperhidrosis patients. Learning Objective: To evaluate baseline demographics and health utility in hyperhidrosis patients receiving onabotulinumtoxinA treatment in Canada. Takeaway Message: The majority of hyperhidrosis patients enrolled in MOBILITY® were female, Caucasian, and naïve to onabotulinumtoxinA treatment. Data indicates that onabotulinumtoxinA treatment can improve or maintain health utility in hyperhidrosis patients. Dr. Rob Miller is a member of CDA. Introduction: While studies have reported on the efficacy of onabotulinumtoxinA (onabotA) on clinical outcomes, patient reported outcome (PRO) data is limited. MOBILITY® is designed to evaluate health utility (HU) related to the clinical use of onabotA across several indications. The objective here is to evaluate baseline demographics and HU in hyperhidrosis patients receiving onabotA treatment in Canada. A20 CDA Abstracts P2.01 A case of “ice-pack dermatosis”: a coldinduced dermatosis that histologically mimics cutaneous lupus erythematosus Learning Objective: To recognize the clinical and histopathologic features of “ice-pack dermatosis.” Takeaway Message: Catherine Villeneuve-Tang;Vincent Richer; Benoît Côté; Annie Bélisle Université de Montréal, Montreal, QC We present the case of a 38-year-old woman with a prior diagnosis of cutaneous lupus erythematosus (LE) of the right shoulder. Her skin disease had shown little improvement over two years despite treatment with antimalarials and dapsone. She also suffered from complex regional pain syndrome of the right shoulder due to past shoulder injury. She presented to the emergency department with fatigue, icterus, and gastrointestinal symptoms. Work-up revealed severe hemolytic anemia, which was attributed to dapsone. Dapsone was subsequently discontinued. On examination, violaceous retiform patches with focal ulceration were observed on her right shoulder. During hospitalization, it was discovered that she had been applying ice to her right shoulder for up to 6 hours per day for relief of chronic pain. This form of analgesia had not been previously documented in her medical chart. Two previous punch biopsies were reviewed. Both biopsies demonstrated a superficial and deep perivascular and perieccrine lymphocytic infiltrate.Vacuolar change with keratinocyte necrosis and mildly increased dermal mucin were also noted. One of the biopsies also demonstrated a significant lymphocytic vasculitis, while the other demonstrated a slight lymphocytic panniculitis. The patient’s condition was compatible with “ice-pack dermatosis,” a cold-induced dermatosis due to chronic ice-pack therapy that has recently been described in the literature. Patients may present with erythematous to violaceous retiform plaques with superficial ulceration at the site of ice-pack contact. Histopathologic findings show similar features to cold panniculitis, perniosis, and cutaneous LE. The patient was encouraged to minimize ice application, and her analgesia was optimized. On follow-up, her condition had improved. It is important to inquire about all forms of self-administered analgesia in patients who present with skin changes at a site of chronic pain. Recognizing that “ice-pack dermatosis” can histologically resemble cutaneous LE will help to prevent iatrogenesis in patients. 1) “Ice-pack dermatosis” is a cold-induced dermatosis that can histologically mimic cutaneous lupus erythematosus (LE). 2) Recognizing that “ice-pack dermatosis” can lead to cutaneous LE-like histopathologic changes will facilitate appropriate diagnosis and treatment. P2.02 Pretibial myxedema: case presentation and review of treatment options Whan B. Kim2 Nisha Mistry1 Afsaneh Alavi1 Cathryn Sibbald1 Ronald G. Sibbald1 1. University of Toronto,Toronto, ON; 2. McMaster University, Hamilton, ON Introduction: Pretibial myxedema (PM) is a rare autoimmune manifestation of Graves’ disease, often presenting 12-24 months after the diagnosis of Graves’ disease and usually after the onset of severe Graves’ opthalmopathy. Clinically, over 50% of patients develop diffuse, nonpitting edema of shins, and less often present with plaques, nodules; or elephantiasis lesions mimicking lymphedema. Case: A 57-year-old woman presents with 12 month history of lower leg pain and pruritus aggravated by sitting. She has bilateral, non-pitting edema of the anterior shins, and slight periorbital edema without exophthalmos. Since treatment of Graves’s disease with radioactive iodine a year previously, the patient has remained euthyroid on levothyroxine. A punch biopsy of the dorsal foot was consistent with PM. The patient was treated with clobetasol propionate 0.05% daily and 20-30 mmHg knee high support stockings. After minimal improvement eight months later, intralesional steroid injections were infiltrated into the dermal tissue. The symptoms improved within 6 weeks and the treatment regimen was continued. However, in 2013, the PM recurred with local erythema and woody edema. The TSH level was on the lower end of normal (sTSH 0.36, Free T4 18) that prompted a decrease in L-thyroxine. Dermatologic treatment continued with topical and intralesional steroid injections and a new pair of support stockings. Methods and Results: A literature review was undertaken of the evidence-based treatment modalities for symptomatic PM. The mainstay of treatment is topical corticosteroid (mid or high-potency) applied directly to the lesions with or without occlusion. Compression therapy (support stockings or compressive bandages) may control associated venous edema. A21 CDA Abstracts Intralesional corticosteroid injections have been successful in several reports; however, long-term effects must be further investigated before routine use be recommended. Treatment of associated hyperthyroidism has not been shown to impact current PM lesions, but maintaining a euthyroid state may prevent recurrence. Conclusions: PM should be considered in patients with history of Graves’ disease. PM is commonly asymptomatic and self-limited; in severe cases, topical corticosteroid, compressive therapy, and intralesional corticosteroid injections are possible treatment options. Learning Objective: • Differentiate pretibial myxedema from lymphedema as a rare autoimmune manifestation of Graves’ disease • Provide an update on the management of this uncommon condition Takeaway Message: Pretibial myxedema is commonly asymptomatic and likely to resolve with time; however, cosmetic issues, impaired function, or localized discomfort may arise, in which case topical corticosteroid, compressive therapy, and intralesional corticosteroid injection may be considered as treatment options. P2.03 Apremilast, an oral phosphodiesterase 4 inhibitor, in patients with moderate to severe psoriasis: results from the randomized treatment withdrawal phase of a phase 3, randomized, controlled trial (ESTEEM 1) Shane Silver1 Kim Papp2 Peter Foley3 Kristian Reich4 Craig Leonardi5 Leon Kircik6 Sergio Chimenti7 ChiaChi Hu8 Randall M. Stevens8 Robert M. Day8 Christopher E. Griffiths9 1. DermAdvances Research,Winnipeg, MB; 2. Probity Medical Research, Waterloo, ON; 3. Skin & Cancer Foundation Inc., St.Vincent’s Hospital, Melbourne, ,VIC, Australia; 4. SCIderm Research Institute and Dermatologikum Hamburg, Hamburg, Germany; 5. Saint Louis University School of Medicine, St. Louis, MO, USA; 6. Physicians Skin Care, PLLC, Louisville, KY, USA; 7. University of Rome Tor Vergata, Rome, Italy; 8. Celgene Corporation,Warren, NJ, USA; 9. Dermatology Centre, University of Manchester, Manchester, United Kingdom APR30 patients who achieved PASI-75 were re-randomized (1:1, blinded) to continue APR30 or receive placebo. Upon loss of PASI-75, patients re-randomized to placebo resumed APR30. At Week 16, significantly more APR30 patients achieved PASI75 (33.1%) and PASI-50 (58.7%) vs. placebo (5.3% and 17.0%; P<0.0001). Mean/median percent change from baseline in PASI was -52.1%/-59.0% (APR30) vs. -16.7%/-14.0% (placebo) (P<0.0001, mean change). PASI responses were generally maintained through Week 32. Similar PASI responses were achieved at Week 32 in placebo patients switched to APR30 at Week 16. In the randomized treatment withdrawal phase, 61.0% of 77 patients randomized to continue APR30 from baseline at Week 32 had PASI-75 at Week 52, and 75.3% had ≥70% improvement in PASI from baseline; mean percent change from baseline in PASI was -81% to -88% from Weeks 32-52. In patients who received APR30 from baseline and were re-randomized to placebo at Week 32 (n=77), 11.7% had PASI-75 at Week 52. Median time to PASI-75 loss in patients re-randomized to placebo was 5.1 weeks. 70.3% of patients re-randomized to placebo who lost response and restarted APR30 regained PASI-75 response after treatment re-initiation. AE incidence did not increase over time. Most common AEs were diarrhea, URTI, nausea, nasopharyngitis, and headache. Most AEs were mild/moderate and did not lead to discontinuation. Serious AEs (serious infections, malignancies, and cardiovascular events) and laboratory changes were consistent with prior APR studies. Conclusions: Over 52 weeks, APR30 was effective in moderate/severe psoriasis. APR30 demonstrated an acceptable safety profile and was generally well-tolerated. Learning Objective: The objective of ESTEEM 1 is to describe the long-term (52-week) efficacy of apremilast 30 mg BID in patients with moderate to severe plaque psoriasis. Takeaway Message: Apremilast significantly reduced the severity of moderate to severe psoriasis over 16 weeks, with response generally maintained in patients remaining on apremilast for 52 weeks. Apremilast demonstrated an acceptable safety profile and was generally well-tolerated for up to 52 weeks with no new safety or laboratory findings compared with previous phase 2 studies. Introduction: Apremilast (APR), an oral phosphodiesterase 4 inhibitor, works intracellularly to regulate inflammatory mediators. Methods/Results: ESTEEM 1 randomized patients with moderate/severe plaque psoriasis (PASI ≥12, BSA ≥10%, sPGA ≥3) 1:2 to placebo or apremilast 30 mg BID (APR30). At Week 16, all placebo patients switched to APR30. At Week 32, all A22 CDA Abstracts P2.04 Biologic treatment utilization in patients with moderate to severe psoriasis: a Canadian healthcare system perspective drugs and determine characteristics of inadequate responders, including longitudinal treatment pathways and reasons for discontinuations or switching. Takeaway Message: Moderate to severe chronic plaque psoriasis patients treated with biologics may optimize their treatment by escalating the dose, reducing dosing intervals or ultimately switching to another treatment. Wayne Gulliver1, 2 Valerie Gregory3 Sam Khalil3 Usha Mallya4 1. Memorial University of Newfoundland, Faculty of Medicine, St. John’s, NL; 2. NewLab Clinical Research Inc., St. John’s, NL; 3. Novartis Pharmaceuticals Canada Inc., Dorval, QC; 4. Novartis Pharmaceutical Corporation, East Hanover, NJ, USA P2.05 HLA-Cw6 polymorphisms may help predict response to biologic therapy in patients with chronic plaque psoriasis Introduction: Psoriasis is a common chronic, recurring skin disease and estimates of its prevalence range from 0.5% to 4.6% worldwide (Lebwohl M (2003), American Academy of Dermatology (2011)). Due to the high prevalence of psoriasis, the severity of the disease, and the costs associated with various treatments, its economic burden is elevated (Fowler JF et al (2008)). Wayne Gulliver 1. Memorial University of Newfoundland, Faculty of Medicine, St. John’s, NL; 2. NewLab Clinical Research Inc., St. John’s, NL There are currently four available biologic treatments for moderate to severe psoriasis in Canada, namely Enbrel® (etanercept), Humira® (adalimumab), Remicade® (infliximab), Stelara® (ustekinumab). The objectives of this study were to describe the treatment patterns of moderate to severe psoriasis patients taking these biologic drugs and determine characteristics of inadequate responders, including longitudinal treatment pathways and reasons for discontinuations or switching. Methodology/Results: This was a retrospective cohort study using data abstracted from medical records of confirmed cases of psoriasis patients who received biologic treatments. The medical records were obtained from a private dermatology clinic in St. John’s, Newfoundland (NewLab Clinical Research Inc.). The study population consisted of moderate to severe psoriasis patients who attended NewLab Clinical Research Inc. (NewLab) between 2008 and 2012 with a confirmed diagnosis of psoriasis by a dermatologist, specifically chronic plaque-type psoriasis diagnosed for at least 6 months before study index date. To date response to biologics has been based on clinical observation and no genetic markers have been found to predict response to treatment. In 1993 our research suggested that HLA-Cw6 was a susceptibility gene for psoriasis. Our data also suggested that HLA-Cw6 was linked to both the age of onset of psoriasis as well as the need for patients to require photo or systemic therapy for psoriasis treatment. Since that time our knowledge of psoriasis genetics and pharmacogenomics has advanced significantly. With the introduction of biologic therapy we now have the tools we need to treat this severe and relentless disease. Biologics offer us not only improved therapeutic benefit but a much more favorable safety profile. As there is variability in the response of patients to biologics single-nucleotide polymorphisms that may identify responders and non-responders would be of benefit. HLA-Cw6 has been implicated in the past as a marker to biological response (Gulliver, AAD 2009). Recent studies also suggest that it may predict clinical response to ustekinumab (Talamonti, BJD 2013). Using the Newfoundland Labrador founder population we genotyped HLA status on 91 patients who were treated with biologics and then classified the patients into two groups: 1 - patients with a clinical response (PASI 75 response); 2 patients who were non-responders (PASI < 75) or who have discontinued treatment. Independent sample t-tests for continuous variables and Chi-square test for categorical variables were used to compare data between treatment groups (Enbrel® (etanercept), Humira® (adalimumab), Remicade® (infliximab), Stelara® (ustekinumab). Comorbidities were presented by age, sex, severity of psoriasis and treatment group, where possible. This study demonstrates the Newfoundland Labrador founder population and HLA-Cw6 status may be helpful in predicting response to certain biologics (Etanercept, Adalimumab, Ustekinumab, Infliximab). A total of 220 moderate to severe chronic plaque-type psoriasis patients were identified and treated with biologics. Learning Objective: To describe the treatment patterns of moderate to severe psoriasis patients taking these biologic A23 CDA Abstracts Parameter Etanercept (N=10) Adalimumab (N=25) Infliximab (N=23) Ustekinumab (N=33) Total (N=91) Methods and Results: We have retrospectively reviewed the charts of all DART patients from the two-year period, July 2011 to June 2013. The data collected includes: patient age, gender, dermatologic diagnosis, rheumatologic diagnosis, biopsies performed, treatment, number of follow-up visits, and co-morbidities. Our chart review revealed that a total of 320 patients were seen (248 female, 72 male). Mean age was 49 years for men, and 47 years for women. The most common rheumatologic diagnoses were systemic lupus erythematosus (58 cases seen), rheumatoid arthritis (49), psoriatic arthritis (41) and undifferentiated connective tissue disease(25). The most common dermatologic diagnoses were dermatitis (60), psoriasis (40), cutaneous lupus (25), alopecia (21), and infections (16). 78 patients had biopsies. The median number of follow-up visits was 1 (range 0-15). Non-responders (or discontinued treatment): HLA Cw6 + 3 (60%) 5 (45.46%) 3 (27.27%) 1 (20%) 12 (37.5%) 2 (40%) 6 (54.54%) 8 (72.73%) 4 (80%) 20 (62.5%) HLA Cw6 + 3 60%) 7 (50%) 9( 75%) 21 (75%) 40 (67.8%) HLA Cw6 - 2( 40%) 7 (50%) 3 (25%) 7 (25%) 19 (32.2%) HLA Cw6 Responders: Learning Objective: In the Newfoundland and Labrador founder population not only is HLA-Cw6 a susceptibility gene but preliminary data suggest it may be able to predict response to certain biologics. Takeaway Message: This study demonstrates the Newfoundland Labrador founder population and HLA-Cw6 status may be helpful in predicting response to certain biologics. This is very preliminary data and results should be confirmed in a larger study. P2.06 Conclusions: The majority of our patients are females with diagnoses of systemic lupus erythematosus or rheumatoid arthritis. Skin conditions seen were both related and unrelated to the underlying rheumatologic diagnosis. Dermatitis, a non-rheumatologic-associated condition, was very common, possibly due to its high incidence in the general population and a clinical appearance that may be suggestive of connective tissue disease. Our data also supports that lupus patients often present with rashes unrelated to the underlying lupus. Rheumatologists and dermatologists can both benefit from being aware of the dermatologic conditions that rheumatologic patients are experiencing. DART clinic review: experiences from a combined dermatology and rheumatology clinic Learning Objective: To gain awareness of the common dermatologic conditions that rheumatologic patients are experiencing. Michael Samycia2 Collette McCourt1 Kam Shojania3 Sheila Au4, 2 Takeaway Message: 1. Department of Dermatology, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, Ireland; 2. Department of Dermatology and Skin Science, University of British Columbia,Vancouver, BC; 3. Division of Rheumatology, Department of Medicine, St. Paul’s Hospital and Providence Health Care, University of British Columbia,Vancouver, BC; 4. Division of Dermatology, Department of Medicine, St. Paul’s Hospital and Providence Health Care,Vancouver, AB 1. Dermatitis, psoriasis, cutaneous lupus and alopecia are highly represented in rheumatologic patients seen in our clinic. 2. Skin problems in rheumatologic patients may not be related to the underlying condition. 3. Rheumatologists and dermatologists can both benefit from being aware of the dermatologic conditions that rheumatologic patients are experiencing. Objectives: The combined Rheumatology and Dermatology Treatment Clinic (DART Clinic) in Vancouver is a novel multi-disciplinary teaching clinic, where patients with both skin and rheumatologic issues are concomitantly assessed by both specialties. The purpose of this study is to determine the number of patients seen in clinic, patient demographics, and most common diagnoses. The information that we gain will be used for quality improvement and to help guide the education of rheumatologists, dermatologists, residents and medical students in our clinic. P2.07 Zoster vaccination of patients on biologics Eric E. Roszell; Lyn Guenther Schulich School of Medicine and Dentistry - University of Western Ontario, London, ON Introduction: Herpes zoster(HZ) causes significant morbidity. Incidence rates appear to be increased in patients with A24 CDA Abstracts psoriasis, rheumatoid arthritis, inflammatory bowel disease, and other autoimmune conditions who receive biologics. It is currently recommended that these patients receive immunization against HZ before receiving immunosuppressive treatments including biologics. Traditionally it has not been recommended to vaccinate immunosuppressed patients with live vaccines such as the zoster or varicella vaccine due to the fear of infection from the vaccine. In this article we review the current evidence regarding the safety and efficacy of zoster vaccination in patients on biologics. P2.08 Omalizumab in dermatology: a review of the literature Justin Chia; P. Régine Mydlarski Division of Dermatology, Department of Medicine, University of Calgary, Calgary, AB Methods: A systematic literature search was performed on PubMed for articles published between May 25th, 2006 and Jan 20th, 2014. All articles discussing HZ and zoster vaccination in patients with autoimmune diseases, including patients on biologics, were reviewed. Results: Patients on biologics have a higher incidence of herpes zoster, but it is unclear if this is attributable to the biologics or due to the underlying disease. Retrospective cohort studies found no adverse effects of zoster vaccination during biologic treatment up to 42 days post vaccination. Hazard ratios calculated from these studies found a decreased risk of HZ two years post vaccination. One case of vaccine viral strain (Oka) retinal necrosis in an IBD patient on multiple immunosuppressants including a biologic was reported after chickenpox vaccination. This vaccine contains the same OKA virus as the zoster vaccine, but the concentration is 1/14th. Heattreated zoster vaccine, although not strongly immunogenic, has been shown to be safe in immunocompromised patients. Conclusion: There is an increased need for HZ prevention in patients on biologics. Current data suggests that vaccination of biologic patients against zoster appears safe and effective in preventing HZ. Larger studies are necessary to confirm these results. Learning Objective: This study was undertaken to review the literature on the safety and efficacy of vaccination against zoster in patients who are on biologics. Takeaway Message: Live vaccines such as the zoster vaccine have been traditionally contraindicated in patients on biologics, however several biologic patients have received the zoster vaccine without ill effects.Vaccination of these patients is efficacious and may prevent zoster. The development of OKA virus retinal necrosis in an immunosuppressed IBD patient after receipt of the chickenpox vaccine, which contains 1/14th the concentration of virus as the zoster vaccine, suggests that it is premature to recommend routine zoster vaccination while on biologic treatment until larger studies are done. Introduction: Omalizumab (Xolair®; Roche/Genetech and Novartis Pharmaceuticals Inc.) is a recombinant humanized monoclonal antibody that inhibits the binding of IgE to the high-affinity IgE receptor (FcεRI) on the surface of mast cells and basophils. By reducing surface-bound IgE on FcεRI -bearing cells, omalizumab impairs the release of inflammatory mediators. Treatment with omalizumab also reduces the number of FcεRI receptors on basophils and may also decrease other autoreactive IgE antibodies. Omalizumab has been approved for use in asthma, and new reports show promise in a variety of dermatological diseases. Herein, we review the literature on omalizumab in dermatology and discuss the safety, efficacy and mechanisms of action for this emerging therapy. Methods: A search of the PubMed, Embase, and MEDLINE databases was performed (1990-2013) using the key words “omalizumab” and “Xolair” in combination with the following: “skin”, “dermatology”, “dermatological”, “cutaneous”, “pemphigus”, “pemphigoid”, “epidermolysis bullosa”, “vesiculobullous”, “papulosquamous”, “psoriasis”, “dermatitis”, “eczema”, “hyperIgE syndrome”, “urticaria”, “angioedema”, “collagen vascular disease”, “vasculitis”, “lupus”, “dermatomyositis”, “scleroderma”, “cryoglobulinemia”, “vitiligo”, “alopecia”, “granulomatous disease” and “graft versus host disease”. The data was extracted and the levels of evidence were graded in accordance with recommendations from the Oxford Centre for EvidenceBased Medicine. Results: A total of 61 dermatology-related publications were identified. They included reports on the use of omalizumab in chronic urticaria (34), atopic dermatitis (20), bullous pemphigoid (3), Churg-Strauss syndrome (2), and hyper-IgE syndrome (2). The safety and efficacy of omalizumab were also evaluated. Conclusions: Omalizumab has demonstrated therapeutic efficacy in a variety of recalcitrant immune-mediated and autoimmune skin disorders. It is a safe and effective treatment for use in chronic idiopathic urticaria (grade of recommendation: A). Randomized clinical trials with long-term follow-ups are warranted to firmly establish the role of omalizumab in the treatment of dermatologic disease. Learning Objective: 1. To review the current literature on the use of omalizumab in dermatology. A25 CDA Abstracts 2. To understand the potential mechanisms of action for omalizumab. Takeaway Message: Omalizumab is an anti-IgE monoclonal antibody that demonstrates efficacy and safety in the treatment of chronic idiopathic urticaria. It is a promising new therapy for many recalcitrant immune-mediated and autoimmune skin disorders. patients receiving higher doses while they may impact efficacy at lower doses. Learning Objective: Evaluate the impact of two baseline variables that may influence the effectiveness of biologics, body weight and prior biologic use, on the response to ixekizumab treatment. P2.09 Impact of body weight and prior biologic use on the effectiveness of ixekizumab in patients with moderate to severe psoriasis in a Phase 2 study P2.10 Efficacy of etanercept combined with topical therapy in patients with moderate-to-severe plaque psoriasis: results from the REFINE study Kim Papp1 Craig Leonardi2 Michael Heffernan 3 Janelle Erickson 3 Youb Chalabi3 1. Probity Medical,Waterloo, ON; 2. St. Louis University School of Medicine, Dermatology, St. Louis, United States, St. Louis, MO, USA; 3. Eli Lilly, Indianapolis, IN, USA Kim A. Papp1 Kirk Barber2 Robert Bissonnette3 Marc Bourcier4 Charles W. Lynde5 Yves Poulin6 Jennifer Shelton7 Jack Toole8 Andrew Vieira9 Melanie Poulin-Costello7 Introduction: Ixekizumab, an anti-IL-17A monoclonal antibody, has been shown to be effective in patients (pts) with moderate-to-severe chronic plaque psoriasis following 20 weeks of therapy in a Phase 2 study 1. Probity Medical Research,Waterloo, ON; 2. Kirk Barber Research, Calgary, AB; 3. Innovaderm Research, Montreal, QC; 4. Dermatology Clinic, Moncton, NB; 5. Lynde Centre for Dermatology, Markham, ON; 6. Centre Dermatologique du Quebec Metropolitain, Quebec, QC; 7. Amgen Canada Inc., Mississauga, ON; 8. University of Manitoba,Winnipeg, MB; 9. Formerly Amgen Canada Inc., Mississauga, ON Material & Methods: A total of 142 pts were randomized to receive subcutaneous injections of 10, 25, 75, or 150 mg of ixekizumab or placebo at weeks 0, 2, 4, 8, 12, and 16. Randomization was stratified according to body weight (<100 kg or ≥100 kg) and by prior biologic use. Regression analyses were performed using PASI 75 response or absolute PASI improvement at Week 12 as the dependent variable, and age, gender, race, duration of disease, baseline body weight, ixekizumab dose, baseline PASI score, and prior biologic use as independent variables. Introduction: Combination therapy is often used to treat moderate-to-severe plaque psoriasis (PsO). However, data from randomized clinical trials to formally evaluate the efficacy of topical corticosteroids as adjunct therapy to systemic agents are limited. Results: Prior biologics were used in 59 pts (42%) and 52 pts (37%) had ≥100 kg body weight with overall mean body weight of 94 (± 26) kg (range 51-180 kg). In the regression analyses of the overall population (all dose groups), baseline body weight was significantly associated with PASI improvement (p=0.045) and PASI 75 response rate (p=0.012) at Week 12 while prior biologic use and other baseline characteristics were not. In the low dose group, absolute PASI improvement was 13±7 for pts weighing <100 kg and 10±8 in pts weighing ≥ 100 kg (p=0.111), while in the high dose group, the PASI improvement was 15±5 for pts weighing <100 kg and 16±7 in pts weighing ≥ 100 kg (p=0.558). In the high dose group, the PASI 75 response rate was 83% in pts with prior biologic use and 82% in pts who were naïve to biologic therapy (p=1.0). Conclusions: Body weight and prior biologic use did not appear to have a major impact on the efficacy of ixekizumab in Takeaway Message: Ixekizumab, an anti-IL-17A monoclonal antibody, has been shown to be effective in patients (pts) with moderate-to-severe chronic plaque psoriasis following 20 weeks of therapy in a Phase 2 study Methods/Results: In the phase 3b, randomized, open-label REFINE study, moderate-to-severe PsO patients received etanercept (ETN) 50mg twice weekly (BIW; initial dose) for 12 weeks. Subjects were then randomized (1:1) to ETN 50mg BIW or ETN 50mg once weekly (QW; maintenance dose) plus topical agent, as needed, for an additional 12 weeks to achieve a clear/almost clear static physician global assessment (sPGA). Endpoints included percent change in Psoriasis Area and Severity Index (PASI) from week 12 (W12) to week 24 (W24); sPGA status; PsO-affected body surface area (BSA); and 50% improvement in PASI (PASI50), PASI75, and PASI90. From W12 to W24, the mean change in PASI (95% CI) in patients on ETN-BIW (N=140) was 17.0% (3.1%, 30.9%) vs. 0.9% (-13.0%, 14.8%) in those on ETN-QW + topical (N=142). At W24, 53.5% (45.3%, 61.7%) and 45.4% (37.2%, 53.6%) in the ETN-BIW and ETN-QW + topical arms, respectively, achieved a clear/almost clear sPGA status. The mean change (95% CI) in A26 CDA Abstracts affected BSA from W12 to W24 was similar between groups (ETN-BIW: 15.6% [-4.4%, 35.6%] vs. ETN-QW + topical: 10.7% [-9.3%, 30.7%]). At W24, the proportions (95% CI) of patients on ETN-BIW achieving PASI50, PASI75, and PASI90 were 78.2% (71.4%, 85.0%), 59.2% (51.1%, 67.2%), and 32.4% (24.7%, 40.1%), respectively. The proportions (95% CI) of patients on ETN-QW + topical achieving PASI50, PASI75, and PASI90 at W24 were 88.7% (83.4%, 93.9%), 60.3% (52.2%, 68.4%), and 27.0% (19.6%, 34.3%), respectively. Conclusions: Moderate-to-severe PsO patients receiving a maintenance dose of ETN (50mg QW) plus topical therapy demonstrated similar clinical benefit compared with patients continuing on the initial dose of 50mg BIW. Learning Objective: To understand the efficacy and safety of combination etanercept plus topical therapy in patients with moderate-to-severe plaque psoriasis Takeaway Message: Combination therapy with etanercept plus topical corticosteroid provided similar clinical benefit compared with etanercept alone in patients with moderate-tosevere plaque psoriasis. P2.11 Maintenance of clinical response with longterm brodalumab (AMG 827) therapy: week 96 results from an open-label extension study in psoriasis patients achieved PASI75, 85.1% (79.0, 90.1) had PASI90, and 62.9% (55.2, 70.0) had PASI100. At W48, 93.3% (95% CI = 88.4, 96.6) achieved PASI75, 83.0% (76.4, 88.4) had PASI90, and 61.8% (53.9, 69.3) had PASI100. At W96, 89.5% (95% CI = 83.6, 93.9) achieved PASI75, 78.4% (71.1, 84.7) had PASI90, and 52.9% (44.7, 61.1) had PASI100. Treatment-emergent AEs occurred in 93.4% of patients. The most common AEs included nasopharyngitis (25%), upper respiratory tract infection (18%), and arthralgia (13%). AEs ≥ grade 3 occurred in 22 (12.2%) patients and serious AEs (SAEs) in 12 (6.6%) patients. Treatment-related AEs were reported in 26.5% of patients (5 [2.8%] ≥ grade 3 and 3 [1.7%] SAEs). Before W48, one esophageal adenocarcinoma and one fatal aortic aneurysm rupture were reported. Conclusions: From week 8 through W96, the majority of patients achieved PASI100. The most frequent AEs were predominantly ≤ grade 2. Based on these results, further studies of brodalumab in moderate-to-severe PsO patients are warranted. Learning Objective: To understand the long-term efficacy and safety of brodalumab in patients with moderate-to-severe plaque psoriasis Takeaway Message: Brodalumab long-term safety and efficacy appear to warrant further investigation based on the positive long-term risk:benefit ratio. P2.12 Kim A. Papp1 Craig Leonardi2 Alan Menter3 Jean-Paul Ortonne4 Elizabeth H. Thompson5 Cassandra E. Milmont5 Ajay Nirula5 Paul Klekotka5 1. Probity Medical Research,Waterloo, ON; 2. St. Louis University, St. Louis, MO, USA; 3. Baylor University Medical Center, Dallas,TX, USA; 4. Hopital de l’Archet, Nice, France; 5. Amgen Inc.,Thousand Oaks, CA, USA Introduction: Brodalumab (anti-interleukin-17 receptor monoclonal antibody) has shown efficacy in moderate-tosevere plaque psoriasis (PsO). Brodalumab long-term efficacy and safety was assessed in an open-label extension (OLE) study in patients rolling over from a phase 2 dose-ranging trial. Methods/Results: In the parent study (NCT00975637), patients received placebo or brodalumab (70, 140, or 210mg every 2 weeks [Q2WK] or 280mg every 4 weeks). Patients in the OLE initially received brodalumab 210mg Q2WK. Following a protocol amendment approximately one year after study start, subjects ≤100kg switched to 140mg Q2WK. Outcomes included Psoriasis Area and Severity Index 75 (PASI75), PASI90, PASI100, and adverse events (AEs). Of 181 subjects enrolled, 165 remained on study at week 48 (W48; 48 on 140mg; 117 on 210mg) and 153 at week 96 (W96; 105 on 140mg; 48 on 210mg). At week 12 (W12), 95.4% (95% CI = 91.2, 98.0) Long-term safety and tolerability of apremilast, an oral phosphodiesterase 4 inhibitor, in patients with moderate to severe psoriasis: results from a phase 3, randomized, controlled trial (ESTEEM 1) Lorne Albrecht1 Kristian Reich2 Kim Papp3 Craig Leonardi4 Leon Kircik5 Peter Foley6 Sergio Chimenti7 Kamal Shah8 ChiaChi Hu8 Randall M. Stevens8 Robert M. Day8 Christopher E. Griffiths9 1. Probity Medical Research, Surrey, BC; 2. SCIderm Research Institute and Dermatologikum Hamburg, Hamburg, Germany; 3. Probity Medical Research, Waterloo, ON; 4. Saint Louis University School of Medicine, St. Louis, MO, USA; 5. Physicians Skin Care, PLLC, Louisville, KY, USA; 6. Skin & Cancer Foundation Inc., St.Vincent’s Hospital, Melbourne,VIC, Australia; 7. University of Rome Tor Vergata, Rome, Italy; 8. Celgene Corporation,Warren, NJ, USA; 9. Dermatology Centre, University of Manchester, Manchester, United Kingdom Background: Apremilast (APR), an oral phosphodiesterase 4 inhibitor, works intracellularly to regulate inflammatory mediators. Methods/Results: ESTEEM 1 randomized patients with moderate/severe plaque psoriasis (PASI ≥12, BSA ≥10%, A27 CDA Abstracts sPGA ≥3) 1:2 to placebo or apremilast 30 mg BID (APR30). At Week 16, all placebo patients switched to APR30 through Week 32. At Week 32, patients treated with APR30 at baseline who achieved PASI-75 were re-randomized (1:1, blinded) to continue APR30 or receive placebo. Upon loss of PASI-75, patients re-randomized to placebo resumed APR30. The APRexposure period (patients who received APR, regardless of when initiated [Weeks 0-52]) included 804 patients treated with APR30 (567.8 patient-years). During the APR-exposure period, adverse events (AEs) in ≥5% of patients were diarrhea (18.7%), URTI (17.8%), nausea (15.3%), nasopharyngitis (13.4%), tension headache (9.6%), and headache (6.5%). These AEs did not appear to increase over time and no new significant AEs emerged with continued APR exposure. AEs were predominantly mild/moderate in severity. Severe AEs occurred in 6% of patients with no clear trend or pattern observed. Discontinuation rate due to AEs was low during the APR-exposure period (7.3%). In APR-treated patients reporting diarrhea and nausea, more than half occurred within 2 weeks of the first dose, were predominantly mild in severity, and generally resolved within 1 month. The occurrence of serious AEs was 4.2% and no specific serious AE was reported for >3 patients during the APR-exposure period. No imbalance in rates of major adverse cardiac events, serious/systemic opportunistic infections, or malignancies between APR and placebo was observed. No cases of tuberculosis reactivation were reported. Over the APR-exposure period, changes in laboratory parameters were transient, and no trend was observed. Conclusions: APR demonstrated an acceptable safety profile and was generally well-tolerated for up to 52 weeks with no new/unexpected safety findings compared with previous phase 2 studies. Learning Objective: The objective of ESTEEM 1 is to describe the long-term (52-week) safety of apremilast 30 mg BID in patients with moderate to severe plaque psoriasis. Takeaway Message: Apremilast demonstrated an acceptable safety profile and was generally well-tolerated for up to 52 weeks. Most AEs were mild or moderate in severity and did not lead to discontinuation. There were no new safety or laboratory findings compared with previous apremilast phase 2 studies. P2.13 Phase 2 study of brodalumab (AMG827) for moderate-to-severe plaque psoriasis: week 12 results on efficacy and safety in patients with psoriatic arthritis Kim A. Papp1 Alan Menter2 Jean-Paul Ortonne3 Bruce Strober1, 4 Greg Kricorian5 Elizabeth H. Thompson5 Cassandra E. Milmont5 Ajay Nirula5 Paul Klekotka5 1. Probity Medical Research,Waterloo, ON; 2. Baylor University Medical Center, Dallas,TX, USA; 3. Hopital de l’Archet, Nice, France; 4. University of Connecticut School of Medicine, Farmington, CT, USA; 5. Amgen Inc.,Thousand Oaks, CA, USA Introduction: Psoriasis (PsO) patients with psoriatic arthritis (PsA) may be challenging to treat. This phase 2, double-blind study assessed brodalumab efficacy and safety in PsO patients with and without PsA. Methods/Results: Moderate-to-severe PsO patients were randomized to brodalumab (70, 140, or 210mg every 2 weeks or 280mg every 4 weeks) or placebo and stratified by history of self-reported PsA. Endpoints included Psoriasis Area and Severity Index 75 (PASI75), PASI100, and adverse events (AEs). Of 198 subjects enrolled, 46 (23.2%) had self-reported PsA. At baseline, these patients had similar/more severe PsO than those without PsA (mean disease duration 24.3 vs. 17.3 years; mean PASI score 19.7 vs. 18.9; mean affected body surface area 26.6% vs. 22.9%). The proportions (95% CI) of subjects with PsA achieving PASI75 at week 12 (W12) were: 37.5% (8.5, 75.5), 70mg arm; 81.8% (48.2, 97.7), 140mg arm; 91.7% (61.5, 99.8), 210mg arm; 37.5% (8.5, 75.5), 280mg arm. Of patients without PsA, the proportions achieving PASI75 at W12 were: 32.3% (16.7, 51.4), 70mg arm; 75.0% (55.1, 89.3), 140mg arm; 78.6% (59.0, 91.7), 210mg arm; 73.5% (55.6, 87.1), 280mg arm. The proportions of patients with PsA achieving W12 PASI100 were: 0% (0.0, 36.9), 70mg arm; 63.6% (30.8, 89.1), 140mg arm; 58.3% (27.7, 84.8), 210mg arm; 12.5% (0.3, 52.7), 280 mg arm. Of patients without PsA, the proportions achieving W12 PASI100 were: 12.9% (3.6, 29.8), 70mg arm; 28.6% (13.2, 48.7), 140mg arm; 64.3% (44.1, 81.4), 210mg arm; 32.4% (17.4, 50.5), 280mg arm. PASI 75/100 was not reached in the placebo arm at W12. Treatment-emergent AEs occurred in 57.1% (PsA) and 63.3% (without PsA) of patients receiving placebo and 71.8% (PsA) and 73.9% (without PsA) receiving brodalumab. Conclusions: Brodalumab treatment was associated with significant clinical improvements and similar levels of benefit in individuals with moderate-to-severe PsO, with and without PsA. A28 CDA Abstracts Learning Objective: To understand the efficacy and safety of brodalumab in patients with moderate-to-severe plaque psoriasis Takeaway Message: Brodalumab treatment was associated with significant clinical improvements and similar levels of benefit in individuals with moderate-to-severe PsO, with and without PsA. Similar levels of treatment-emergent AEs were observed among patients receiving brodalumab, with and without PsA. P2.14 Measuring the self-reported satisfaction scores of patients receiving different psoriasis treatments and their dermatologists Conclusion: Interim data suggests that patients on biologic therapy for ≥9 months (and their physicians) are more satisfied with current therapy than patients taking non-biologic therapy or newly prescribed/initiated biologic therapy (and their physicians), and satisfaction correlates with disease severity. Physicians treating biologic-experienced patients were more likely to agree with their patients’ satisfaction levels than were physicians treating patients on non-biologics. Longitudinal results from the newly prescribed/initiated group may provide insight into changes in satisfaction following initiation of a biologic. Learning Objective: To describe psoriasis patient satisfaction with treatment and identify drivers of satisfaction. Takeaway Message: Patients on biologic therapy for 9 months or longer, as well as their dermatologists, are more satisfied with their current therapy as compared to patients on non-biologic therapy, or those patients newly prescribed or initiated on a biologic. Vincent Ho1 Kim Papp2, 3, 6 Neil H. Shear4 Wayne P. Gulliver2 Yves Poulin5 1. University of British Columbia,Vancouver, BC; 2. Memorial University, St. John’s, NL; 3. K. Papp Clinical Research Inc.,Waterloo, ON; 4. University of Toronto, Toronto, ON; 5. Laval University, Quebec City, QC; 6. Probity Medical Research Inc.,Waterloo, ON Introduction: This observational study was designed to describe patient satisfaction with psoriasis treatment and identify its drivers. Methods and Results: Thirty-seven Canadian dermatologists each enrolled up to 30 adult psoriasis patients: 10 on non-biologic therapy for >3 months and candidates for/already on systemic therapy; 10 newly prescribed or initiated on biologic therapy; 10 biologic-experienced (taken ≥1 biologic for ≥9 months). During a routine visit, dermatologists completed a questionnaire about the patient. Patients completed a similar questionnaire at home. These interim analyses are qualitative. Biologic-experienced patients (n=66) were more satisfied with current therapy than non-biologic patients (n=48) or newly prescribed/initiated patients (n=35), based on a 5-point rating (5 = extremely satisfied); mean scores 4.33 vs. 3.73 vs. 3.71. Physicians were more satisfied with the current therapy of their biologic-experienced patients (n=167; mean score 4.43) than their non-biologic patients (n=119; mean score 3.19). More biologic-experienced patients (50%) agreed with the statement “I feel as good as I possibly could when it comes to my psoriasis” than non-biologic patients (19%) or newly prescribed/initiated patients (17%); physician ratings were similar. Biologic-experienced patients were more likely to describe their current psoriasis severity as very mild or mild, nonbiologic patients were more likely to describe it as moderate or severe, and newly prescribed/initiated patients were split among very mild, mild, moderate, and severe. P2.15 Comparison of dermatologist and patient rankings of psoriasis medication attributes Kim Papp1, 6, 3 Neil H. Shear2 Wayne P. Gulliver1 Yves Poulin4 Vincent Ho5 1. Memorial University, St. John’s, NL; 2. University of Toronto,Toronto, ON; 3. Probity Medical Research Inc.,Waterloo, ON; 4. Laval University, Quebec City, QC; 5. University of British Columbia,Vancouver, BC; 6. K. Papp Clinical Research Inc.,Waterloo, ON Introduction: This observational study was designed to compare patient and physician valuations of psoriasis treatment attributes. Methods and Results: Thirty-seven Canadian dermatologists each enrolled up to 30 adult psoriasis patients: 10 on non-biologic therapy for >3 months and candidates for/already on systemic therapy; 10 newly prescribed or initiated on biologic therapy; 10 biologic-experienced (taken ≥1 biologic for ≥9 months). During a routine visit, dermatologists completed a questionnaire about the patient, patients completed a questionnaire at home. These interim analyses are qualitative. A29 CDA Abstracts Most important psoriasis treatment attributes (matches bolded): Treatment group Attributes most valued by patients Attributes physicians believed were most valued by patients Attributes most valued by physicians 1. Efficacy, 2. Long-term efficacy, 3. Tie: Safety / Physician/ pharmacist recommendation (n=66) 1. Efficacy, 2. Safety, 3. Side effects (n=167) 1. Efficacy, 2. Safety, 3. Side effects (n=158) Newly prescribed/ initiated on a biologic 1. Efficacy, 2. Physician/ pharmacist recommendation, 3. Tie: Long-term efficacy / Side effects (n=35) 1. Efficacy, 2. Safety, 3. Side effects (n=118) 1. Efficacy, 2. Safety, 3. Side effects (n=68) Non-biologic 1. Efficacy, 2. Long-term efficacy, 3. Physician/ pharmacist recommendation (n=86) 1. Safety, 2. Efficacy, 3. Side effects (n=173) 1. Efficacy, 2. Safety, 3. Side effects (n=119) Biologic-experienced P2.16 Assessment of psoriasis treatment attributes that drive patient satisfaction Neil H. Shear1 Wayne P. Gulliver2 Yves Poulin3 Vincent Ho4 Kim Papp2, 6, 5 1. University of Toronto,Toronto, ON; 2. Memorial University, St. John’s, NL; 3. Laval University, Quebec City, QC; 4. University of British Columbia,Vancouver, BC; 5. Probity Medical Research Inc.,Waterloo, ON; 6. K. Papp Clinical Research Inc.,Waterloo, ON Introduction: This observational study assessed whether psoriasis treatment attributes most valued by patients also provided the greatest satisfaction in their current therapy. Methods and results: Thirty-seven Canadian dermatologists each enrolled up to 30 adult psoriasis patients: 10 on non-biologic therapy for >3 months and candidates for/already on systemic therapy; 10 newly prescribed or initiated on biologic therapy; 10 biologic-experienced (taken ≥1 biologic for ≥9 months). During a routine visit, dermatologists completed a questionnaire about the patient, patients completed a separate questionnaire at home. These interim analyses are qualitative. Physician valuation of attributes depended on the agent biologic-experienced patients were taking, with those prescribing infliximab (n=16) most valuing efficacy, those prescribing etanercept (n=44) most valuing safety, those prescribing adalimumab (n=37) most valuing side effect profile, and those prescribing ustekinumab (n=61) highly valuing all three factors. Conclusion: Interim data suggest physicians and psoriasis patients generally agree on important treatment attributes. Physicians do not always accurately predict these attributes’ relative importance to patients: long term efficacy is valued by patients, but is not considered as strongly by physicians. The physician misconception that patients in the non-biologic group most value safety may suggest a barrier to initiating these patients on a biologic. Learning Objective: Compare patient and dermatologist valuations of psoriasis treatment attributes Takeaway Message: Dermatologists and their patients generally agree on important treatment attributes. However, results suggest a common misconception among dermatologists that patients on a non-biologic most value safety, when these patients indicated they valued efficacy as most important. Treatment attributes most important to biologic-experienced patients (n=66): efficacy, long-term efficacy, and safety and physician/pharmacist recommendation (tied). Efficacy was the attribute these patients were most satisfied with in their current therapy, followed by side effects, and safety (average overall satisfaction rating: 4.33/5). Ustekinumab patients were satisfied with efficacy and side effects, adalimumab and etanercept patients identified cost, and infliximab patients identified longterm efficacy and frequency of administration. Patients newly prescribed/initiated on a biologic (n=35) most valued efficacy, physician/pharmacist recommendation and long-term efficacy/ side effects (tied). Attributes they were most satisfied with: efficacy, side effects, and safety (average overall satisfaction rating: 3.73/5). Non-biologic patients (n=86) most valued efficacy, long-term efficacy, and physician/pharmacist recommendation. Attributes they were most satisfied with: efficacy, long-term efficacy, and safety (average overall satisfaction rating: 3.71/5). Conclusion: Most patients across all groups valued efficacy and indicated they were most satisfied with this attribute in their current therapy. The low overall satisfaction of the newly prescribed/initiated biologic and non-biologic groups suggests room for improvement in their psoriasis treatment. Satisfaction with treatment attributes was dependent on the biologic prescribed; ustekinumab provided the highest rate of efficacy satisfaction. Long-term efficacy was valued by biologicexperienced and newly prescribed/initiated patients, but not identified as an attribute they were most satisfied with in their current therapy. A30 CDA Abstracts Learning Objective: Assess whether psoriasis treatment attributes most valued by patients also provide the greatest satisfaction in their current therapy Discussion: This is the first report that we are aware of describing eczema in the context of CVID in an adult. The underlying mechanism of both diseases is relatively unknown but involves a complex interplay between the barrier function of the skin and the immune system in eczema. Disregulation of the humoral immune system, depending on the mechanism, can have pro-inflammatory consequences and in a susceptible patient perhaps contribute to impaired barrier function of the skin and thus drive atopic dermatitis Takeaway Message: Most psoriasis patients across all types of treatment highly value efficacy in a treatment and indicated they were most satisfied with this attribute in their current therapy. Satisfaction with treatment attributes was dependent on the biologic prescribed; ustekinumab provided the highest rate of efficacy satisfaction P2.17 Learning Objective: Call the attention for the possibility of Atopic Dermatitis in a CVID patients Takeaway Message: It is possible that this association has not been described because the difficult of establishing the diagnosis at CVID. A 61-year-old male with a history of common variable immunodeficiency and atopic dermatitis Tim Olynych; Heather Bocz; Judah A. Denburg; Hermenio C. Lima P2.18 McMaster University, Hamilton, ON Introduction: Atopic Dermatitis is a clinical diagnosis characterized by: pruritis, xerosis, eczematous changes, with a chronic fluctuating course. Here we present a case of atopic dermatitis in a 61-year-old man with common variable immunodeficiency (CVID). Eczematous rashes are associated with primary immunodeficiencies such as SCID, Omenn syndrome, IPEX, Wiskott-Aldrich Syndrome, hyper-IgE syndrome, but there is little reported with CVID. Our patient had late onset atopic dermatitis and his lesions were advanced and difficult to treat. Case Description: A 61-year-old white male with a history of CVID presented with a pruritic, erythematous, maculopapular rash on his face, neck, shoulders, chest, groin, and flexor surfaces of his limbs. This rash had been variably present for 3 years, and was exacerbated by heat, stress, and perspiration; however, recently it had become progressively more advanced. Review of systems was negative. He reported no childhood history of allergic rhinitis, asthma, or eczema, but had a possible seafood allergy. Family history was noncontributory. On examination, the rash was highly lichenified, with scattered vesicles that wept clear fluid. Bloodwork revealed lymphopenia (0.8x10^9/L with CD4 of 180 (23%), CD4/CD8 ratio of 0.4), mild eosinophilia (0.5x10^9/L), IgA 0.64, IgG 4.36, IgM 0.91, and negative ANA/inflammatory markers. A biopsy 3 years ago suggested nummular eczema or contact atopic dermatitis. A repeat ruled out other possible diagnoses. His itch was refractory to antihistamines and topical steroids but responsive to prednisone. His is currently being treated with clobetasol 0.5% and doxepine 10mg. He has not restarted IVIG. Differences in psoriasis patient and dermatologist perception of treatment discussion and decision making Wayne P. Gulliver1 Yves Poulin2 Vincent Ho3 Kim Papp1, 6, 4 Neil H. Shear5 1. Memorial University, St. John’s, NL; 2. Laval University, Quebec City, QC; 3. University of British Columbia,Vancouver, BC; 4. Probity Medical Research Inc., Waterloo, ON; 5. University of Toronto,Toronto, ON; 6. K. Papp Clinical Research Inc.,Waterloo, ON Introduction: This observational study investigated treatment decision-making processes in psoriasis. Methods and Results: Thirty-seven Canadian dermatologists each enrolled up to 30 adult psoriasis patients: 10 on non-biologic therapy for >3 months and candidates for/ already on systemic therapy; 10 newly prescribed or initiated on biologic therapy; 10 biologic-experienced (taken ≥1 biologic for ≥9 months). During a routine visit, dermatologists completed a questionnaire about the patient; patients completed a questionnaire at home. These interim analyses are qualitative. Biologic-experienced patients (n=66) and their physicians (n=167) differed in perceptions of how current treatment was decided: 64% of patients said the physician and patient discussed options and decided together (vs 43% of physicians). 42% of physicians said they discussed options with the patient then decided themselves (vs 26% of patients). Among newly prescribed/initiated patients (n=35), 49% said they made the decision with their physician (vs 32% of physicians [n=68]); 49% of physicians said they made the choice themselves (vs 29% of patients). In non-biologic patients (n=53) and their physicians (n=119) 47% of patients and 42% of physicians claimed a joint decision, and 28% of patients and 42% of physicians said A31 CDA Abstracts after discussion, the patient chose. Average number of visits to select therapy was 3.31 (n=61) in the newly initiated/prescribed group, and 2.47 in biologic experienced (n=114) and non-biologic (n=96) patients. tive. Interim results showed at baseline, biologic-experienced patients (n=66) were more satisfied with current therapy than non-biologic patients (n=48), or newly prescribed/initiated patients (n=35), (mean scores 4.33 vs. 3.73 vs. 3.71 out of 5, where 5 = extremely satisfied). More non-biologic patients (42%) and newly prescribed/initiated patients (48%) agreed with the statement “There is still a lot of room for further improvement when it comes to my psoriasis” than biologicexperienced patients (12%). Biologic-experienced patients taking ustekinumab (n=26) were more satisfied than those taking etanercept (n=15), adalimumab (n=13) or infliximab (n=8) (mean satisfaction scores 4.58, 4.20, 4.38 and 3.75, respectively); their physicians’ responses were similar (4.62, 4.43, 4.38 and 4.06, respectively). After three months, mean satisfaction rose to 4.30 among newly prescribed/initiated patients (n=33), and remained comparatively stable among biologicexperienced patients (4.23; n=26) and non-biologic patients (3.5; n=28). Conclusion: Patients prescribed biologics believed they played a greater role in treatment decisions than did their physicians. This was reversed in patients taking non-biologic agents, suggesting patients on biologics feel more engaged in decision-making. The increased number of visits to select therapy for newly prescribed/initiated patients compared to patients switching within treatment groups suggests transitioning to a biologic can be an involved process. A biologic discussion early in a patient’s treatment course may help with a successful and appropriately timed transition to a biologic. Learning Objective: Compare perceptions of the treatment decision making process in psoriasis between dermatologists and their patients Takeaway Message: Patients prescribed a biologic felt engaged in decision-making and they believed they played a greater role in the treatment decision than did their physicians and patients taking non-biologic agents or newly prescribed/ initiated on a biologic. As the process of decision making takes longer when initiating a biologic, it is important to begin discussions early in a patient’s treatment. P2.19 Satisfaction with psoriasis treatment experience in biologic-experienced, naïve or newly initiated patients Conclusion: Biologic-experienced patients and newly prescribed/initiated patients at three month follow-up showed the highest satisfaction levels among treatment groups. This suggests after at least three months of treatment, patients find biologic therapy is a highly satisfying treatment experience. Sustained satisfaction ratings in the biologic experienced group at baseline and three months suggests longitudinal satisfaction with the biologic treatment experience. Among biologics, ustekinumab provided the most satisfying treatment experience. Learning Objective: Compare psoriasis patient satisfaction among biologic-experienced, naive, and newly initiated patients over time Yves Poulin1 Vincent Ho2 Kim Papp3, 4, 5 Neil H. Shear6 Wayne P. Gulliver3 Takeaway Message: Among treatment groups (biologicexperienced, naive, and newly initiated), patients on a biologic for at least 3 months reported the highest satisfaction with their treatment experience. Of the biologic examined, ustekinumab provided the most satisfying treatment experience for patients. 1. Laval University, Quebec City, QC; 2. University of British Columbia,Vancouver, BC; 3. Memorial University, St. John’s, NL; 4. K. Papp Clinical Research Inc., Waterloo, ON; 5. Probity Medical Research Inc.,Waterloo, ON; 6. University of Toronto,Toronto, ON Introduction: This observational study compared satisfaction among treatment groups at baseline and after three months to capture satisfaction through different treatment experiences. Methods and Results: Thirty-seven Canadian dermatologists each enrolled up to 30 adult psoriasis patients: 10 on non-biologic therapy for >3 months and candidates for/ already on systemic therapy; 10 newly prescribed or initiated on biologic therapy; 10 biologic-experienced (taken ≥1 biologic for ≥9 months). During a routine visit, dermatologists completed a questionnaire about the patient; patients completed a questionnaire at home. These interim analyses are qualitaA32 CDA Abstracts P2.20 Assessment of dermatologist satisfaction when considering a treatment change in psoriasis patients Takeaway Message: Dermatologists planning to switch biologic therapy perceive their patient satisfaction to be lower than in patients in which a dose adjustment or addition of a medication is being considered. Patients on etanercept and ustekinumb showed the highest and lowest propensity to change treatment, respectively. Vincent Ho1 Kim Papp2, 4, 5 Neil H. Shear3 Wayne P. Gulliver2 Yves Poulin6 1. University of British Columbia,Vancouver, BC; 2. Memorial University, St. John’s, NL; 3. University of Toronto,Toronto, ON; 4. K. Papp Clinical Research Inc.,Waterloo, ON; 5. Probity Medical Research Inc.,Waterloo, ON; 6. Laval University, Quebec City, QC P3.01 Introduction: This observational study was designed to describe patient satisfaction with psoriasis treatment and identify its drivers. Specifically, this study examined perceived satisfaction by physicians in patients on a biologic whose physicians are considering treatment changes. Methods and Results: Thirty-seven Canadian dermatologists each enrolled up to 30 adult psoriasis patients: 10 on non-biologic therapy for >3 months and candidates for/ already on systemic therapy; 10 newly prescribed or initiated on biologic therapy; 10 biologic-experienced (taken ≥1 biologic for ≥9 months). During a routine visit, dermatologists completed a questionnaire about the patient; patients completed a questionnaire at home. These interim analyses are qualitative. Interim results show physician rate of considering treatment change versus the current treatment of the biologic-experienced patient. Current biologic Patients for which treatment change considered, % (n) % of patients who switched medications Etanercept 23 (44) 7 Adalimumab 22 (37) 5 Infliximab 19 (16) 6 Ustekinumab 13 (61) 0 Learning Objective: Assess drivers of treatment changes in psoriasis patients on a biologic therapy Leprosy: a case to recognize Farheen Mussani1 Irene Lara-Corrales2 1. Division of Dermatology, University of Toronto,Toronto, ON; 2.The Hospital for Sick Children,Toronto, ON Introduction: Leprosy is a slowly progressive infectious disease, caused by mycobacterium leprae, which can lead to significant mutilation as well as irreversible morbidity. While the primary organs affected are the skin and peripheral nervous system, leprosy can have a number of very distinct clinical presentations. This disease is currently only endemic in tropical and subtropical regions; however, given the diverse ethnic background of the Canadian population, this disease should not be forgotten in the Canadian context. Methods and Results: We report a case of a 15-year-old male from the Philippines who immigrated to Canada with his family four years prior to his presentation to the Pediatric Dermatology clinic at The Hospital for Sick Children. He had a five-year history of a slowly progressive loss of sensation of his face and arms and a flexion contracture of the right hand. One year prior to his assessment, he started to develop a distinct infiltrative papulo-nodular and plaque-like eruption on his face, back, chest and arms. This was biopsy proven on presentation to Dermatology as leprosy. A literature review of leprosy diagnosis and treatment, especially in the North American context, was conducted. Among physicians considering any change (n=32), 71% gave these patients a moderate, severe or very severe score on PGA. Physicians considering switching medications believed their patients to be less satisfied with current treatment than physicians considering dose adjustments or adding medications (mean satisfaction scores: 2.8, 3.84, and 4.0, respectively). Conclusions: While leprosy is not endemic in North America, given the diversity of the countries of origin of those in Canada, especially in Toronto, in patients presenting with loss of sensation with skin findings a diagnosis of leprosy should be considered and ruled out. Conclusions: Physicians planning to switch their biologicexperienced psoriasis patients to another medication perceive those patients to be less satisfied than do physicians planning to adjust doses or add medications. Ustekinumab patients appeared to have the lowest propensity to switch their biologic treatment. Learning Objective: The objective of this study was to highlight a pediatric case of leprosy diagnosed recently at The Hospital for Sick Children and review the literature on the diagnosis and treatment of the disease. A33 CDA Abstracts Takeaway Message: 1. Leprosy should be suspected in anyone with loss of sensation and skin findings. 2. Multibacillary therapy remains the mainstay of treatment of leprosy. 3. The emergence of drug resistance poses a threat to leprosy control programs. P3.02 Combination cryotherapy and intralesional amphotericin B for chromoblastomycosis: a case report and review of the literature ery(11). Intralesional antifungal administration may enhance drug delivery, and cryotherapy provides tissue necrosis and enhanced penetration. Our case suggests this combination is a potential alternative, especially if barriers or contraindications exist to systemic agents. Learning Objective: To present a case of Chromoblastomycosis, review treatment challenges, and introduce a potential therapeutic alternative. Takeaway Message: Cryotherapy combined with intralesional amphotericin is a potential alternative for the treatment of Chromoblastomycosis in patients who are not candidates for systemic therapies. Cathryn Sibbald; Afsaneh Alavi; R Gary Sibbald; Jay S. Keystone P3.03 University of Toronto,Toronto, ON Chronic larva currens following tourist travel to the Gambia more than 20 years ago Background: Chromoblastomycosis is a deep fungal infection resulting from penetration of fungi into the skin, usually after trauma. It is more common in tropical and subtropical countries with isolated organisms including Fonsecaea pedrosoi, Phialophora. verrucosa, Cladosporium carrioni, and Rhinocladiella aquaspersa. Therapy is challenging, requiring long-term systemic treatment(1). For resistant cases, systemic antifungals have been combined with cryotherapy (2-5). Despite reports of intralesional amphotericin monotherapy (6-10), there is limited evidence on combination therapy of cryotherapy with intralesional antifungals. Kristy Bailey1 Alexis Danylo2 Andrea Boggild1 1. University of Toronto,Toronto, ON; 2. University of Laval, Laval, QC Background: We present a case of chronic larvae currens following tourist travel more than 20 years ago Conclusion: This case highlights several important features of larvae currens and strongyloidiasis including the long incubation period, the cutaneous findings, and the possibility of unmasking an autoimmune disease with increased strongyloides burden. Strongyloidiasis is a life-long infection unless treated. A high index of suspicion is needed to prevent chronic symptoms being worked up by expensive tests and referrals and to prevent fatal dissemination. Case: A 32 yr old female presented with a 6-year history of verrucous lesions on her knee and lower leg following an injury she sustained in St Lucia. After 6 months of systemic itraconazole at 200mg daily, there was no improvement. A biopsy confirmed Fonsecaea pedrosoi, sensitive to itraconazole. Despite an increase in the dose of itraconazole to 400mg daily for 5 months followed by 4 months of combination with terbinafine, the lesions progressed. Given cost constraints of alternative systemic therapies, treatment with weekly cryotherapy and biweekly intralesional amphotericin was trialed, with good rapid clinical response. By 10 weeks, the lesions had significantly improved, and by 6 months, only residual post inflammatory hyper and hypopigmentation associated with discrete small plaques of resolving fungal infection remained (images available). Learning Objective: Several important features of larvae currens and strongyloidiasis are discussed as it relates to the case including the long incubation period, the cutaneous findings, and the possibility of unmasking an autoimmune disease with increased strongyloides burden. Takeaway Message: A high index of suspicion is needed to prevent chronic symptoms being worked up by expensive tests and referrals and to prevent fatal dissemination. Discussion and Conclusion: Both itraconazole and terbinafine are considered first line agents for Fonsacaea Pedrosi, their primary differences being mechanistic (itraconazole is fungistatic whereas terbinafine is fungicidal). Failure of response to systemic treatment in this case despite in vitro sensitivity to itraconzole may have been related to the fibrotic nature of our patient’s lesions that led to limited drug delivA34 CDA Abstracts P3.04 A novel method for confirming the diagnosis of cutaneous deep fungal and atypical mycobacterial infections Mohammad Pannu; Shane Silver; Rochelle Van De Velde; Tarek Afifi University of Manitoba,Winnipeg, MB Confirming the diagnosis of cutaneous deep fungal and atypical mycobacterial infections can be problematic. A positive culture is the diagnostic gold standard. Unfortunately, false negative culture results are common and present a roadblock to initiating appropriate treatment.1 Although a diagnosis may be clinically suspected, treatment durations are lengthy and drug resistance and toxicities are a concern with inappropriate use. Therefore, initiating treatment without diagnostic confirmation is not recommended. We present two patients that demonstrate a novel method for enhancing the diagnostic yield of tissue culture in cutaneous deep fungal and atypical mycobacterial infections. The first patient, a 48-year-old male, presented with a nonhealing ulcer on the right lateral ankle. A diagnosis of blastomycosis was suspected clinically. Histology showed a yeast-like organism suggestive of blastomycosis. Multiple cultures failed to grow blastomycosis. The patient was evaluated by infectious disease, who felt infection had been adequately ruled out. The patient was seen by a colleague, who treated him with clobetasol cream and intralesional steroids. The patient returned to clinic for reassessment. Post steroids, a positive culture was obtained and the patient responded to antimicrobial therapy. The second patient, a 63-year-old male, presented with a 1-year history of a vegetative plaque on his left hand. Two biopsies from the referring doctor revealed suppurated granulomatous inflammation, suspicious for infection. Stains for organisms were negative. Two subsequent biopsies for tissue culture were negative. Given the serendipitous experience with the first patient, 10 days of clobetasol cream was applied to the lesion under occlusion. M.marinum was then successfully cultured. Appropriated antimicrobial therapy was curative. Although both diagnoses mentioned were strongly suspected clinically, repeated cultures were negative. Topical clobetasol application, presumably allowing increased organism load due to local immune suppression, increased the sensitivity of culture. Both patients were then treated successfully. Learning Objective: After reading the presented cases, the reader should better appreciate the difficulty in confirming the diagnosis of cutaneous deep fungal and atypical mycobacterial infections. It should be understood that a diagnosis should be confirmed prior to treatment initiation. Finally, local immune suppression, obtained by application of clobetasol under occlusion, may be a useful method of converting a false negative culture into a true positive culture. Takeaway Message: When a cutaneous deep fungal or atypical mycobacterial infection is strongly suspected, negative culture results cannot be considered definitive. The application of a potent topical steroid may increase the likelihood of obtaining a positive culture, thus allowing for appropriate diagnosis and treatment. P3.05 Dermatologic conditions in the returning Canadian traveller: surveillance report from CanTravNet surveillance data, 2009- 2012 Michael S. Stevens1 Jennifer Geduld2 Michael Libman3 Brian Ward3 Anne McCarthy8 Jean Vincelette10 Wayne Ghesquiere11 Jan Hajek7 Susan Kuhn9 Kevin C. Kain6, 4 Andrea K. Boggild4, 5 1. University of Toronto Dermatology Residency Program,Toronto, ON; 2.Travel and Migration Health Division, Infectious Disease Prevention and Control Branch, Public Health Agency of Canada, Ottawa, ON; 3. Division of Infectious Diseases, Department of Microbiology, and JD Maclean Centre for Tropical Diseases, McGill University Health Centre, Montreal, QC; 4.Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University Health Network and the University of Toronto,Toronto, ON; 5. Public Health Ontario Laboratories, Public Health Ontario,Toronto, ON; 6. SAR laboratories, Sandra Rotman Centre for Global Health,Toronto, ON; 7. Division of Infectious Diseases, Department of Medicine, University of British Columbia,Vancouver, BC; 8.Tropical Medicine and International Health Clinic, Division of Infectious Diseases, Ottawa Hospital and the University of Ottawa, Ottawa, ON; 9. Section of Pediatric Infectious Diseases, Departments of Pediatrics and Medicine, Alberta Children’s Hospital and the University of Calgary, Calgary, AB; 10. Hôpital Saint-Luc du Centre hospitalier de l’Université de Montréal (CHUM), Montreal, QC; 11. Infectious Diseases,Vancouver Island Health Authority, Department of Medicine, University of British Columbia,Victoria, BC Introduction: Canadians are increasingly travelling to tropical and developing countries. Travel acquired dermatological conditions have been reported to be among the leading causes of medical problems in travellers. However, a multi-centre analysis of the spectrum of dermatologic conditions acquired by a broad range of Canadian travellers has been lacking. The purpose of this paper was two fold: (1) to provide a comprehensive, Canada specific surveillance summary of travel related dermatologic conditions in a cohort of returned Canadian travellers and immigrants, and (2) to provide a summary of the appropriate confirmatory diagnostic testing for the most common tropical dermatological diseases. Methods and Results: Data on Canadian travellers returning with a primary dermatologic diagnosis presenting to A35 CDA Abstracts a CanTravNet Surveillance Network site between September of 2009 and September of 2012 were extracted and analyzed. During the study period, 6639 patients presented to CanTravNet sites across Canada; Just over 16% or 1076 patients, were diagnosed with an ascertainable travel related primary dermatological diagnosis. The majority of individuals seen during this surveillance period were travelling for the purpose of tourism (N=754, 70.1%). Arthropod bites (N=162, 21.5%), rash (N=141, 18.7%), cutaneous larva migrans (N=98, 12.2%), and skin and soft tissue infection (N=92, 12.2%) were the most common dermatologic diagnoses issued to returning Canadian tourists. The top dermatologic diagnoses varied based on the reason for travel. In immigrants, the most frequent dermatologic diagnoses were leprosy (N=15, 24%), rash (N=13, 20.6%), pruritis of unknown origin (N=7, 11.1%) and cutaneous leishmaniasis (N=6, 9.5%). Conclusions: This analysis of surveillance data has detailed the spectrum of travel related dermatological conditions presenting to CanTravNet sites across Canada and provides an epidemiological framework for Canadian physicians encountering these patients. In addition, we have summarized the confirmatory diagnostic testing for the most common tropical dermatological diseases in returning Canadian travellers. Learning Objective: At the end of this activity the participant will be more aware of the spectrum of primary dermatological conditions seen in the returning Canadian traveller and will be more familiar with the appropriate confirmatory diagnostic testing. Takeaway Message: It is important to be familiar with the most common primary dermatological conditions in returning Canadian travellers and how to effectively diagnose these dermatoses, in order to prevent misdiagnosis or a delay in the diagnosis of these patients. the form of heat. Fungicidal effects are experienced at temperatures above 55°C with a pulsed release of photons for more than 10 minutes. The 300 microsecond 1064nm pulsed Nd:YAG Laser offers a promising way to target onychomycosis. Methods: We examined the results of a series of 6 patients with onychomycoisis treated with the 300 microsecond 1064nm pulsed Nd:YAG laser. Most of these patients were previously treated with various topical and oral anti-fungal agents over a prolonged period of time with minimal improvement. Results: Upon follow-up, there were partial to complete clearing of the nail plates. Patients experienced minimal adverse effects and tissue necrosis did not occur in any of the treatments. In the market, there are many lasers that have been granted FDA approval for the treatment of onychomycosis. These lasers include: PinPointe™ FootLaser™ (PinPointe USA, Inc.), Cutera GenesisPlus™ (Cutera, Inc.), Q-Clear™ (Light Age, Inc.), CoolTouch VARIA™ (CoolTouch, Inc.), and JOULE ClearSense™ (Sciton, Inc.). However, a comparison of the relative efficacy of these aforementioned lasers and the duration of treatment still remains to be investigated. Conclusion: The 300 microsecond 1064nm pulsed Nd:YAG laser can be a helpful modality in the treatment of onychomycosis given the treatment options are limited and may be an additional option in the treatment for onychomychosis especially when patient cannot tolerate or respond to oral antifungals due to underlying medical conditions. Learning Objective: To educate the benefits of using the 300 microsecond 1064nm pulsed Nd:YAG laser treatments for onychomycosis. Takeaway Message: The 300 microsecond 1064nm pulsed Nd:YAG laser can be an effective treatment modality of resistant onychomycosis. P3.06 A case series of successful treatment of onychomycosis using a 1064nm pulsed Nd:YAG Laser Joseph Doumit1 Jeewanjit Gill2 Alexandra Zhang1 1. Cleveland Clinic, Cleveland, OH, USA; 2. University of Ottawa, Ottawa, ON Background: Onychomycosis can be quite resistant to oral and topical treatments. Lasers offer another route of treatment and use the principle of photothermolysis to eradicate the causative organisms. This technology exploits the differences in laser energy absorption and thermal conductivity between the fungal infection and surrounding tissue. When the photons are absorbed by mycelia, they release energy in P3.07 Secondary syphilis Andrew A. Simone Private Practice,Toronto, ON Patients initials: G.B. Age: 45 Gender: Male Body region: Perineal Skin History: 45 year old male “BUMPS OF SKIN” in PERINEUM, not itchy or painful A36 CDA Abstracts • patient “surfed the net”, closest thing that he could find was “PRURITIC PAPULES OF PREGNANCY”, but he commented “I am not pregnant!” • girlfriend ‘LULU’ suggested to “use TEA TREE OIL” • girlfriend ‘SUGAR’ suggested “ACCUPUNCTURE” o although her mother said “REFLEXOLOGY” is the answer and added “Don’t go to a dermatologist – they don’t know nothing” • girlfriend ‘HONEY’ told him “Your best bet is a NATUROPATH” and “try NOXZEMA” • his neighbor ‘BORIS’ thought it could be “POISON IVY that is not itchy”, he told the patient “I got me a good SALVE from Europe. (HEIL-U WUNDJALBE) I use it for everything.” • Medical student in our office said “PORPHYRIA CUTANEA TARDA INVERSUS” (upside down Porphyria) o the patient denied sun exposure in this area • Infectious Disease Residents said “STAPH AUREUS PYODERMA” Physical Examination • 20 round or oval mushroom like papules and plaques • lesion NON TENDER but MALODOROUS • SKIN BIOPSY: inflammatory infiltrate – lymphocytes and PLASMA CELLS • Blood for HIV – negative • Blood for SYPHILIS – POSITIVE – EARLY SYHILIS o SYPHILIS RPR Quantitation Reactive 1:32 Dx: CONDYLOMA LATA of SECONDARY SYPHILIS Learning Objective: How to identify syphilis in later stages. Takeaway Message: 1. Many patients do not remember a primary chancre – “no pain” 2. Secondary syphilis- 50% Condylomata lata, 50% maculopapular eruption 3. Pustular syphilis HIV+ patients 4. Cases of congenital syphilis were presented at the pediatric update in 2007 by Perla Langsang MD 5. Since 1998 a 10 fold increase in syphilis 6. 90% of 508 cases in Toronto in 2009 affected men. 60% were HIV+ 7. 2012- 3 cases of NEUROSYPHILIS (CMAJ, April 2, 2013). This means that 10 and 20 syphilis’ were not diagnosed. 8. Syphilis is the great IMPOSTER. Do blood tests for syphilis & HIV. 9. If individuals engage in “risky” exposures, suggest blood test. 10.Patient was presented who had diffuse eruption of Necrotic papules and nodules. DX. Syphilis (JAMA Dermatology Dec. 2013) 11.Dr. William Osler “If you see a tattoo do a blood test for syphilis” 12.World Wide epidemic of syphilis. Eg. Syphilis was eliminated in China, now it is increasing. 13.Increase in sexually transmitted infections (STIs) in older people – the “BLUE PILL” (Rivers, Jason Jan/Feb 2014) Rx: BENZATHINE PENICILLIN G 2.4 million U IM x 2 P3.08 Course: • Next two days very sick, lack of appetite, weak could not go to work (Jarisch–Herxheimer reaction) • 7 days post Rx, pt. commented “I feel good and all my spots are going away” A case of primary cutaneous blastomycosis on the nasal tip Jane Wu; Trevor Champagne; Renita Ahluwalia Division of Dermatology, Department of Medicine, University of Toronto,Toronto, ON Background: Blastomycosis is a fungal infection endemic to North America, caused by the dimorphic fungus Blastomyces dermatitidis. The disease is usually contracted by inhalation of the organism, which is most commonly found in soil, leading to pulmonary infection and secondary cutaneous dissemination. Primary cutaneous blastomycosis from direct inoculation of the skin is an uncommon presentation. In Ontario, the disease has been primarily described to affect northern regions, with isolated case reports in the southern areas. Clinically, blastomycosis presents as papulopustules and well-demarcated A37 CDA Abstracts verrucous or granulomatous plaques on the skin, often with ulceration. The patient had noted a 10-pound weight loss over the past 6 months. The remainder of the review of symptoms was non-contributory. Previous treatments for the lesions included topical steroids and a course of oral antibiotics, neither providing benefit. The patient’s past medical history included diabetes and gastro-esophageal reflux disease. Her medications were metformin and omeprazole. On exam, there were numerous pink and yellow-brown papules and nodules on the patient’s cheeks, ears, and eyebrows. Many papules were confluent and coalesced into plaques, giving the patient a Leoninefacies appearance. Objective: We report a case of a healthy man from Lake Simcoe, Ontario, presenting with primary cutaneous blastomycosis involving the nasal tip. Methods: This 76-year-old man presented with a six-month history of verrucous papules and pustules on the nose, a thirty-pound weight loss, and progressive shortness of breath on exertion. The skin lesions initially started as a small pustule, which then became crusted and was associated with intermittent bleeding. For several months prior to his visit, he was treated with topical and oral antibiotics as phymatous rosacea with no improvement. A biopsy done showed a deep fungal infection suspicious for blastomycosis, which was later confirmed by serology. The patient was seen by the Infectious Diseases service and additional investigations showed no evidence of pulmonary or systemic involvement. He was started on itraconazole with excellent response and rapid resolution of both the cutaneous and systemic manifestations. Investigations: Skin biopsy showed a non-langerhans cell histiocytosis, undetermined type. Bloodwork showed a microcytic anemia, elevated ESR, elevated triglycerides, normal liver and renal function. Chest x-ray was unremarkable. Favoured diagnosis: Non-langerhan’s histiocytosis: Eruptive xanthogranulomas vs. progressive nodular histiocytosis. Discussion: Histiocytoses are a diverse group of proliferative disorders with a common CD34-positive progenitor cell in the bone marrow. They can be grouped into langerhans and non langerhans cell varieties based on the type of histiocyte causing the disease. These disorders are rare but important to recognize as they can involve multiple organs and can be associated with underlying hematologic malignancy. Conclusion: This case provides evidence that blastomycosis may be endemic to Southern Ontario and that clinicians should have a high index of suspicion for this infection when presented with non-resolving granulomatous or verrucous lesions. Prompt treatment with a systemic antifungal agent, such as itraconazole, is important in the management of blastomycosis. Learning Objective: Learning Objective: To present a case of primary cutaneous blastomycosis in Southern Ontario and to review the clinical features of blastomycosis as well as the treatment options. Takeaway Message: Clinicians should have a high index of suspicion when presented with non-resolving granulomatous or verrucous lesions and consider blastomycosis in the differential diagnosis. A thorough workup and prompt treatment with a systemic antifungal agent is important in the management of blastomycosis. 1. To describe an unusual case of non-langerhans cell histiocytosis. 2. To review approach to histiocytoses as well as their associated systemic features. 3. To review the appropriate work-up and management for a patient in whom a diagnosis of non langerhans cell histiocytosis is being considered. Takeaway Message: Histiocytoses are rare skin conditions that dermatologists should be aware of given their association with underlying malignancy and systemic disease. P3.09 An unusual case of non-langerhans cell histiocytosis Anna C. Chaplin;Yvette Miller-Monthrope University of Toronto Division of Dermatology, Department of Medicine,Toronto, ON A 53-year-old woman presented to our dermatology clinic with a 6-month history of eruptive pink and yellow-brown papules and nodules that initially involved the face, but progressed to involve the cheeks, ears, and eyebrows as well. The lesions were slightly pruritic, but otherwise asymptomatic. P4.01 Drug-induced AGEP: a case series and review of patch-testing guidelines Ashley C. O’Toole; Melanie Pratt; Jennifer Beecker; Julie Lacroix University of Ottawa, Ottawa, ON PGY2 Dermatology Resident Background: Acute generalized exanthematous pustulosis (AGEP) is a significant adverse cutaneous reaction most often induced by drugs and also by acute infections. A38 CDA Abstracts Clinically, this eruption was most consistent with a chemotherapy-induced lupus-like reaction. Objective: We present a case series of AGEP caused by two commonly used medications, topical Benzocaine and oral Hydroxyzine, in two patients who went on to have positive patch test results to their respective drug. Methods: We completed a review of the literature for similar cases using PubMed and Medline, as well as a review of the current Consensus Guidelines in Contact Dermatitis. Results: There are no previously reported cases of AGEP secondary to Benzocaine use. AGEP caused by Hydroxyzine is also extremely rare – having been reported in the literature on only two other occasions. Conclusion: The relationship between each drug, Hydroxyzine and Benzocaine, and the development of AGEP is established. The guidelines for patch testing in AGEP is defined. Learning Objective: We wish to review the pathophysiology of Acute Generalized Exanthematous Pustulosis (AGEP) and discuss the role of patch testing in drug eruptions. Takeaway Message: The relationship between each drug, Hydroxyzine and Benzocaine, and the development of AGEP is established. The guidelines for patch testing in AGEP is defined. P4.02 Gemcitabine-induced subacute cutaneous lupus erythematosus-like eruption responding to insulin therapy in a patient with pancreatic cancer Lauren Lam; Duane Barber; Susan Poelman University of Calgary, Calgary, AB A 73 year old woman underwent pancreaticoduodenectomy for Stage IIB pancreatic adenocarcinoma. Gemcitabine was initiated due to regional lymph node metastasis. No other new medications were initiated. Five months later, she developed an erythematous, pruritic patch on her left upper chest and nailfold erythema. Within the next 4 months, similar patches developed on her scalp, back, mons pubis, right forearm, and bilaterally on the hands and anterior tibial surfaces. Gemcitabine was discontinued one month later. Histopathology was consistent with sub-acute cutaneous lupus erythematosus (SCLE), although a non-specific drug eruption could not be ruled out. The pathogenesis of chemotherapy-induced SCLE is unknown. Other reports suggest antigens are targeted towards nucleosomes released during chemotherapy-induced apoptosis. Trunk, limb, scalp and pubic lesions resolved 7 months after initial presentation with topical corticosteroid therapy. Eight months after the initial eruption, she started insulin due to pancreatic insufficiency secondary to pancreaticoduodenectomy. Within days, the chest lesion resolved. However, hand and nailfold lesions persisted. Autoimmune serology revealed negative ANA, anti-Ro, La, Sm, histone and Scl-70 antibodies. A39 CDA Abstracts Table 1. Characteristics of Reported Cases vs. This Case Reported Cases* This Case Doxorubin with cyclophosphamide, capecitabine, docetaxel, fluorouracil, paclitaxel, tamoxifen, gemcitabine Gemcitabine Eruption Morphology Erythematous, scaly, nonscarring, often annular plaques on the neck, upper trunk, back, arms, and dorsal hands Erythematous, pruritic patch on her left upper chest, scalp, back, mons pubis, right forearm, and bilaterally on the hands and anterior tibial surfaces Duration of Eruption Days to 6 months 7-8 months Offending Agent(s) P4.03 Shiitake mushroom-induced flagellate dermatitis Jill Greenspoon1 Tom Szakacs2 Symptom Resolution 2 weeks to 6 months after withdrawing offending agent 7-8 months, however hand and nailfold lesions still persist Therapy Inducing Resolution Spontaneous, Topical Corticosteroid Topical Corticosteroid, Insulin Autoimmune Serology 90% of cases Anti-Ro positive Negative ANA, anti-Ro, La, Sm, histone and Scl-70 antibodies Hypothesized Pathogenesis Inflammatory infiltrate Insulin may protect against gemcitabine-induced apoptosis in human keratinocytes 1. Division of Dermatology, University of Toronto,Toronto, ON; 2. Infectious Diseases, Brant Community Healthcare System, Brantford, ON Background: Few case reports have discussed a relationship between a flagellate dermatitic rash and the ingestion of raw or cooked shiitake mushrooms. It is most commonly reported in patients from eastern Asia; however there have been recent reports in both Europe and North America. The pathogenesis is largely unknown; however it is speculated to be a toxinmediated phenomenon as opposed to an allergic reaction. Shiitake mushroom dermatitis is often treated symptomatically, as its course is benign and the rash typically resolves on its own within a few weeks. *Wiznia LE, Subtil A, Choi JN. Subacute Cutaneous Lupus Eyrthematosus Induced by Chemotherapy. JAMA Dermatol. 2013;149(9):1071-5. Learning Objective: This case demonstrates the necessity for dermatologists to have an index of suspicion for SCLE in chemotherapy patients with eruptions, even with negative autoimmune serology. Takeaway Message: • Numerous cases of chemotherapy-induced Subacute Cutaneous Lupus Erythematosus have been reported to respond either spontaneously or with topical steroid therapy. • This patient’s time course, morphology, distribution and histology resemble other reported cases. However, this case was unique in that it responded to insulin therapy, and autoimmune serology was negative. • This case suggests that insulin may protect against gemcitabine-induced apoptosis in human keratinocytes and may be an area worth further investigation. In experimental models, insulin upregulates anti-apoptosis pathways. Methods and Results: A 44 year old previously healthy male chef presented with a 7-day history of an intensely pruritic non-resolving rash on his trunk. He noted a history of eating a rehydrated shiitake mushroom the evening prior to eruption of the rash. On examination, he had well-demarcated erythematous linear grouped papules in a flagellated pattern most severely on his back, as well as affecting his abdomen, forearms and upper thighs. He denied any systemic symptoms. No biopsies were obtained, as a clinical diagnosis was clear. The patient was treated with prednisone 50mg for a total of five days. Follow up after completion of prednisone and avoidance of shiitake mushrooms showed significant improvement in redness and amount of pruritus. No new lesions had appeared. Conclusions: We present a typical presentation of flagellate dermatitis secondary to shiitake mushroom ingestion. Learning Objective: To become familiar with a rare toxininduced benign skin reaction Takeaway Message: 1. Shiitake dermatitis is a rare toxidermic reaction with a unique, recognizable clinical appearance 2. This case describes the typical eruption and clinical course of the reaction. 3. Although the association between shiitake mushrooms and cutaneous eruptions is very uncommon, dermatologists should be aware of this relationship. A40 CDA Abstracts P4.04 Cutaneous adverse events during vemurafenib therapy P4.05 Shivani F. Chandrakumar1 Jensen Yeung2, 3, 4 Pustular psoriasis complicated with acute generalized exanthematous pustulosis simulating toxic epidermal necrolysis 1. Queen’s University, Kingston, ON; 2. University of Toronto,Toronto, ON; 3. Sunnybrook Hospital,Toronto, ON; 4.Women’s College Hospital,Toronto, ON Mariam Abbas; Danielle Desjardins; Karen Holfeld; June Zimmer Background: Vemurafenib, an oral agent that selectively targets the BRAF V600E mutation, has recently emerged as the mainstay of treatment in patients with BRAF-positive stage IV melanoma. However, a spectrum of cutaneous adverse events has been associated with this agent. The objective of this study was to review clinical data regarding the frequency and severity of the common dermatologic side effects associated with vemurafenib. University of Alberta, Department of Dermatology and Cutaneous Sciences, Edmonton, AB Methods: The adverse event data from phase I, II, and III randomized controlled trials of vemurafenib were reviewed and summarized; case series and non-controlled studies evaluating the safety of vemurafenib therapy were used to further characterize these events. Conclusion: A spectrum of cutaneous adverse events which range from non-malignant findings such as rash, alopecia, and pruritus to malignant side effects, namely squamous cell carcinoma (SCC), were observed in patients on vemurafenib therapy. SCC is the most commonly reported Grade 3 adverse event in clinical trials; however, SCCs and keratoacanthomas associated with vemurafenib therapy are easily treated by simple excision of the lesion without discontinuation of vemurafenib. Benign vemurafenib-induced side effects generally tend not to be severe or life-threatening, with most patients managed by dose interruptions, dose reductions, or topical therapies. Thus, awareness of potential adverse events coupled with routine dermatological assessment and timely management will allow for optimal therapeutic benefit in patients receiving vemurafenib therapy. Learning Objective: A review of dermatologic side effects induced by vemurafenib therapy for malignant melanoma. Takeaway Message: A large proportion of patients in clinical trials experienced a high rate of cutaneous adverse events while on vemurafenib therapy. However, these side effects generally were not severe or life-threatening and were managed with relative ease. Introduction: Pustular psoriasis of the digits (acrodermatitis continua of Hallopeau) may be localized to one or more digits for an extended period of time. Characteristically this presents with tender, diffusely eroded, and fissured pustular plaques on one or more digits. Transition to other forms of psoriasis and to generalized pustular psoriasis has been reported. These patients have an increased risk of acute generalized exanthematous pustulosis (AGEP) compared to the general population. Pustular psoriasis is often considered therapy resistant. Methods/Results: We report the case of a 54-year-old Caucasian woman who presented with a pustular psoriasis flare complicated by AGEP. Treatment course included hospital admission, cyclosporine, acitretin, and discontinuation of cephalexin. Her psoriasis is currently being managed with ustekinumab successfully. Conclusion: The precipitating factor in the course of treatment is thought to be cephalexin. When treating patients with pustular psoriasis the occurrence of drug-induced complications should be carefully examined. Our case suggests that avoidance of β-lactam antibiotics in these patients is warranted unless absolutely indicated. Learning Objective: 1) Avoidance of β-lactam antibiotics in a pustular psoriasis flare is recommended to avoid drug induced complications 2) Management of pustular psoriasis remains complex, with the utility of certain biologics to be determined. Takeaway Message: 1) Our case suggests that avoidance of β-lactam antibiotics in patients with pustular psoriasis is warranted unless absolutely indicated. A41 CDA Abstracts P4.06 Toxic epidermal necrolysis (TEN) in recessive dystrophic epidermolysis bullosa status post hematopoetic stem cell transplant Dusan Sajic1 Christina Boull2 Jakub Tolar2 Sara Hylwa2 Kristen Hook2 Ingrid Polcari2 John Wagner2 1. University of Toronto,Toronto, ON; 2. University of Minnesota, Minneapolis, MN, USA Herein we present the first reported case of TEN in a patient with recessive dystrophic epidermolysis bullosa (RDEB). Prior to developing TEN, the 3 year old male in question was treated with a hematopoetic stem cell transplant (HSCT). On day 16 days post-transplant, the patient was hospitalized due to fever in the setting of immunosuppression with cyclosporine and mycophenolate mofetil.Vancomycin and ceftazidime were empirically started, with transition to single-agent cefepime after 24 hours. Past exposure to all medications was documented. On hospital day (HD) 3 he developed a pink papular rash that became vesiculobullous with progressive skin sloughing distinct from his EB lesions. Work-up failed to reveal an infectious source. Initial exam by dermatology on HD 11 showed erythema covering 98% of his BSA with denuded skin [Fig.1]. No milia or bullae were present and Nikolsky sign was negative. Photophobia, hemorrhagic sloughing of the oral mucosa, and urethral erosions were noted. TEN was confirmed by a biopsy showing full thickness epidermal necrosis with sparse inflammation [Fig.2]. SCORTEN scores, calculated retrospectively, were 1 on day one and 3 on day three of his skin eruption. He had no other extra-cutaneous findings suggestive of graft-versus-host disease. Extensive chart review and time course of his skin eruption suggested vancomycin as the inciting agent. Literature review of the 5 previously reported cases of vancomycin-induced TEN supports this time course. In all cases the patient was immunosuppressed, had previously received vancomycin, and developed TEN following re-exposure within 3-72 hours. Vancomycin was discontinued and the patient was started on IVIG. Three days later the patient developed diffuse firm flesh-colored, folliculocentric papules, which on biopsy were consistent with re-epithelialization. On HD 69, with approximately 50% BSA involved with bullae/erosisons (his baseline RDEB level) he was transferred to a facility in his home city. While GVHD cannot be fully excluded, severe mucosal involvement is atypical in GVHD. Further, our patient had no hepatic abnormalities and minimal diarrhea. Perhaps most importantly, our patient improved without increasing GVHDtargeting immuno-suppression. Learning Objective: Wide spread vesiculobullous rash of the skin and mucosal membranes in the context of HSC transplant has a wide clinical differential diagnosis including TEN, Graft versus host disease, and Erythema Multiforme among others. Additionally, given our patients exposure to vancomycin, TEN like linear IgA bullous disease has been described in patients receiving vancomycin. Detailed clinico-histopathologic assessment as well are required for establishing the correct diagnosis and directing appropriate treatment. Takeaway Message: This article describes the first known case report of TEN in a patient with EBH. Clinical experience from our institution has shown lower than expected levels of severe drug reactions and GVHD among the RDEB population (14,unpublished data), suggesting that these patients may have altered immune reactivity. Whether this is simply a reflection of a low likelihood for intersection of two rare events, or a true clinical observation remains currently unknown and warrants further study. P4.07 The treatment of Toxic Epidermal Necrolysis (TEN) in North America Roni P. Dodiuk-Gad1, 3, 2 Robert Cartotto4, 2 Marc Jeschke4, 2 Joel Fish5, 2 Neil H. Shear1, 6, 2 1. Division of Dermatology, Sunnybrook Health Sciences Centre,Toronto, ON; 2. University of Toronto,Toronto, ON; 3. Department of Dermatology, Ha’Emek Medical Center, Afula, Israel; 4. Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre,Toronto, ON; 5. Burn Program at The Hospital for Sick Children, Toronto, ON; 6. Division of Clinical Pharmacology and Toxicology, Department of Medicine, Sunnybrook Health Sciences Centre,Toronto, ON Introduction: There is no consensus regarding the optimal management of patients with toxic epidermal necrolysis (TEN). The most recent treatment protocol recommended by the American Burn Association was issued in 2008. Since then new data has accumulated on the lack of survival benefits with intravenous immunoglobulin (IVIg), and on the effectiveness of cyclosporine, anti-TNF agents and pulse corticosteroids. Purpose: To evaluate the different management regimens for patients with TEN in burn centres and dermatology departments in North America, and to assess the implementation of the published recommendations and studies. Methods: Directors of burn centres and dermatology departments in North America were requested by letter to complete a questionnaire on their protocol for the management of patients with TEN. Results: Thirty-seven centres completed the survey (25% response rate), and 54% of them reported using treatment guidelines, mostly those of their own centre. IVIg was the A42 CDA Abstracts most common systemic treatment for TEN, reported by 81% of centres. Only 24% reported using systemic corticosteroids and 11% cyclosporine and anti-TNF agents (etanercept and infliximab). Sixty-four percent of the centres reported having experience with amniotic membrane transplantation. The majority of the centres’ directors (70%) thought that there is a need to formulate international treatment guidelines for TEN. Conclusions: The failure of physicians to acknowledge the reported lack of survival benefits with IVIg, and the benefits of cyclosporine, ant-TNF and pulse corticosteroids in the treatment of TEN, point to the crucial need to formulate upto-date treatment guidelines for patients with TEN in North America, a need confirmed by the majority of centres’ directors. Learning Objective: To present the management of Toxic Epidermal Necrolysis (TEN) in North America. Takeaway Message: There is an imperative need to update the management guidelines for patients with Toxic Epidermal Necrolysis (TEN) in North America. P4.08 stage breast cancer. The patient had a fluctuating rash with early cycles of her FEC-D chemotherapy, which significantly worsened after her first cycle of docetaxel. Her rash progressed to involve her scalp, cheeks, ears, back, neck, as well as membranes of the nose and vagina, resulting in epistaxis and vaginal bleeding. Due to the severity of her presentation, an urgent dermatology consultation was obtained, with a working diagnosis of Stevens – Johnson syndrome. The diagnosis was further refined upon pathology, which was consistent with subacute cutaneous lupus erythematosus, and high titres of anti-SSA/Ro and anti-SSB/La antibodies were identified. Following chemotherapy discontinuation, the rash fully resolved after a two-month period, with supportive measures including topical betamethasone cream. This case serves to highlight the symptom severity and clinical course of docetaxel-induced SCLE, and emphasizes the importance of recognizing this uncommon chemotherapy-associated cutaneous reaction. Learning Objective: This case highlights the symptom severity and clinical course of docetaxel-induced SCLE, and emphasizes the importance of recognizing this uncommon but potentially severe chemotherapy-associated cutaneous reaction. Takeaway Message: Drug-induced subacute cutaneous lupus erythematosus associated with docetaxel chemotherapy 1) Drug-induced subacute cutaneous lupus erythematosus (SCLE) associated with docetaxel chemotherapy is an uncommon but potentially severe disease state. 2) The identification and discontinuation of the offending agent is essential in the management of drug-induced cutaneous reactions. Noelle Y. Wong2 Laurie M. Parsons1 Martin J. Trotter3 Roger Y. Tsang4 1. Department of Dermatology- University of Calgary, Calgary, AB; 2. MD Candidate 2015 - Undergraduate Medical Education - University of Calgary, Calgary, AB; 3. Department of Pathology & Oncology - University of Calgary, Calgary, AB; 4. Department of Oncology, Division of Medical Oncology University of Calgary, Calgary, AB P4.09 Subacute cutaneous lupus erythematosus (SCLE) is a type of cutaneous lupus erythematosus most commonly characterized by photodistributed, non-scarring, papulosquamous or polycyclic annular plaques. SCLE is often associated with high titers of anti-SSA/Ro antibodies in the serum, and roughly 20% of newly diagnosed cases of SCLE are due to a drug or another exacerbating agent. Development of drug-induced SCLE has been linked to a number of common pharmacological agents including thiazide diuretics, calcium channel blockers, angiotensin converting enzyme inhibitors, and taxane chemotherapy. Taxanes, such as docetaxel and paclitaxel, are anti-microtubule chemotherapeutic agents which are widely used in many solid tumor malignancies including non-small cell lung cancer and breast cancer. In this case report, we describe a severe case of docetaxel-induced SCLE in a 60 year old female with Sjogren’s syndrome receiving adjuvant FEC-D chemotherapy for early Stevens-Johnson syndrome and toxic epidermal necrolysis: an analysis of triggers Monica Miliszewski; Mark Kirchhof; Sheena Sikora; Anthony Papp; Jan Dutz University of British Columbia,Vancouver, BC Introduction: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) represent a spectrum of rare, acute and severe mucocutaneous adverse drug reactions characterized by extensive epidermal detachment. The mortality rates have been reported to be between 1-5% for SJS and 25-35% for patients with TEN. Early recognition and prompt withdrawal of the causative agent leads to improved patient survival rates. The aim of this study was to identify the medications most often implicated in triggering SJS and TEN as well as to determine the timeline of identification and removal of these triggers. A43 CDA Abstracts Methods/Results: A retrospective chart review was conducted on 64 patients admitted to Vancouver General Hospital with a diagnosis of SJS or TEN from 2000 to 2011. In 75% of cases, a trigger was identified. Allopurinol was the single most common offending agent, implicated in 20% of cases. Anticonvulsants and antibiotics made up the majority of remaining triggers. Most often, the offending agent was removed at time of hospital admission or at time of diagnosis and not at the onset of symptoms. Conclusion: Increasing physician awareness of the early signs and symptoms of SJS and TEN, the triggers that cause it, and what investigations can be done to prevent it, are key to improving patient care and outcomes in cases of SJS and TEN. Learning Objective: To be able to identify the most common medications implicated in triggering Stevens-Johnson syndrome and toxic epidermal necrolysis P4.10 Jeff Donovan University of Toronto,Toronto, ON Drugs can affect the hair growth cycle by disrupting growing anagen hairs or catapulting hairs prematruely into telogen phase. The result is anagen effluvium or telogen effluvium. Other drugs cause acceleration of androgenetic alopecia and others have the potential to trigger scarring alopecia and possibly alopecia areata. Examples are provided from the University of Toronto Hair Clinic. Retinoids, lithium and interferon are examples of well recognized contributors of drug-induced telogen effluvium. Chemotherapeutic drugs may cause anagen efflvuium, especially antimicrotubule agents (docitaxel, paclitaxel) and topoisomerase inhibitors (doxorubicin). It is increasingly being recognized that a proportion of patients fail to completely regrow hair after chemotherapy, and this is referred to as ‘permanent chemotherapy induced alopecia’. Common culiprit drugs for permanent hair loss include docitaxel, busulfan, cyclophosphamide and cisplatin. We are seeing increasing hair loss in men receiving testosterone therapy for low testosterone. Many of these men experience acceleration of hair loss. An acceleration of androgenetic EGFR inhibitors may rarely cause scarring and non scarring hair loss, and TNF inhibitors may cause a variety of hair loss effects, including precipiation of alopecia areata, lichen planopilaris and folliculitis decalvans. Treatment for drug induced hair loss may involve consideration of stopping the drug. For cancer treatments, this is not possible and focus on prevention is more relevant. Scalp cooling has had an interesting history and is currently undergoing rigorous FDA studies in the USA. Health Canada has approved one scalp cooling system as a medical device and some hospitals are now using these caps. Learning Objective: Takeaway Message: Increasing physician awareness of the early signs and symptoms of SJS and TEN, the triggers that cause it, and what investigations can be done to prevent it, are key to improving patient care and outcomes in cases of SJS and TEN. Drug induced hair loss: new additions, new concepts & new treatments alopecia may also occur in a proportion of women using androgenetic oral contraceptives, particularly those with the progestin component levonorgestrel. 1. To review the common causes of drug-induced hair loss. 2. To review drugs that are implicated in permanent chemotherapy induced alopecia 3. To highlight targetted molecular therapies, including EGFR inhbitors and TNF inhibitors, that are associated with hair loss Takeaway Message: 1. Drugs may cause hair loss through multiple mechanisms 2. Some chemotherapy drugs are associated with a risk for permanent hair loss 3. Scalp cooling as a means to prevent chemotherapy induced alopecia is finding increasing acceptance in cancer programs around the world P5.01 Psoriatic nail changes are associated with clinical outcomes in psoriatic arthritis Matthew Sandre5, 1 Sherry Rohekar4, 2 Lyn Guenther3, 2 1. McMaster University, Hamilton, ON; 2. Schulich School of Medicine and Dentistry, London, ON; 3.The Guenther Dermatology Research Centre, London, ON; 4. St. Joseph’s Health Care London, London, ON; 5. Michael G. DeGroote School of Medicine, Hamilton, ON Introduction: Psoriatic nail changes are common in psoriatic arthritis (PsA). This study aimed to characterize relationships between specific nail changes, psoriasis and joint involvement. Methods/Results: PsA patients meeting CASPAR criteria had joint counts, axial measurements and physician global assessment of disease activity (MDGA) recorded by their rheumatologist. Fingernails were assessed, and hand and A44 CDA Abstracts fingernail photographs taken and reviewed by a dermatologist. 188 patients participated (52.4% male, mean age 53.8 years [SD 12.5], mean psoriasis and PsA duration 20.4 years and 12.5 years respectively). 85.7% ever had skin disease, 89.9% peripheral arthritis and 12.7% axial arthritis. The mean tender joint count was 2.5 (SD 4.8), mean swollen joint count 2.0 (SD 3.7), mean modified Schober’s 4.4 cm (SD 1.5), mean occiputto-wall distance 0.7 cm (SD 2.3), mean chest expansion 4.1 cm (SD 1.5) and mean MDGA 2.3 (SD 2.3). 91.5% had at least one nail change (matrix in 78.7%, nail bed in 73.9%). The most common nail matrix changes were pitting (59.0%), leukonychia (42.0%) and rough onychorrhexis (23.9%). The most common nail bed changes were splinter hemorrhages (55.9%), onycholysis (51.6%) and oil spots (27.7%). Higher swollen joint counts were associated with distal interphalangeal/periungual psoriasis (p=0.001), higher number of splinter hemorrhages (p=0.006) and any nail bed change (p=0.03). Higher tender joint counts were associated with rough onychorrhexis (p<0.001), distal/ periungual psoriasis (p=0.03), red spots in the lunula (p=0.001), nail crumbling (p=0.046), any nail matrix change (p=0.03) and any nail bed change (p=0.03). Those with any nail change had a significantly higher mean modified Schober’s measurement (p=0.01). Mean MDGA was worse in those with any nail matrix (p=0.03) or nail bed change (p=0.002). Conclusions: Distal interphalangeal/periungual psoriasis, splinter hemorrhages, rough onychorrhexis and red spots in the lunula were associated with higher joint counts, and nail matrix and nail bed changes with higher disease activity. dermatologic diseases of the nail unit and tumors. Severe cases may affect the quality of life including physical, social dilemmas and emotional health. Multiple reports have been published of successful treatment of onychomycosis with laser, however none exist to date that describe the treatment of non-infectious onychodystrophy with laser modalities. Methods: We report two case reports where the first patient is a 54-year-old woman who presented with painful noninfectious onychodystrophy of the bilateral thumbs of at least 5-year duration with repeated negative fungal cultures and clippings, and a 73-year-old woman who presented with persistent painful pincer-nail deformity of the bilateral thumbs after treated onychomycosis of at least 2-year duration. A 1064 nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser was used for the dystrophic thumbnails in both patients. The laser treatment was targeted at the nail plate, the entire cuticle and nail folds, in order to target the nail matrix. Laser settings included a spot size of 5 mm, fluence of 16 Joules/ cm2, and pulse duration of 300 microseconds at a rate of 7 Hz. Between 250 and 450 pulses were administered in total to both nails at each visit. The patients underwent six to nine treatments, at 4 to 6 week intervals. Results: A dramatic improvement was noticed in the appearance of the nails of the bilateral thumbs, in terms of shape and texture. The patients’ quality of life also improved since the discomfort and pain around the nails significantly decreased. Conclusion: Using the 1064 nm Nd:YAG laser is a viable, noninvasive and novel option for the treatment of non-infectious onychodystrophy. Treatment targeted at the nail plate itself as well as the nail matrix may lead to significant improvements in nail appearance and patients’ quality of life. Learning Objective: This study sought to examine the relationship between psoriatic nail change subtypes with signs and symptoms of PsA. Takeaway Message: Nail changes in PsA may be more common than has been previously noted. Psoriatic nail change subtypes once thought to be rare, such as rough onychorrhexis, may more frequently occur with PsA. Specific subtypes of nail changes may be a predictor of PsA disease activity. Learning Objective: To educate the benefits of using a 300 microsecond 1064 nm Nd:YAG laser for the treatment of onychodystrophy P5.02 Takeaway Message: The 300 microsecond 1064 nm Nd:YAG laser is an effective and novel modality in the treatment of onychodystrophy. Successful management of onychodystrophy using a 300 microsecond 1064 nm Nd:YAG laser Joseph Doumit2, 1 Omar Ibrahim2 Alexandra Zhang2 1. University of Ottawa, Ottawa, ON; 2. Cleveland Clinic, Cleveland, OH, USA Completed dermatology residency in 2013. Background: Onychodystrophy is the dystrophic changes in the nails occurring as a result of many diseases such as fungal and nonfungal infections, various noninfectious inflammatory A45 CDA Abstracts P6.01 Diffuse normolipemic plane xanthomas associated with rectal adenocarcinoma: report of a case Learning Objective: Gain an appreciation of diffuse normolipemic plane xanthomas as a rare condition which may be associated with serious underlying systemic disease. Takeaway Message: 1) DNPX is characterized clinically by yellow macules and papules on the face, neck and upper trunk. 2) DNPX most commonly occurs in individuals with multiple myeloma or other causes of monoclonal gammopathy. 3) In rare cases, other neoplasms including rectal adenocarcinoma may be associated with DNPX. Ariel Burns1 Noreen Walsh1 John Hickey3 Robert Miller2 1. Dalhousie University, Halifax, NS; 2. Dermatology Associates, Halifax, NS; 3. Primacy Medical Clinic, Antigonish, NS A 70 year old man presented with a 5-6 year history of an asymptomatic eruption on the face and upper trunk. Past medical history was significant for treated rectal carcinoma with resected liver metastases, portal hypertension, systemic hypertension and prostatic hypertrophy. Medications included furosemide, nadolol, spironolactone and zopiclone. On examination diffuse yellow papules and plaques were seen on the face with prominent periorbital involvement, and on the shoulders and upper chest. No flexural or acral involvement was noted. A biopsy was performed which demonstrated perivascular and interstitial foamy histiocytes in the upper dermis. The patient was diagnosed with diffuse normolipemic plane xanthomas. Investigations for underlying hematologic dyscrasias were negative. No treatment was initiated. P6.02 Subcutaneous panniculitis-like lymphoma Alice Dahl; Mylène S.Veilleux; Marie-Marthe Thibeault Université Laval, Québec, QC Initially described in 1962, the entity termed ‘diffuse normolipemic plane xanthomas’ (DNPX) is rare, presenting with yellow macules, papules and plaques. Histopathology demonstrates foamy macrophages in the upper dermis sometimes accompanied by Touton giant cells and perivascular lymphocytes. Plane xanthomas, commonly in flexures or on acral sites, can occur with familial or cholestasis-related hyperlipidemia. In normolipemic individuals, lesions on the upper trunk, flexures and periorbital area are often associated with multiple myeloma or other plasma cell dyscrasias with a monoclonal gammopathy. Rare associations include leukemia, Castleman’s disease, Sezary syndrome and photosensitivity. To our knowledge, a link with rectal adenocarcinoma has been reported only once previously. In some individuals, no underlying disease is identified, necessitating close follow-up as skin changes can precede the diagnosis of malignancy. With an underlying monoclonal gammopathy, the pathogenesis may involve antibody-low-density lipoprotein complex deposition in skin and subsequent phagocytosis; the pathogenesis is unclear with other associations. Limited disease may be treated with excision, resurfacing lasers and dermabrasion; treatment of diffuse disease is primarily aimed at the underlying condition. We present our case to raise awareness of this rare condition, which may have serious systemic associations. A 71 year old woman, with a pertinent medical history of non classified arthritis on Plaquenil, presented with numerous nonulcerated subcutaneous erythematous and painful nodules. The nodules were first localized on the shins on a background of lipodermatosclerosis. Initially : Laboratory : • • • • Quantiferon (tuberculosis test) and cultures : negative Antinuclear antibody (ANA) : 1/160 Remaining auto-immune profile : normal Non specific histology of a mixed septal-lobular panniculitis (lower legs) With this context, lipodermatosclerosis was the main diagnosis, with lupus panniculitis as a differential diagnosis Partial improvement was obtained with bandage compression and topical mid-potency corticosteroid Two years later : The nodules had gradually progressed to the thighs and forearms Laboratory : • Lymphopenia • ANA 1/360 • Biopsy (forearm) :Clear diagnosis of lymphoma A few phenotypic and genotypic features oriented towards a primary cutaneous gamma/delta T-cell lymphoma (PCGD-TCL) with subcutaneous involvement, but the global portrait tipped the diagnosis toward SPTCL- αβ Bone marrow biopsy : normal A46 CDA Abstracts A rapid clinical and paraclinical improvement was obtained with prednisone 50 mg per day, responding as expected for a SPTCL- αβ lymphoma Methotrexate has recently been introduced Learning Objective: SPTCL are associated to autoimmune diseases in 20% of cases, lupus being the most frequent association There can be overlapping features between SPTCL and lupus panniculitis Cytopenias can occur in SPTCL, but should alert us of a possible underlying hemophagocytic syndrome, which is present in ~ 15% of SPTCL The histological profile of SPTCL might have mixed features of both SPTCL- αβ and PCGD-TCL. In those cases, a closer follow-up is suggested Learning Objective: Takeaway Message: There should be no hesitation in repeating biopsies in a patient previously diagnosed with lupus panniculitis, because a SPTCL might be associated P6.03 An aesthetic procedure that reveals internal illness • Recognizing a special manifestation of sarcoidosis. • Increasing our sensitivity to investigate benign appearing lesions that are out of the ordinary Takeaway Message: It is always best to investigate unexplained dermatologic phenomenon to help in the best way we can our patients. Steve Mathieu1 Solange Beauregard1 Stéphanie Turmel2 1. Université Laval, Québec, QC; 2. Hôpital Hôtel-Dieu de Québec, CHU, Québec, QC A young woman underwent axillary hair electrolysis performed by an esthecian. Following that procedure, she developed brown papules that suggested a Koebner phenomenon. In order to clarify their nature, a punch biopsy was performed which revealed naked granulomas, highly suggestive of sarcoidosis. An investigation was performed and revealed pulmonary sarcoidosis. P6.04 A new variant of white fibrous papulosis of the neck in the context of limited systemic sclerosis Mohammad A. Almohideb1 Thusanth Thuraisingam 1 Barbara Miedzybrodzki1 A. Kevin Watters2 Khue Nguyen1 1. McGill University- Dermatology, Montreal, QC; 2. McGill UniversityDepartment of Pathology, Montreal, QC White fibrous papulosis of the neck (WFPN) is a rare condition initially described by Shimizu et al. in 1985. Although the pathogenesis still remains unknown, some authors believe Pseudoxanthoma elasticum–like papillary dermal elastolysis (PXE-PDE) and WFPN form a continuum of the same disease process having comparable clinical and histopathological presentations. Herein, we present a 57 year old female with a recent diagnosis of limited scleroderma and a two year history of monomorphous, discrete skin colored to yellowish 2-4 mm papules on both sides of her neck. Histopathologically there was an increase of collagen and normal elastic fibres. WFPN is characterised by increased collagen with reduced elastic tissue. To our knowledge, this is the first case to describe WFPN with normal elastic fibres and in association with Limited Systemic Sclerosis. A47 CDA Abstracts Learning Objective: Learn about a new variant of a rare condition known as white fibrous papulosis of the neck and its possible association with autoimmune connective tissue diseases. Takeaway Message: White fibrous papulosis of the neck can have different histological variants and can be associated with autoimmune connective tissue diseases. P6.05 Iatrogenic kaposi’s sarcoma treated with doxorubicin in a patient with granulomatosis with polyangiitis: a case report Anjali Saxena; Raqiya Al-Rajaibi; Osama A. Roshdy McGill University, Montréal, QC Introduction: Iatrogenic Kaposi’s sarcoma (KS) is a vascular neoplasm that develops secondary to immunosuppressive therapy. Although the majority of these cases are reported in transplant recipients, there are increasing reports of iatrogenic KS in patients undergoing treatment for autoimmune disorders. Granulomatosis with polyangiitis (GPA) formerly called Wegner’s granulomatosis is an autoimmune ANCA associated vasculitis, classically treated with immunosupressants. Learning Objective: Management of iatrogenic kaposi’s sarcoma secondary to treatment of granulomatosis with polyangiitis (GPA). Takeaway Message: Iatrogenic KS, secondary to GPA treatment, that has not resolved despite removal of the immunosuppressive agents, can potentially be treated with IV doxorubicin. Methods and Results: We present the case of a 66-yearold HIV negative female who developed iatrogenic KS secondary to immunosuppressive treatment for her GPA. Her treatment consisted of induction with monthly IV cyclophosphamide pulse therapy, one dose of IV methylprednisolone and daily oral prednisone. Five months after treatment initiation, the patient developed violaceous maculopapular lesions on her lower limbs and arms. Biopsy of the leg nodules confirmed KS. Despite reduction and removal of immunosupressants, which has been the reported treatment of choice in GPA patients with iatrogenic KS, her KS rapidly progressed (Figure 1). She was consequently started on IV doxorubicin, which resulted in significant improvement of her lesions (Figure 2). Conclusion: To our knowledge, this is the first case report of iatrogenic KS secondary to GPA treatment that has not resolved despite removal of the immunosuppressive agents and has instead been successfully treated with IV doxorubicin. Physicians should consider doxorubicin as a possible treatment option in patients with persistent iatrogenic KS. P6.06 Acquired zinc deficiency secondary to total parenteral nutrition presenting as a pustular eruption Lindsay Eminger; Stacy Cohen; Tammie Ferringer Geisinger Medical Center, Danville, PA, USA Introduction: Zinc deficiency may be inherited, known as acrodermatitis enteropathica, or acquired. Herein, we report a case of acquired zinc deficiency secondary to total parenteral nutrition (TPN) presenting as a pustular eruption. Case presentation: A 55 year old male presented with a 3 week eruption of papules and pustules on his face, neck and chest. His history was significant for a recent motor vehicle accident followed by a complicated medical course, including numerous abdominal surgeries. He had developed an enterocutaneous fistula, and was dependent on TPN. Initially, culture revealed Staphylococcus aureus. Topical and oral antibiotics were prescribed but his eruption progressed. His first biopsy revealed suppurative folliculitis with Pityrosporum yeast, hence antifungal medications were added. Despite treatment, his eruption evolved into crusted plaques on the face and scalp and well-demarcated, scaly, pink plaques in the axillae and donor graft sites. Dusky erythema was noted in the palmar A48 CDA Abstracts creases. Subsequent biopsies revealed epidermal necrosis and focal acantholysis, suggestive of nutritional deficiency. Zinc level was found to be 7 mcg/dL (normal range 60-130 mcg/dL). He improved rapidly following additional zinc supplementation. Discussion/Conclusions: Zinc deficiency typically presents with dermatitis, diarrhea and alopecia. Dermatitis is characterized by a psoriasiform, eczematous or vesiculobullous eruption predominantly affecting periorificial areas, the scalp, and acral sites. While our patient eventually developed dermatitis, his initial presentation was a pustular eruption. Conclusion: To our knowledge, these two cases are the first reported in medical literature to illustrate the efficacy of solifenacin succinate (Vesicare®) in the treatment of primary focal hyperhydrosis. As it is safe, effective and well tolerated, we suggest that it should be considered as an alternative treatment option. Learning Objective: We are the first to describe two cases of primary focal hyperhidrosis successfully treated with solifenacin succinate (Vesicare®). At the time of diagnosis, our patient was receiving 1.3 mg/d of zinc in his TPN. It is estimated that patients require 3 mg/d in patients without gastrointestinal losses, and up to 12 mg/d in patients with diarrhea or fistula losses. Since late 2012, there has been a limited supply of injectable zinc in the United States resulting in several cases of zinc deficiency in infants receiving TPN. Our case further emphasizes the need for available parenteral trace elements to prevent nutritional deficiency. Learning Objective: Following this presentation, attendees will be able to describe the clinical and histologic manifestations of zinc deficiency. Nutritional deficiencies commonly associated with total parenteral nutrition will also be discussed. Takeaway Message: Solifenacin succinate (Vesicare®) has been demonstrated for the first time, in two isolated cases, as a safe, effective and well tolerated therapeutical option for the treatment of primary focal hyperhidrosis. P6.08 Henoch–Schönlein purpura post-renal transplantation in a patient with long standing IgA nephropathy: case report and literature review Bahman Sotoodian University of Alberta, Edmonton, AB Takeaway Message: In patients receiving total parental nutrition, a pustular eruption should raise suspicion for zinc deficiency. PGY1 Dermatology Resident, University of Alberta P6.07 Solifenacin Succinate (Vesicare®) in the treatment of primary focal hyperhidrosis Hélène Veillette; Anne-Marie Hunt; Pierre-Olivier Grenier Henoch–Schönlein purpura (HSP) is a type of small vessel vasculitis that presents as palpable purpura (100%), arthritis (75%), abdominal pain (65%) and nephritis (40-50%). HSP is mainly a pediatric disease with 90% of patients <10 years of age. The presence of IgA in renal mesangium and cutaneous venules in patients with HSP demonstrates the significance of IgA in pathogenesis of this disease. This paper is the second case to describe new diagnosis of HSP vasculitis in a patient with renal biopsy proven IgA nephropathy while being treated with immunosuppressive medications post renal transplant. Hôpital du St-Sacrement, CHU(Q), Université Laval, Québec, QC Introduction: Primary focal hyperhidrosis is a common disorder presenting as excessive symmetrical sweating in the palms, soles, axilla or the craniofacial region. It frequently presents a significant therapeutical challenge. As many patients suffer substantially from the social, occupational and physical repercussions of this disease, an efficient treatment is in high demand amongst this population. Method/Results: We report 2 cases of longstanding primary focal hyperhidrosis. The first, presenting in the cranio-facial region of a 67 year old woman and the second affecting the palms and soles of a 21 year old woman. The two were treated with solifenacin succinate (Vesicare®). Both patients observed a considerable decrease of sweating episodes and reported a high level of satisfaction. The treatment was generally well tolerated and benefits were maintained. Cutaneous vasculitis post-renal transplantations are mostly due to secondary infections or drug reactions. The presence of cutaneous vasculitis subsequent to renal transplant could also indicate the recurrence of underlying renal disease. Our patient never experienced cutaneous vasculitis or any clinical symptoms of HSP prior to his renal transplant. Interestingly, the HSP vasculitis manifested while the patient was receiving Tacrolimus, Mycophenolate mofetil and tapering dose of prednisone. The choice of immunosuppressive regimens post renal transplant does not alter the recurrence likelihood of IgA or HSP nephropathy. The question remains as to why our patient developed HSP while receiving immunosuppressive treatments. A49 CDA Abstracts In conclusion, this is the second case of cutaneous HSP after renal transplant due to isolated IgA nephropathy. Literature review indicated presence of similar manifestation in a patient who developed HSP vasculitis post renal transplant when his prednisone regimen was stopped. Similarly, this patient was receiving MMF & Tacrolimus immunosuppressive treatments. In both cases, the patients recovered shortly after re-establishing their previous prednisone regimens. Learning Objective: The presence of cutaneous vasculitis subsequent to renal transplant could indicate the recurrence of underlying renal disease Takeaway Message: 1. Patients with IgA nephropathy can present with HSP vasculitis post-renal transplantation 2. Patients can develop cutaneous vasculitis while being treated with immunosuppressive medications 3. The reduction in dosage of prednisone seems to predispose the occurrence of more systemic vasculitis in patients with prior history of isolated IgA nephropathy. P6.09 were normal. Review of symptoms showed only mild fatigue. History is notable for missionary work abroad and remote pulmonary tuberculosis. The patient had no history of hepatitis, but had an episode of abdominal pain, nausea and vomiting in 2007. Upon returning to clinic, the patient was started on zinc supplementation and referred to the hepatology service for consideration of systemic treatment of her viral infection. Conclusion: We report here a case of NAE in an 88-yearold nun, leading to the discovery of previously undiagnosed hepatitis C. We would like to highlight the unusual morphology of this case with its nummular eczema-like appearance. Given that NAE often has non-specific psoriasiform histopathological findings without necrolytic keratinocytes, a high index of clinical suspicion must be maintained. Learning Objective: Recognition of the rare entity Necrolytic Acral Erythema based on clinical-pathological correlation are key, given that both the morphology and the histopathology of this condition can be non-specific. Takeaway Message: A high index of suspicion must be maintained in order to diagnose Necrolytic Acral Erythema, a condition that is pathognomonic for Hepatitis C and which may lead to early diagnoses of this infection. Necrolytic acral erythema presenting with nummular lesions Carolyn Jack Robin Billick 1 1, 2 P7.01 Khue H. Nguyen 1 Orofacial granulomatosis: case report 1. McGill University, Montreal, QC; 2. Jewish General Hospital, Montreal , QC Michelle Pratt; Patricia Wadden; Robert Fowler; Wayne Gulliver Introduction: Necrolytic acral erythema (NAE) is a rare but increasingly recognized manifestation of hepatitis C infection and is considered pathognomonic for this condition. It is characterized by well-circumscribed, dusky, erythematous-toviolaceous plaques with adherent scale and a predominantly acral distribution. Memorial University of Newfoundland, St. John’s , NL Methods/Results: An 88-year-old nun in good health presented with a seven-month history of multiple well-demarcated, dusky erythematous nummular plaques with adherent, micaceous scales distributed over her legs, dorsal feet and, to a lesser degree, arms. High potency topical corticosteroids and antifungals were ineffective. A previous biopsy in the community was non-specific, with both psoriasiform changes and spongiosis. Seen in our clinic, we entertained the diagnoses of nummular eczema, atypical psoriasis or NAE. Repeat biopsy was performed with screening blood work. The patient was found to be positive for hepatitis C, confirmed by PCR; importantly, this was previously undiagnosed. Histopathological findings remained non-specific, demonstrating a psoriasiform and spongiotic lymphocytic dermatitis with overlying parakeratotic scales containing numerous neutrophils. Stains and culture results revealed only normal skin flora, and liver function tests Introduction: Orofacial granulomatosis (OFG) is an uncommon condition that presents as chronic granulomatous inflammation of the lips, face, and oral cavity, in the absence of systemic disease. The most common presentation is non-tender, non-pruritic, oral labial swelling. Additional extra and intraoral manifestations may include facial swelling, lip fissuring, angular cheilitis, perioral erythema, cobblestoning, ulceration, gingivitis, and lingua plicata. Similar to other granulomatous diseases, such as Crohn’s disease and sarcoidosis, OFG most likely has an immunologic etiology. There is debate whether OFG is in fact a separate entity, or merely an initial and/or localized form of Crohn’s disease. OFG is a diagnosis of exclusion and therefore requires a systemic workup. Case Report: The patient, a 37 year old Caucasian male from Newfoundland, presented with a persistent eruption of the lower lip, as well as the mid portion of the upper lip. The mouth appeared normal with no dental or salivary gland lesions. CBC was normal. Serology was negative for ANCAs and ANA, and positive for rheumatoid factor. Mantoux skin testing A50 CDA Abstracts NO CARCINOMA was negative. IgE was normal and patch testing was negative. Biopsy of the lower lip showed non-caseating, granulomatous inflammation characterized by sarcoidal-like organoid granulomas in perivascular distribution, without mucin deposition or interface change. Acid-fast staining, fungal staining, and polarization were negative. Full axial CT was unremarkable, but in particular, negative for pathologic lymph nodes or pulmonary infiltrate.Visualized portions of the GI tract were normal. Endoscopy was performed from the nasopharynx to the glottis and was unremarkable. June 2013: lesion “itchy” -Rx. Kenaog ‘10’ 0.3mL September 2013: lesion “not healing” • Biopsy repeated • DDx: INFLAMINATORY ACNE PAPULE vs DENTAL SINUS October 2013: ABSCESSES OF TEETH UNDER PATIENTS FALSE TEETH. Discussion: Given the clinical and histologic findings, with a negative workup for systemic disease, a diagnosis of OFG was confirmed. Although there is no standardized treatment protocol, corticosteroids are considered the mainstay of therapy, and have been shown to alleviate swelling. In this case, the patient has been managed using topical corticosteroid cream, and occasional intralesional injections. Significant improvement has been noted. There are reports of orofacial symptoms preceding the onset of systemic Crohn’s disease, and therefore the patient continues to be followed closely. • when pressure was applied to the area, allowed pus to exit from skin of chin Dx: DENTAL SINUS 2o TO ABSCESSED TEETH Learning Objective: At the end of this activity the participant should be able to appreciate orofacial granulomatosis as a diagnosis of exclusion, and as part of the differential diagnosis for chronic oral labial swelling. Takeaway Message: Orofacial granulomatosis is an uncommon disease that presents as chronic oral labial swelling, and its diagnosis requires a systemic workup to exclude other causes of granulomatous inflammation, such as Crohn’s disease, sarcoidosis, and tuberculosis. P7.02 Dental sinus Andrew A. Simone Private Practice,Toronto, ON Patients initials: F.K. Age: 88 Gender: Female Body region: Left Chin, Left lower Gingiva History: 88 year old female with a SORE OF THE LEFT CHIN since November 2012. Unresponsive to antibiotic treatment. March 2013: Dermatology consult and Dx: BASAL CELL CARCINOMA • because of “pearly border and ulceration” • Treated with curettage and electrodesiccation. • Biopsy report March 2013: MIXED INFLAMMATORY INFILTRATE DDx: ACNE ACNEIFORM PAPULE vs DENTAL SINUS References 1. Pasternak-Júnior B., et al. Diagnosis and treatment of odontogenic cutaneous sinus tracts of ondodontic origin: three case studies. Int Endod J. 2009 Mar;42(3):271-6 A51 CDA Abstracts Learning Objective: The objective of this study was to review the return to work experience of four nurses with cumulative ICD. 2. Guevara-Gutiérrez E., et al. Odontogenic cutaneous fistulas: clinical and epidemiologic characteristics of 75 cases. Int J Dermatol. 2013 Oct 18. [Epub ahead of print] 3. Wigler R., et al. Oral cutaneous sinus tract, vertical root fracture, and bisphosphonate-related osteonecrosis: a case report. J Endod. 2013 Aug;39(8):1088-90 Many thanks to Dr. Dalal Assaad for DX of this case Takeaway Message: Altering cumulative exposure to an allergen is one administrative control that is an important workplace modification for those with cumulative irritant contact dermatitis. Learning Objective: DENTAL SINUS P8.02 Takeaway Message: Off-label uses of topical vitamin D in dermatology: a systematic review 1. DENTAL SINUS (odontogenic cutaneous sinus tracks) is a difficult clinical diagnosis 2. Presently people with BONE CANCER are being treated with BIOPHOSPHONATES that cause bone resorption. There will be an increased incidence of dental sinuses because of the side effects of these drugs. 3. Sores of the face → think of the diagnosis and check the teeth Heidi Wat; Marlene Dytoc University of Alberta, Edmonton, AB Background: Topical vitamin D analogues are FDA approved for the treatment of psoriasis. However, the range of dermatological disease amenable to topical vitamin D therapy is broad and there is a need for evidence-based guidelines for clinical decision making. P8.01 Cumulative irritant contact dermatitis in nurses Farheen Mussani1 Sandy Skotnicki1 Pilar Gomez2 1. Division of Dermatology, University of Toronto,Toronto, ON; 2. Department of Occupational and Environmental Health, St Michael’s Hospital,Toronto, ON Introduction: Cumulative irritant contact dermatitis (ICD) is the most common clinical type of contact dermatitis. Common irritants in the health care setting include soaps, disinfectants, alcohol based hand sanitizers and glove wearing, in addition to wet work. Objective: The objective of this study was to review the return to work experience of four nurses with cumulative ICD. Methods and Results: A chart review was conducted to examine the return to work experience of four nurses. In addition to ICD, three of the nurses had allergic contact dermatitis. Removal of the allergen alone did not result in a successful return to work. In addition to proper skin care management and monitoring, administrative changes of either alternating shifts or decreasing consecutive shifts, thereby decreasing the cumulative dose of irritation, resulted in successful return to work. Conclusions: Administrative controls altering cumulative exposure are an important workplace modification to accomplish successful return to work. Methods: A search of the MEDLINE, EMBASE and CENTRAL databases was conducted on May 2013. A total of 165 studies that assessed efficacy and safety of topical vitamin D analogues were included. Study characteristics analyzed include: study design, patient characteristics, intervention and comparison arm, response, adverse effects, and follow-up. The primary outcome sought was degree of clinical improvement in skin lesions. Recommendations were established for both the efficacy and inefficacy of topical vitamin D based on the highest quality evidence available (Levels A-D, Strong-Weak). Results: Evidenced-based recommendations was generated for 24 dermatological disorders. A moderate to strong recommendation was made for use in combination with PUVA (A), topical corticosteroids (B), and narrow-band UVB (B) for treatment of vitiligo. In contrast, its role as monotherapy or in combination with sun exposure was limited. A moderate to strong recommendation was also given for its use in plaque type morphea (B), pityriasis alba (A), prurigo nodularis (B) and polymorphous light eruption (A). There is moderate to strong evidence showing that topical vitamin D is ineffective for actinic keratoses, seborrheic keratoses, lichen planus, seborrheic dermatitis, alopecia areata, and hypertrophic scars. Treatment was well tolerated in all patients. Conclusion: Topical vitamin D has an important role in the off-label treatment of dermatological disease, but the therapeutic potential is to be further validated by higher quality studies. In recalcitrant cases, it may be a worthwhile second line option for the reviewed disorders. A52 CDA Abstracts Topical vitamin D plus topical corticosteroid B: Moderate Learning Objective: The objective of this study is to provide evidence-based clinical guidelines for the off-label use of topical vitamin D in dermatological conditions refractory to conventional therapy, and serve to promote higher quality future research. Topical vitamin D plus NB-UVB B: Moderate Topical vitamin D plus PUVA A: Strong Takeaway Message: Topical vitamin D plus sun exposure Ineffective (A: Strong) Topical vitamin D monotherapy Ineffective (B: Moderate) Dermatological Disease Evidence Based Recommendation Vitiligo Disorders of Keratinization Congenital ichthyosis, X-linked ichthyosis, lamellar ichthyosis, epidermolytic ichthyosis B: Moderate Confluent and reticulated papillomatosis D: Weak Disseminated superficial actinic porokeratosis D: Weak Neoplasms and Hamartomas Inflammatory linear verrucous epidermal nevus D: Weak Actinic keratosis No proven efficacy (B: Moderate) Seborrheic keratosis No proven efficacy (B: Moderate) Sclerodermoid Conditions Morphea (plaque type) • There is strong evidence suggesting topical vitamin D analogues can potentiate repigmentation of vitiligo by PUVA phototherapy, and a moderate level of evidence for combination with NB-UVB and topical corticorticosteroids. • There is also moderate to strong evidence for its efficacy in various ichthyoses, morphea, pityriasis alba, prurigo nodularis, and polymorphous light eruption. • Higher quality studies are still needed to further define its therapeutic potential in these disorders. P8.03 Use of facebook as a tool for knowledge dissemination in dermatology Whan B. Kim; Ronald B.Vender Department of Medicine, McMaster University, Hamilton, ON B: Moderate Papulosquamous Conditions Pityriasis alba A: Strong Prurigo nodularis B: Moderate Granular parakeratosis D: Weak Keratosis lichenoides chronicus D: Weak Palmoplantar eczema D: Weak Pityriasis rubra pilaris D: Weak Lichen planus No proven efficacy (B: Moderate) Seborrheic dermatitis Ineffective (A: Strong) Hair Disorders Alopecia areata Ineffective (A: Strong) Chemotherapy-induced alopecia Ineffective (A: Strong) Other Verruca vulgaris C: Fair Polymorphous light eruption A: Strong Trachyonychia C: Fair Lichen amyloidosis C: Fair Oral leukoplakia C: Fair Hypertrophic scars and keloids Ineffective (A: Strong) Background: The need to utilize social media as a tool for knowledge dissemination is fast growing. Out of various available platforms, Facebook remains as the most popular in the world with 1.26 billion users as of October 2013. Hence, it is easy to see the potential in utilizing Facebook as an accessible, interactive, and inexpensive tool for knowledge dissemination in many fields of medicine, including dermatology. Methods: Through a search on Facebook, academic journals, professional societies, and patient-centred groups in dermatology with the highest number of Facebook likes were identified. Then, the Yearly Page Engagement Rate was calculated (total number of likes, comments, shares for all Facebook posts published on the page in 2013/ total number of likes for the page as of Dec 31, 2013). Engagement Rate is a metric used by marketers and recently adopted by Facebook to assess how well a page engages its fans. Results: As of December 31 2013, the Yearly Page Engagement Rate was 4.332, 0.673, and 0.212 for Journal of the American Academy of Dermatology, Journal of the American Medical Association Dermatology, and Journal of Investigative Dermatology, respectively; 2.482, 0.313, and 0.247 for American Academy of Dermatology, Canadian Dermatology Association, and British Association of Dermatologists, respectively; and 1.688, 1.563, and 0.688 for Melanoma Research Foundation, National Psoriasis Foundation, and Skin Cancer Foundation, respectively. A53 CDA Abstracts case was re-submitted. We will examine patient records to see whether indeed the patient was seen by the recommended specialist for their condition. Conclusions: Based on the robust average (i.e. median), patient-centred groups engaged with their fans significantly more than academic journals or professional societies did. Engagement Rate is important because unless the user engages with the Facebook page, the chance that the content of the page shows up on the fan’s Facebook Newsfeed is slim. Furthermore, the Engagement Rate provides a valuable gauge of whether the fans that “liked” the page continue to remain engaged or not. Thus, as important, if not more than number of Facebook likes, is the Engagement Rate. Results: Of 980 consultations, there was a significant female preponderance 606 (61.8%). Age range of patients included 157 (16.2%) 0-20 years, 167 (17.2%) 20-40 years, 305 (31.4%) 40-60 years, 275 (28.3%) 60-80 years, and 66 (6.8%) 80+ years. Of the 21 cases that had technical errors with imaging, only 6 (28.5%) were ever re-sent. 51 cases were recommended for further in-person assessment through the Patch Test Clinic although only 2 (3.9%) patients ever completed patch testing. Learning Objective: The Engagement Rate (# of likes, comments, shares/ total fans) can be used to quantify and objectively evaluate the degree of engagement that dermatologyrelated Facebook pages have with the public. Conclusions: Otn.TeledermSF is a valuable asset, bringing access to specialist dermatological assessment to patients who cannot see a dermatologist in their community. There are some technical and knowledge-based shortfalls in the the system. Primary provider education and technical improvement is necessary to optimize the service and ultimately the care for the patient. Takeaway Message: Facebook pages devoted to disseminating knowledge in dermatology should first, consider the Engagement Rate and second, raise the Engagement Rate by investigating the various factors in play, such as the time of the day and day of the week that the fans are most engaged or the types of contents that trigger the most likes, comments, and shares. P8.04 Teledermatology: a review of the Ottawa experience of otn.TeledermSF Ashley C. O’Toole; Steven Glassman; Loretta Cheung University of Ottawa, Ottawa, ON PGY2 Dermatology Resident Background: The use of communications technology to facilitate the provision of healthcare for persons is an area of increasing interest. In Ontario, Otn.teledermSF® is a provincial government-funded program initiated in 2006 which provides a free service for doctors to securely send photographs of a patient’s skin condition and relevant health information to an Ontario-based dermatologist for consultation. Objectives: To review the demographics and common presentations of the patients being referred to otn.TeledermSF between 2008-2012. We will analyze what percent of cases have technical submission errors associated with the online system and whether or not the case is re-sent. We also intend to study whether consultations suggested for individual patients are being carried out by the referring provider. Methods: We will examine 980 patient consults collected by the one Otn.teledermSF dermatologist between 2008-2012. We will analyze the demographic variables and the dermatological disease classification. We will review the number of cases that had technical errors and whether or not the same Learning Objective: We intend to study the demographics of the initial cohort of patients referred to Otn.TeledermSF. We will also analyze the technical aspects of the system. Thirdly, we will evaluate whether in-person consultations suggested for individual patients are being carried out. Takeaway Message: Otn.TeledermSF is a valuable asset, bringing access to specialist dermatological assessment and advice to patients who cannot see a dermatologist in their community. However, there are certain technical and knowledgebased shortfalls in the proper use of the system as well as the fulfillment of the recommendations by the referring provider that require improvement. P8.05 Familial Dowling-Degos Disease: case report and review of the literature Dominique Fausto de Souza1 Christine Neagoe2 Herbert Srolovitz1 Osama Roshdy1 1. McGill University, Montreal, QC; 2. Sherbrooke University, Sherbrooke, QC Dowling-Degos disease (DDD) is a rare genodermatosis that is inherited in autosomal dominant manner, and demonstrates varying degrees of penetrance. It is characterized by acquired, symmetric, reticular hyperpigmented macules in the large flexural areas. Associated findings include facial pitted scars and hyperkeratotic follicular comedo-like papules[1]. We describe the case of a 66-year-old female that presented with reticulated, hyperpigmented, confluent macules in the axillae, inguinal folds, inner thighs, vulva, as well as the inframammary and intergluteal regions. She was also known for hidradenitis suppurativa (HS) of the axillae, pitted scars on the nose, and A54 CDA Abstracts comedo-like follicular papules on the face and neck. Histopathological findings from the right axilla showed acanthosis with elongation of the rete ridges, basilar hyperpigmentation, and dermal melanosis. On history, her father and grandfather had similar lesions and her 30-year-old son had recently developed a similar eruption on the testicles and inguinal folds. Loss-offunction mutations in keratin 5 gene have been described in DDD[2]. A single defect in epidermal and follicular keratinization may account for the association of DDD with HS and epidermal cysts[3-4]. To our knowledge, only about 65 cases have been reported in the literature. We present a classic case of familial DDD and reviewed the literature of this rare condition, in order for clinicians to consider this entity in the differential diagnosis when appropriate. 1 Batycka-Barana A, et al. Dowling-Degos Disease: Case Report and Review of the Literature. Dermatology 2010;220:254–258. 2 Betz RC, et al. Loss-of-function mutations in the keratin 5 gene lead to Dowling-Degos disease. Am J Hum Genet, 2006. 78(3): p. 510-9. 3 Fenske NA, et al. Dowling- Degos disease, hidradenitis suppurativa, and multiple keratoacanthomas. A disorder that may be caused by a single underlying defect in pilosebaceous epithelial proliferation. J Am Acad Dermatol, 1991. 24(5 Pt 2): p. 888-92. 4 Loo WJ, et al. Hidradenitis suppurativa, Dowling-Degos and multiple epidermal cysts: a new follicular occlusion triad. Clin Exp Dermatol, 2004. 29(6): p. 622-4. Learning Objective: To present a classic case of familial Dowling-Degos disease (DDD) and to review the literature of this rare condition, in order for clinicians to consider this entity in the differential diagnosis when appropriate. Takeaway Message: • Dowling-Degos disease (DDD) is a rare genodermatosis characterized by acquired, symmetric, reticular hyperpigmented macules in the large flexural areas. • It can be associated with hidradenitis suppurativa, facial pitted scars, comedo-like follicular papules, and epidermal cysts. • Loss-of-function mutations in keratin 5 gene have been described in DDD. P8.06 Cyclosporine in the management of poststreptococcal pustulosis: a report on two cases Patrick Fleming; James Shaw University of Toronto,Toronto, ON Introduction: Post-streptococcal pustulosis (a.k.a. pustulosis acuta generalisata) is a rare post-streptococcal disease characterized by sterile pustules predominantly on the acral surfaces. It is often associated with fever, leukocytosis, and elevated acute phase reactants. It may present with arthropathy and/or glomerulonephritis. Case: A mother and daughter presented together five days after a culture positive group A streptococcal pharyngitis with painful, pruritic palmoplantar pustules and leukocytosis. We used a short course of low-dose cyclosporine as an alternative to prednisone to induce rapid remission of this painful eruption. Conclusion: Cyclosporine appeared to have rapid positive results and was well-tolerated by our two patients. This finding offers a potential alternative to systemic corticosteroids in the management of neutrophilic eruptions such as post-streptococcal pustulosis. Learning Objective: 1) Review clinical features and complications of post-streptococcal skin disease 2) Discuss the use of cyclosporine in post-streptococcal pustulosis Takeaway Message: Post-streptococcal pustulosis is characterized by sterile pustules after a group A streptococcal pharyngitis and may be associated with systemic features. Cyclosporine may be an alternative to prednisone to induce rapid resolution of his disease. P8.07 Validating the diagnostic codes for psoriasis and acne Aiza Ejaz1 Viba Malaiyandi1 Raed Alhusayen1, 2 1. University of Toronto,Toronto, ON; 2. Sunnybrook Health Sciences Center, Toronto, ON The administrative databases serve as reservoirs of extremely valuable data and are often used to conduct population-based clinical and epidemiologic studies. However, the accuracy of diagnostic codes to independently identify patients with a specific diagnosis is unknown. There have been no studies A55 CDA Abstracts conducted to validate the codes for common dermatological conditions. The objective of this study was to evaluate the validity of ICD-9-CM codes 696 and 706 for psoriasis and acne, respectively. Methods and Results: Questionnaires were sent out to all orthopedic surgeons involved in the care of all patients who had been referred to the UBC Contact Dermatitis Clinic to rule out a metal sensitivity in the perioperative setting. The questionnaires were designed to assess whether the results of patch testing changed patient management, whether the patients had any postoperative complications and if symptoms improved after adjustments were made in the setting of positive patch test results. The questionnaire response rate was 87% (34/39). Twenty-one out of 34 (62%) returned questionnaires were regarding cases of patch testing in the preoperative setting. In the preoperative setting, 62% of orthopedic surgeons stated that patch testing results influenced their management whereas only 46% of orthopaedic surgeons in the postoperative group stated that patch test results changed their management. A proposal for a prospective controlled trial was subsequently created. The data and controlled trial proposal will be presented at the British Columbia Orthopedic Society 2014 annual general meeting to initiate discussion about beginning a prospective controlled trial on the role of patch testing for metal sensitivity in the perioperative setting. This was a retrospective cohort study that included all patients seen in general dermatology clinics at Sunnybrook Health Sciences Centre between March 1 - May 31, 2013. Billing sheets, collected for each clinic visit during this period were reviewed. The code identified during that visit was compared to the clinical diagnosis documented in the medical chart corresponding to the same clinical encounter. Using this data sensitivity, specificity and positive predictive value (PPV) for the ICD-9-CM 696 (psoriasis) and 706 (acne) were calculated. Our preliminary analysis, based on 3,034 patients, showed that the ICD-9-CM code for acne had a PPV of 83.7% and for psoriasis 90.7%. The sensitivities were 86.6% and 86.1% for acne and psoriasis respectively. Both ICD-9-CM codes were highly specific at 99%. We have demonstrated that in a dermatology setting, ICD9-CM codes 696 and 706 can be used to accurately identify patients with psoriasis and acne, respectively. This information can be applied to identify patients with these diseases from administrative databases for future clinical and epidemiologic studies. Conclusions: This data will be used to conduct a prospective trial in conjunction with orthopedic surgeons to investigate the role of patch testing in the perioperative setting. Learning Objective: 1) To discuss the lack of evidence based guidelines for patch testing in the perioperative setting. 2) To discuss a proposed prospective trial to look at the role of patch testing for metal sensitivity in the perioperative setting. Takeaway Message: A prospective trial examining the role of patch testing for metal sensitivity in the perioperative setting is needed. Evidence based guidelines are needed. Learning Objective: To determine whether ICD-9-CM codes 696 and 706 for psoriasis and acne, respectively, accurately identify patients with these clinical diagnoses. Takeaway Message: The ICD-9-CM codes for Psoriasis (696) and Acne (706), in a dermatology setting, can be used as tools to identify this group of patients from administrative databases to conduct future studies in dermatology. P8.08 A collaborative effort between dermatologists and orthopedic surgeons to develop a controlled trial examining the role of patch testing for metal sensitivity in the perioperative setting Kristin L. Noiles1 Gillian de Gannes1, 2 1. University of British Columbia Dermatology,Vancouver, BC; 2. University of British Columbia Contact Dermatitis Clinic,Vancouver, BC Introduction: The role of patch testing for metal sensitivity in the perioperative setting is unknown. Evidence based guidelines are lacking with the majority of current recommendations based on retrospective studies, case reports, and case series. P8.09 Erythrokeratodermia variabilis: migratory skin lesions resolved with acitretin Ari Juda1 John Kraft2 1. Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON; 2. Lynde Dermatology, Markham, ON Introduction: Erythrokeratodermia variabilis (EKV) is a rare condition characterized by the co-existence of 1) transient migratory circinate erythematous lesions and 2) fixed hyperkeratotic plaques, most commonly in the extremities, trunk and buttocks. It typically presents initially at birth or within the first year of life. EKV is generally inherited in an autosomal dominant fashion and stems from defects in A56 CDA Abstracts specific connexin genes, GJB3 and GJB4, which each encode for a different gap junction protein. EKV is a clinical diagnosis and dermatopathologic features are non-specific, but include orthokeratotic hyperkeratosis, papillomatosis, acanthosis, and vascular dilatation. Mild presentations of EKV often respond well to topical keratolytics and retinoids. Extensive skin involvement is optimally treated with systemic retinoid therapy, with low doses of acitretin, a 2nd generation retinoid, often the drug of choice. Low doses have been found to have success in clearing lesions. Case: A 48 year old female with a longstanding history of EKV presented to clinic with characteristic lesions present on her trunk for over 20 years. She was significantly distressed by the lesions, attempting to hide them from her husband over this period. Examination showed figurate erythematous plaques present on her trunk. Patient was started on a trial of acitretin, 10 mg/day orally for 2 months, at which time the lesions had resolved. At 8 month follow-up she remained clear of all lesions. Discussion: EKV is a rare dermatogenetic disorder. Our case demonstrated successful resolution of lesions on a low dose (10 mg/day) oral trial of acitretin, after 2 months of treatment. Follow-up at 8 months showed no recurrence, while improving the patient’s quality of life. Learning Objective: Demonstrate understanding of proper identification and medical management of EKV. Takeaway Message: EKV is a rare condition that can significantly affect quality of life. Low-dose acitretin therapy can be successful in clearing of lesions. Methods and Results: A 25-question dermatology handbook was created. These questions were based on concepts listed in the medical school curriculum objectives. These handbooks were distributed to third and forth year medical students at the start of their Ottawa dermatology rotation. Residents and staff were made available to meet with students as needed to review the material and a final answer document was distributed. At the end of the rotation, students were asked to complete a survey regarding how and why the booklet was used, what aspects they liked about it, and suggestions for improvement. Results were encouraging: 88% of students used this tool, 62% made use of it one to three times per week and 79% of students that responded stated that they would be interested in doing another elective in dermatology. Conclusions: With limited number of dermatology staff and clinics combined with a large number of medical students, creative methods of teaching dermatology to future physicians are required. Supplemental resources, such as this dermatology handbook, can be used to direct one’s learning while not in clinic. Future prospects include interactive electronic versions of this handbook – with quizzes, tutorials, and procedural videos. Learning Objective: 1. To appreciate the adjuvant teaching tools that can be provided to medical students during a dermatology rotation. 2. How to assess the use and usefulness of a supplemental resource for medical students during a dermatology rotation. Takeaway Message: Creative and interactive methods of teaching dermatology to future physicians are required. P8.10 P8.11 The implementation of a dermatology handbook in medical student education at the University of Ottawa Intravenous immunoglobulin (IVIG) for the treatment of recalcitrant atopic dermatitis Margaret J. Mioduszewski Monica K. Li; Beata Komierowski; P. Régine Mydlarski University of Ottawa, Ottawa, ON Division of Dermatology, University of Calgary, Calgary, AB Introduction: Medical students receive limited exposure to dermatology. The amount of time that is devoted to dermatology teaching during medical school can range from zero to ten hours. Despite this limited amount of teaching, these future physicians are expected to diagnose and manage patients with several kinds of skin manifestations. The intent of this study was to determine if a supplemental dermatology handbook could help enhance medical knowledge in dermatology, direct medical students’ learning, and stimulate interest in the discipline. Background: Atopic dermatitis (AD) is a chronic, relapsing skin disorder affecting between 3.7 and 9.5% of adults. Although most patients can be effectively treated with topical agents, there is a subgroup of patients who require systemic immunosuppression to achieve disease control. Unfortunately, some patients have recalcitrant disease or develop adverse events from systemic therapy. Intravenous immunoglobulin (IVIG) displays various immunomodulatory and anti-inflammatory properties that make it a candidate for the treatment of AD. Though there are reports on the use of IVIG in adult AD, the results are inconsistent. A57 CDA Abstracts Objective: To describe our experience and review the literature on use of IVIG in the treatment of adult AD patients with severe, recalcitrant disease. Methods: A retrospective chart review was performed on 11 adult patients with severe, resistant AD. Patients who were assessed in the Immunodermatology Clinic, University of Calgary between March 2007 and July 2012, received high-dose IVIG infusions (i.e., 2 g/kg/month). Clinical response was determined by: (1) change in SCORAD (SCORing Atopic Dermatitis) skin scores from baseline to cessation of treatment; and (2) serum immunoglobulin E (IgE) levels at baseline and throughout IVIG therapy. Results: Adults with recalcitrant AD received IVIG for a mean of 12.7 months, with initial signs of improvement noted by three months of therapy. IVIG treatment resulted in significant reductions in both SCORAD skin scores and serum IgE levels, thereby allowing systemic immunosuppression to be tapered. Fewer infection-related exacerbations were noted, and no significant adverse events were attributable to the IVIG infusions. Conclusion: In adults with severe, recalcitrant AD, IVIG provides a safe and effective therapeutic option. Larger, randomized controlled trials are required to validate the use of this promising therapy. Learning Objective: To review the safety and efficacy of intravenous immunoglobulin (IVIG) in the treatment of recalcitrant atopic dermatitis in adults. Takeaway Message: Intravenous immunoglobulin is a safe and effective treatment option for patients with severe, recalcitrant atopic dermatitis. Methods, Results: A retrospective review was carried out on patients with POD seen at Vancouver General Hospital Skin Care Centre, University of British Columbia, between June 1, 2003 to June 1, 2013. Charts with an ICD9 diagnostic code of 695.3 (Rosacea or Perioral Dermatitis) as reported to the British Columbia Medical Services Plan were selected, and those with rosacea were excluded. A total of 229 patients, ranging from 9 to 85 years of age, were included. Eighty-three percent of patients were female. The average age at presentation was 43. Fifty-one percent of patients presented with perioral involvement, 10% presented with periocular involvement and 3% presented with perinasal involvement. Thirty-six percent of patients had POD for greater than 12 months at presentation. Prior use of topical corticosteroids was reported in 68% of cases. Systemic minocycline was the most common effective treatment regimen in 66% of patients. Conclusions: The retrospective data is consistent with previous literature on POD. POD affects patients of all ages although the average age of onset appears to be in the fourth decade. It occurs more frequently in female patients, generally involves one area of the face, specifically the perioral area, and is associated with previous systemic steroid or topical corticosteroid use. Treatment with minocycline is one of the most common successful therapies for POD. Learning Objective: To discuss findings from one of the largest cohorts of patients with POD studied with regards to epidemiology, etiology, clinical presentation, and effective treatment options. Takeaway Message: Periorificial dermatitis affects patients of all ages, occurs more frequently in females, generally involves the perioral area and treatment with minocycline is one of the most common effective therapies. P8.12 P8.13 Periorificial dermatitis: a review of 229 cases Open-label pilot study of acitretin for the treatment of severe chronic hand dermatitis Diana Lam1 Kristin Noiles1 Shannon Humphrey1, 2 1. University of British Columbia,Vancouver, BC; 2.Vancouver Coastal Health Research Institute,Vancouver, BC Introduction: Periorificial dermatitis (POD), also known as perioral dermatitis, is a cutaneous inflammatory disorder with an unknown etiology that commonly presents in children, young or middle-aged females. Although its pathogenesis is incompletely understood, it has been associated with the use of both topical corticosteroids and cosmetics. A large chart review was completed of patients with POD with the aim of adding to the current understanding of POD, particularly with regards to potential etiologic factors, unique demographic information and effective treatment regimens. Jerry Tan2 Simon Nigen1 Catherine Maari1 Chantal Bolduc1 Robert Bissonnette1 1. Innovaderm Research Inc., Montreal, QC; 2.Windsor Clinical Research Inc., Windsor, ON Introduction: Chronic hand dermatitis can be a severe and debilitating condition. A proof of concept study suggested that acitretin, a systemic retinoid currently approved for the treatment of psoriasis, could improve mild to moderate chronic hand dermatitis. The objective of this study was to explore the safety and efficacy of acitretin in patients with severe chronic hand dermatitis. A58 CDA Abstracts Methods: Open label treatment was initiated with acitretin 10 mg once daily and progressively increased to 30 mg daily over a period of 4 weeks, as tolerated. Treatment duration was for up to 24 weeks or until the physician global assessment (PGA) was clear or almost clear. Hand dermatitis severity was evaluated using a 5-grade PGA scale and the modified total lesion symptom score (mTLSS). gene. The patient’s mother had similar symptoms, but much milder. She never sought treatment but gets relief with Aveeno lotion. She was found to carry the same KRT5 mutation. Her son tried topical retinoids and soriatane with minimal success. He began using tattoos to camouflage his disease and noticed an improvement in his symptoms on the tattooed skin. He reported fewer papules and less pruritis in the tattooed areas. Results: A total of 9 patients with severe chronic hand dermatitis were enrolled. All patients received acitretin at 20 mg once a day and it was possible to increase the dose to 30 mg once daily for 7 patients. The proportion of patients achieving PGA of clear or almost clear was 33.3% (95% CI: 9-69%) and the proportion who reached a PGA of clear, almost clear or mild was 44% (95% CI: 15-77%). The mTLSS was decreased by 45% (-6.3 ±4.7; p=0.02). Three patients did not complete the study: one withdrew due to lack of efficacy, one because of an increase in facial dermatitis and one withdrew consent. Conclusion: We describe two cases of the papular variant of Dowling-Degos disease in a mother and son. We present these cases to illustrate the varying severity of Dowling-Degos disease in two patients with identical genetic mutations. This suggests that severity is not dictated by the specific keratin mutation. We also present the notion of tattooing as an unconventional coping strategy. Tattoo art has sometimes been used by patients post mastectomy as a way to take creative control over their post-operative bodies. Although we cannot comment on whether tattooing actually minimizes the burden of disease, it is an interesting phenomenon that is gaining popularity among patients with disfiguring diseases. Conclusions: This pilot study suggests that acitretin may be beneficial in severe chronic hand dermatitis. Further studies, including placebo-controlled studies, are needed to better assess the efficacy and safety of acitretin in patients with severe chronic hand dermatitis. Learning Objective: To illustrate two cases of DowlingDegos disease Learning Objective: To explore the safety and efficacy of acitretin in the treatment of severe chronic hand dermatitis. Takeaway Message: There is a spectrum of severity of Dowling-Degos disease, which is not dictated by the specific mutation in the KRT5 gene. Takeaway Message: Acitretin may be beneficial in the treatment of severe chronic hand dermatitis. Dowling-Degos disease remains a therapeutic challenge for dermatologists. P8.14 P8.15 Two cases of Dowling-Degos disease in a mother and son Rachel Vale Lea Velsher A case of epoxy allergic dermatitis negative to standardized series 1. University of Toronto,Toronto, ON; 2. North York General Hospital,Toronto, ON Lin Xing; Melanie D. Pratt Introduction: Dowling-Degos disease is a rare autosomal dominant genodermatosis that is caused by a mutation in the keratin 5 gene (KRT5). Several phenotypic presentations have been described. Patients may present with reticulate hyperpigmention, comedo-like lesions, pitted acneiform scars or follicular papules. The lesions may be pruritic and cause emotional distress. Unfortunately, Dowling-Degos disease remains a therapeutic challenge for dermatologists. The Ottawa Hospital Division of Dermatology and University of Ottawa, Ottawa, ON 1 2 Results/Methods: A 31 year-old male was referred to genetics with a longstanding history of a papular eruption over his chest and back, and prominent axillary involvement. Histopathologic examination revealed filiform down growth of the epidermis and multiple small horn cysts, characteristic Dowling-Degos disease. Genetic testing confirmed the diagnosis and showed a heterozygous p.Gln4Stop mutation in the KRT5 Introduction: Epoxy resins are frequently used chemicals in industrial adhesives, laminates, electrical equipment, sealants, coating and molds. Sensitization can be seen in workers who have contact with the uncured material. This is one of the most common causes of occupational allergic contact dermatitis and carries significant impact on job prospects and quality of life. Patch testing is the “gold standard” for diagnosis and standardized screening series of allergens have been developed for epoxy resins. Methods: A literature search was performed using Medline and PubMed with the terms “epoxy”, “resins”, “allergic contact dermatitis”, “occupational” and “patch test”. Patient record was reviewed. A59 CDA Abstracts Case: We report a case of 51-year-old female industrial electronics assembler who presented with a two year history of pruritic, papulovesicular dermatitis on her fingertips and nails folds with extension to the hypothenar eminence. She has been handling circuit boards at work for at least a year. Patch testing was conducted using The North American Contact Dermatitis Group Standard Screening Series, Epoxy Series, Extensive Acrylates Series, Metal Series and additional allergens in the Plastic and Glue Series. Readings were done at 48 and 96 hours. Patient was negative for all series. Further testing was conducted using patient’s workplace materials diluted to 1% in petrolatum. She was then found to be positive for a number of epoxy acrylates in those. Arrangements were made through Worker’s Compensation to transfer her to a different sector of work and her symptoms resolved within one month. Conclusions: Previous studies have shown that allergic contact dermatitis can be missed if the patient is only patch tested to standardized allergen series. As demonstrated by our case, we strongly urge including additional patch testing of suspected sensitizing chemical at the works place. Learning Objective: To describe a case of epoxy allergic contact dermatitis negative to standardized epoxy series. the University of Calgary were randomized into two groups to receive didactic or group-based education. Dermatology teaching was provided once monthly for three consecutive months, with pre- and post-tests administered for each educational intervention. A final test to evaluate long-term knowledge retention will be administered three months after the last educational intervention. Only test scores of trainees who provided consent to the study were analyzed. Results: Preliminary findings show improvement of scores from pre- to post-test following dermatology education. Near significant difference was found in test scores associated with the first teaching intervention (median pre-test 51% to post-test 55.2%, p-value 0.11, n=13), and a significant increase was found in test scores associated with the second teaching intervention (median pre-test 33.4% to post-test 59.6%, p value 0.03, n=6). No statistical difference in improvement of test scores were observed between didactic teaching and group-based learning methods. Further analysis of demographic factors that may affect the acquisition of knowledge, on test scores for the third teaching intervention, and on knowledge retention will be performed when the data becomes available. Conclusion: Preliminary results of our study support the importance of dermatology education for internal medicine trainees. Further analysis will provide insights that may contribute to the development of effective dermatology curricula for this important group of care providers. Takeaway Message: Apart from the North American Contact Dermatitis Group Standard Screening Series and epoxy series, additional patch testing of suspected sensitizing chemical at the works place is strongly recommended for the diagnosis of epoxy allergic dermatitis. P8.16 Teaching dermatology to internal medicine residents: evaluating the effectiveness of an educational intervention Learning Objective: To provide insights on the impact of a dermatology educational intervention for internal medicine trainees. Takeaway Message: Dermatology education has the potential to directly impact the competence of internal medicine trainees in managing cutaneous problems. Monica K. Li1 Steve Doucette2 Laurie M. Parsons1 P8.17 1. University of Calgary, Calgary, AB; 2. Research Methods Unit, Capital Health, Halifax, NS Background: Internists often encounter dermatologic issues, yet studies have shown that internal medicine trainees perform poorly at diagnosing skin diseases, and have suboptimal education in dermatology. Specifically, there is no published data comparing different educational interventions in dermatology and its impact on long-term knowledge retention in internal medicine residents. Objective: We aim to evaluate the impact of teaching dermatology to internal medicine trainees, and compare different educational methods on long-term knowledge retention. Methods: A prospective, interventional study design was used. Trainees of the Internal Medicine residency program at Wait times for routine, urgent and cosmetic dermatologic care in Ontario Geeta Yadav1 Jack Resneck, Jr.2 Davina Lau1 Hanna Goldberg3 Chaim Bell1 1. University of Toronto,Toronto, ON; 2. University of California, San Francisco, San Francisco, CA, USA; 3. University of Western Ontario, London, ON The field of dermatology is experiencing a physician workforce shortage, especially in more remote parts of Canada where patients are waiting longer for routine dermatology appointments. In Ontario, however, there is little empiric data on this topic. This presentation will give an overview of wait times for patients seeking medical dermatology services and wait times for cosmetic procedures. Some have hypothesized that while A60 CDA Abstracts patients with medical dermatology problems face long waits, those paying cash for cosmetic procedures are seen more quickly, but this has not been examined in any studies. We will present data collected through a survey of dermatology practices to discuss the differences between wait times for medical dermatology (routine and urgent) appointments versus the wait times for cosmetic procedures. We will be comparing wait times by region. Learning Objective: Attendees will learn about the dermatology workforce in Ontario including wait times across the province and the regional variation for accessibility to routine, urgent, and cosmetic dermatologic care. Takeaway Message: This study raises important questions about workforce adequacy in Ontario and current incentives for the care of sick patients compared with those who have cosmetic complaints. P9-03 Pimples in prepuberty: a five-year-old with an unusual cause of facial comedones Learning Objective: 1. Comedones in the pre-pubertal age group are a sign of early virilization and warrant clinical and laboratory investigations for precocious puberty. 2. 11OHD is an uncommon form of congenital adrenal hyperplasia that can present with early virilization. 3. Early diagnosis of 11OHD is important to prevent virilization, hypertension and short stature in adulthood. Takeaway Message: Comedones in pre-puberty are never normal, and should be thoroughly investigated to prevent the development of serious and permanent sequelae. P9.01 Neel Malhotra1 Karine Katchadourian2 Daniel Metzger2 Joseph Lam2 1. University of Alberta, Edmonton, AB; 2. University of British Columbia, Vancouver, BC Zinc deficiency and its management in the pediatric population: A literature review and proposed etiologic classification Michael D. Corbo Introduction: Congenital adrenal hyperplasia (CAH) refers to a family of inherited disorders caused by a partial or severe impairment in adrenal steroidogenesis. Over 90% of CAH cases are caused by a defect in the enzyme 21-hydroxylase and can present with salt wasting, adrenal crisis and virilization. A less common cause of CAH is 11β-hydroxylase deficiency (11OHD). Methods: We report the case of a 5-year-old boy who presented with a one-year history of papules over the cheeks, glabella and ears. His mother noted that he experienced several episodes of body odor that resolved spontaneously. He had no history of salt-craving, axillary or pubic hair, or change in phallus size. Rapid growth was noted in the past six months. His medical history was otherwise unremarkable. Family history revealed that the paternal grandmother’s first child died shortly after birth with the cause of death unknown. Results & Conclusions: Examination revealed multiple keratotic papules on his cheeks, as well as open comedones around the inner and outer ears and nose. The facial papules were initially diagnosed as keratosis pilaris. Facial comedones may be mistaken for other entities, and the differential diagnosis is large; however, without further investigation, a serious underlying diagnosis could be overlooked. Testing revealed a diagnosis of 11OHD. Our patient was treated with hydrocortisone 2.5 mg orally three times per day (8.8 mg/m2/day) with counseling to double the dose in times of mild illness and to triple it for moderate-to-severe illness. He appears to be responding well with the current therapy, but ongoing monitoring is required for central precocious puberty. University of Toronto,Toronto, ON Zinc is a trace element essential to the gastrointestinal, immune, integumentary, reproductive, and central nervous systems. Zinc deficiency is prevalent in many areas of the world and is a diagnostically challenging condition. Cutaneous manifestations typically occur in moderate to severe zinc deficiency and present as alopecia and dermatitis in the perioral, acral, and perineal regions. Zinc deficiency is a potentially fatal disease process. The aim of this review is to focus on the cutaneous manifestations, diagnosis, and treatment of zinc deficiency in children, and to propose an etiologic classification system. Learning Objective: To review the cutaneous manifestations, diagnostic measures, and treatment options for children with zinc deficiency. Takeaway Message: Zinc deficiency can be a diagnostically challenging condition. A proposed etiologic classification system may help facilitate the diagnosis and management of zinc deficiency in children. A61 CDA Abstracts P9.02 Rare localized form of infantile Systemic Hyalinosis in a 45 year old Methods: A retrospective chart review was performed from January 2002 to September 2012. Inclusion criteria were patients under 18 years of age with histopathologic diagnosis of DFSP. Data on demographics, clinical characteristics, treatments and outcomes were collected. Jordana Schachter1 Bryan Arthurs2 1. McGill University Department of Dermatology, Montreal, QC; 2. McGill University Department of Ophthalmology, Montreal, QC Inherited systemic hyalinosis is a rare inherited disorder characterized by a broad clinical spectrum encompassing both infantile systemic hyalinosis and juvenile hyaline fibromatosis. Clinical features involve multiple subcutaneous nodules composed of hyaline, hyperpigmented skin over bony prominences, progressive joint contractures, gingival hyperplasia, fleshy perianal lesions, pink pearly papules on the head and neck, bone lesions and dental abnormalities. In more severe cases there is involvement of the gastrointestinal system leading to protein losing enteropathy. Two localized variants have been described in patients in their 20-30’s with only cutaneous involvement. We present a case of a 45 year old woman, born to consanguineous parents, diagnosed as juvenile hyaline fibromatosis at the age of 6 in Syria with a known mutation in ANTXR2 with localized cutaneous involvement. She has had over 40 surgeries, many with general anesthesia and has had children without issue. We present this case for interest as she is the oldest patient described with inherited systemic hyalinosis and has a localized variant enabling her to have a normal lifespan. Learning Objective: Review the features of this rare syndrome and the spectrum between infantile systemic hyalinosis and juvenile hyaline fibromatosis (systemic involvement versus isolated cutaneous involvement) The Hospital for Sick Children,Toronto, ON Introduction: Dermatofibrosarcoma protuberans (DFSP) is an uncommon low-grade malignant soft tissue tumor. In children, there are acquired and congenital presentations. Due to clinical similarities with other conditions, it may associate with a delayed diagnosis. The objective of this study was to re- Conclusions: Our study documents the clinical characteristics and treatment of DFSP in pediatric patients. A detailed medical history and identification of the natural course of common conditions seen in pediatric patients are important to identify less common lesions and to suspect DFSP. Learning Objective: This study documents the clinical characteristics and treatment of Dermatofibrosarcoma Protuberans in 17 pediatric patients. Takeaway Message: A detailed medical history and identification of the natural course of common conditions seen in pediatric patients are important to identify less common lesions in pediatric dermatology avoiding diagnosis delay. Evaluation of a triage system based on the emergency department referrals using dermatology priority guidelines in a pediatric dermatology clinic in Toronto, Canada Claudia J. Posso-De Los Rios; Miriam Weinstein The Hospital for Sick Children,Toronto, ON P9.04 Claudia J. Posso-De Los Rios; Irene Lara-Corrales; Nhung Ho Results: Information was gathered from a total of 17 patients, 9 (53%) were female. Congenital lesions were reported in 7 patients. The mean delay of diagnosis was 5.7 years; the most common anatomic location was the trunk in 8/17 (47%) cases. Treatment options included wide local surgery, Mohs surgery and imatinib mesylate. P9.05 Takeaway Message: Inherited systemic hyalinosis is a disease on a spectrum, encompassing both infantile systemic hyalinosis and juvenile hyaline fibromatosis. While the disease may be life threatening for some patients, it is clear that some will have a mild form which has only cutaneous involvement, and normal life expectancy. Dermatofibrosarcoma protuberans in pediatric patients: a report of 17 cases view clinical characteristics and treatment of DFSP in pediatric patients. Introduction: Triage is used to categorize patients based on diagnosis and severity to optimize medical attention and patient’s safety. There is lack of information about dermatologic triage systems in pediatric patients. The objective of this study was to evaluate the standardized triage system in a dermatology clinic from a tertiary hospital based on the emergency department referrals. Methods: A retrospective review of clinical charts from a tertiary hospital was performed from January 1, 2010 to March 31, 2010 at the Hospital for Sick Children in Toronto, Canada. Inclusion criteria included patients evaluated at the emergency department with a referral to dermatology clinic. We collected data on the date of the medical evaluations, A62 CDA Abstracts presumptive and final diagnosis. Three evaluations for triage priority levels were defined: actual, ideal and final. The concordance of priority levels was evaluated. ing the need of careful follow-up given the broad spectrum of LCH. Results: Among total 538 referrals to the dermatology clinic during the study period, 67 (12%) were cases referred from the emergency department. The mean waiting time for an appointment was 83 ± 51 days. Inflammatory diseases were the most common type of conditions in 32/63 (51%) evaluated cases. Atopic dermatitis (included in the inflammatory disease category) was the leading cause of referrals. Diagnostic agreement between the emergency room physician and dermatology clinic physician was 75% based on the final diagnosis. The concordance of priority level assignments based on final dermatologic diagnosis varies from 19% to 47.6% for actual or ideal triage, respectively. Conclusions: The triage system in our clinic helps to categorize dermatologic patients based on type and severity of the skin condition in order to prioritize when referred patients will be seen. A highly accurate diagnosis or assessment from the emergency department, would allow the best triage decisions to be made enhancing best care for patients. Our evaluation shows this accuracy could be improved. Learning Objective: This study presents new information about a standardized triage system in a pediatric dermatology clinic based on the emergency department referrals. Takeaway Message: A standardized triage system in a pediatric dermatology clinic may help to categorize dermatologic patients favoring safety and best care for patients. P9.06 Congenital Self-Healing Reticulohistiocytosis: cutaneous clinical spectrum Jérôme Coulombe; Michele Ramien; Afshin Hatami CHU Ste-Justine, Montreal, QC Langerhans cell histiocytosis (LCH) is an uncommon disorder of unknown etiology that may occur at any age. The congenital form is even rarer and have been described as a single or multi-organ disease with or without organ dysfunction. Skin manifestations are frequent and critical in accurate diagnosis and management. However, cutaneous presentations of congenital LCH are variable and can be misleading. Thus, we present two recent cases of congenital self-healing reticulohistiocytosis (formerly Hashimoto-Pritzker disease) seen in our pediatric dermatology clinic in CHU Ste-Justine to highlight and describe it’s polymorphous presentation. We also briefly review appropriate management of those patients emphasiz- Learning Objective: To recognize dermatologic presentation of congenital self-healing reticulohistiocytosis. Takeaway Message: 1. Congenital self-healing reticulohistiocytosis presentation is variable. 2. Ruling out systemic involvement is imperative. 3. Despite the self-healing clinical course long term follow-up is indicated. P9.07 Retrospective review of relapse after systemic cyclosporine in children with atopic dermatitis Cathryn Sibbald1 Nhung Ho1, 2 Elena Pope1, 2 Miriam Weinstein1, 2 1. University of Toronto,Toronto, ON; 2. Hospital for Sick Children,Toronto, ON Background/Objectives: Cyclosporine is a systemic therapy used for control of severe atopic dermatitis (AD) in children. Although traditionally recommended at a dose of 5mg/kg/day for 6 months, longer duration of treatment may be necessary to bring a child with active and severe disease into remission. There is little data on the short and long term effectiveness of longer courses of therapy. Methods: A retrospective chart review of children treated with cyclosporine at a Canadian hospital-affiliated clinic between 2000 and 2013. Results: Fifteen patients were identified with adequate follow-up. Twelve patients (80%) were male, and the mean age at initiation of cyclosporine was 11.20 ± 3.41 yrs. The mean duration of cyclosporine therapy was 10.86 ± 2.70 months (range 7-15), at a starting dose of 2.83 ± 0.59 mg/kg. Twelve patients (80%) responded to cyclosporine. Of these, 5 patients had relapsed (42%) at a follow-up of 22.67 ± 15 months. Duration of therapy was longer in patients who did not relapse (17.71 ± 10.69 versus 10.2 ± 2.70, 0.06). Adverse events led to discontinuation in 3 patients (20%) and included infectionrelated complications in 2 patients and reversible renal toxicity in 1 patient. Conclusions: These results suggest that a longer duration of low dose cyclosporine may help decrease risk of relapse in patients with severe AD who are resistant to topical therapies. Learning Objective: To report on the relapse rate of atopic dermatitis and time to relapse after treatment with A63 CDA Abstracts cyclosporine in a pediatric cohort, determine any predictors of sustained remission, and describe adverse effects Takeaway Message: A longer duration of low dose cyclosporine may help decrease risk of relapse in patients with severe AD who are resistant to topical therapies P9.08 Ataxia-telangiectasia associated with noninfectious granulomas Learning Objective: Non-infectious cutaneous granulomas may be associated with primary immunodeficiencies, such as ataxia-telangiectasia. Takeaway Message: The presence of multiple noninfectious granulomas in a child may be the initial sign of an immune deficiency and should alert the astute clinician to investigate for an underlying primary immunodeficiency. Ilya Shoimer; Richard M. Haber University of Calgary, Calgary, AB Introduction: Ataxia–telangiectasia (A-T) is a rare autosomal recessive disorder that is characterized by cerebellar ataxia, oculocutaneous telangiectasias, pulmonary infections, chromosomal instability, immunodeficiency, and malignancy. Other cutaneous features of A-T include hyper- and hypopigmented macules, vitiligo, café-au-lait macules, seborrheic dermatitis, premature graying of the hair, and premature aging. Rarely, primary immunodeficiency disorders, such as A-T, may also be associated with cutaneous granulomas. P9.09 An unusual case of congenital blue nevus Sophie Vadeboncoeur; Julie Powell;Victor Kokta Université de Montréal, Montréal, QC Case Report: A three-year-old boy with A-T and an associated immunodeficiency presented to the clinic with a one-year history of non-resolving erythematous nodules on the right arm and left thigh. The lesions were thought to be triggered by mosquito bites. Subsequently, the lesions became pruritic and crusted. Histopathology revealed a necrotizing granulomatous dermatitis; however, no organisms were detected with special stains and cultures. The patient was started on clobetasol cream under occlusion. Six weeks later, the lesions revealed marked improvement. Discussion: There have been nineteen cases reported in the literature of non-infectious granulomatous inflammation associated with A-T. Individuals with A-T most often present in childhood with cutaneous granulomas involving the face and extremities. The lesions may present as papules, plaques, or nodules that often become crusted, atrophic, or ulcerated. Histopathology of these lesions is quite variable; the reported findings include non-necrotizing epithelioid granulomas (sarcoid-like), caseating granulomas (tuberculoid-like), or necrobiotic granulomas. As such, these presentations may be misdiagnosed as sarcoidosis or necrobiosis lipoidica. Noninfectious granulomas have also been associated with other primary immunodeficiencies, including common variable immunodeficiency, chronic granulomatous disease, combined immunodeficiency, X-linked hypogammaglobulinemia, Wiskott-Aldrich syndrome, X-linked hyper-IgM syndrome, and Nijmegen breakage syndrome. Moreover, granulomatous inflammation may also involve the joints, lungs, liver, spleen, and conjunctiva. Conclusion: Non-infectious cutaneous granulomas may be associated with primary immunodeficiencies, such as A-T. As such, the presence of multiple non-infectious granulomas in a child may be the initial sign of an immune deficiency and should alert the astute clinician to investigate for an underlying primary immunodeficiency. Introduction: Blue nevi are present in less than 1/3000 newborns and are generally acquired. Different histopathologic variants exist including common, plaque-like, cellular, deeppenetrating, epithelioid (associated with the Carney complex), sclerosing, hypopigmented, compound and atypical blue nevi. We report a case of an atypical congenital cellular digital blue nevus. Methods/Results: A 3 year old male patient was referred to our dermatology clinic for evaluation of an atypical nodule on the dorsum of a finger. It was first noticed at birth and was initially blue in color. It has grown proportionately to the child’s growth and has slightly faded in color. On examination, a firm, slightly mobile, skin colored with a blue halo nodule measuring 1,5 X 1,0 cm was noticed on the dorsum of the proximal interphalangeal joint of the right index. No limitation in movement or pain upon palpation was noted. Our initial differential diagnosis included an infantile localised myofibroma, an atypical infantile digital fibroma or any other fibrohistiocytic localised tumor. A punch biopsy was performed and revealed a dense population of dendritic pigmented dermal melanocytes compatible with a cellular blue nevus, which is a benign melanocytic tumor. Typical locations are the sacrum, dorsal hand and dorsal foot, where dermal melanocytes are generally most numerous. When they are of 1- 3 cm in size, they are classified as plaque-type. Melanoma may develop in a cellular blue nevus, although this seems to be rare. Conclusion: Surgical excision is not always indicated although it should be considered because of its rare malignant potential. However, a careful clinical follow-up is necessary. A64 CDA Abstracts Learning Objective: Review the clinical and histopathological subtypes of blue nevi, as well as there occasional associated conditions. the management of AD, and reduce the number of appointments required to manage AD. Takeaway Message: 1 Blue nevi are generally acquired but may rarely be congenital. 2 Cellular blue nevi have an increased risk of melanoma development. 3 Surgical excision is not always indicated, although clinical follow-up is necessary. P9.10 The Children’s Hospital of Eastern Ontario’s eczema action plan Maxwell B. Sauder; Alana C. McEvoy; Nordau Kanigsberg University of Ottawa, Ottawa, ON Introduction: Atopic Dermatitis (AD) is a pruritic dermatosis that is chronic and relapsing, making it a complex disease to manage in the pediatric population. There is a growing body of literature supporting the use of action plans in the management of AD. An action plan specifically outlines the various severities of AD an individual can experience as well as a therapeutic ladder. In one study, after 3 months of using an eczema action plan (EAP), 86% of parents found it helpful with 80% rating their child’s eczema on a lower severity scale. It is believed that the use of an EAP in the dermatology clinic at The Children’s Hospital of Eastern Ontario (CHEO) will improve patient adherence and treatment outcomes in the pediatric population suffering from this chronic disease. Learning Objective: To showcase the Children’s Hospital of Eastern Ontario’s Eczema Action Plan currently being studied. Methods: The EAP is a single page, carbon copied sheet that outlines a therapeutic ladder for managing children with AD. Specifically, it outlines three different treatment scenarios: under control, eczema flare and eczema out of control. Four copies of the EAP distributed among the patient, pharmacist, primary care physician, and health records to ensure continuity of care. Takeaway Message: Eczema action plans are relatively simply to create and implement. This project will hopefully demonstrate the value of this or similar plans with improved treatment adherence, improved parental comfort and understanding the management of atopic dermatitis, and reduced number of appointments required to manage atopic dermatitis. The EAP will be implemented to all patients at the CHEO dermatology clinic, while subjective and objective data of the patient experience will be measured using surveys and a threeitem severity scale. This will be compared against current management of eczema at CHEO. Conclusion: The abstract will focus on the EAP form and study design. Once completed, this project will hopefully demonstrate that an EAP will improve quality of care in the pediatric population suffering from AD. Specifically, the goals of this project are to: improve adherence with individualized treatment plans, improve parental comfort and understanding P9.11 Linear atrophoderma of moulin: an underrecognized entity Omid Zahedi Niaki1 Wendy Sissons2 Van-Hung Nguyen2 Ramin Zargham1 Fatemeh Jafarian2 1. McGill University, Montreal, QC; 2. Montreal Children’s Hospital - MUHC, Montreal, QC Linear atrophoderma of Moulin (LAM) is an acquired skin condition that manifests in early childhood and adolescence. It A65 CDA Abstracts likely represents a form of cutaneous mosaicism that presents with linear, hyperpigmented and atrophic lesions appearing on the trunk and limbs. Its clinical appearance varies and may closely resemble localized forms of scleroderma. It usually follows a benign course and no effective treatment options exist. We present a case of a young and healthy patient that developed such lesions on her upper and lower extremities over 5 years. The initial clinical impression of linear scleroderma was reviewed in favor of LAM following histological examination of the lesions which revealed no significant inflammatory and sclerotic changes. LAM remains a rare and possibly underrecognized entity with few reports in the dermatologic literature. This case highlights the importance of recognizing LAM and distinguishing it from localized forms of scleroderma given the significant differences in management options and prognosis. pairment is an important complication and requires intensive physical therapy. SSS is essentially a diagnosis of exclusion in the differential of sclerodermoid disorders. Clinical evolution (descriptive and pictorial), investigation, and management of our cases are discussed to highlight characteristic features of this difficult-todiagnose entity. Learning Objective: To make the clinician aware of this condition in the differential diagnosis of pediatric sclerodermoid disorders. Takeaway Message: Stiff skin syndrome is a rare condition that should be considered in children presenting with skin hardening and thickening in a limb girdle distribution. Learning Objective: P9.13 1. To recognize clinical features of Atrophoderma of Moulin. 2. To discuss the histopathological features’ of Atrophoderma of Moulin. 3. To discuss the management of this entity. Takeaway Message: LAM is an underrecognized disease that can easily be confused with other entities showing similar patterns of distribution, atrophy, and hyperpigmentation. No effective treatment options have yet been identified for this condition. A case of SCN9A-related inherited erythromelalgia Michele Ramien1, 2 Jérôme Coulombe1 Afshin Hatami1 1. CHU Sainte-Justine, Université de Montréal, Montréal, QC; 2. Division of Dermatology, University of Ottawa, Ottawa, ON P9.12 Stiff skin syndrome - a case series from CHU Sainte-Justine Michele Ramien1, 2 Jérôme Coulombe1 Danielle Marcoux1 Julie Powell1 Erythromelalgia is characterized by recurrent episodes of burning pain aggravated by warmth and relieved by cooling, erythema, warmth and swelling of the extremities. There are 3 major types: associated with thrombocythemia (Type 1), primary/idiopathic (Type 2), and associated with other underlying diseases (Type 3). Type 2 or inherited erythromelalgia (IEM) is autosomal dominant and caused by mutations in the voltage-gated sodium channel subunit Nav1.7 (SCN9A). No accurate prevalence data is available, but IEM is very rare and likely underreported. We present a case of confirmed SCN9A-related inherited erythromelalgia to detail the clinical presentation and evolution. We review the management approach for erythromelalgia. Our patient suffers from extreme pain that remains poorly controlled in spite of the plethora of specific and non-specific therapies trialed. 1. CHU Sainte-Justine, Université de Montréal, Montréal, QC; 2. Division of Dermatology, University of Ottawa, Ottawa, ON Stiff skin syndrome (SSS) is a rare disorder with approximately 40 reported cases in the literature. It classically presents with stony-hard skin predominantly affecting the hip and pelvic girdle areas, limited joint mobility, and mild hypertrichosis in infancy or early childhood. Differential diagnoses include deep morphea, systemic sclerosis, eosinophilic fasciitis and scleredema but SSS is histopathologically distinct. We present 2 cases of SSS followed at our institution. Given IEM’s significant cutaneous manifestations, dermatologists are often implicated early. Heightened awareness of this condition can promote early diagnosis and appropriate management of these challenging patients. Therapeutic suggestions are welcomed. Our patients both presented in early childhood with indurated skin in the hip girdle area that was initially diagnosed and treated as deep morphea. Imaging and pathology were consistent with the proposed diagnosis of SSS. Both cases have remained treatment-refractory, displaying slow progression despite aggressive immunosuppressive therapy. Functional im- Learning Objective: To describe the presentation and evolution of IEM. Takeaway Message: IEM is a rare condition that presents with cutaneous manifestations and significant pain that is difficult to manage. A66 CDA Abstracts P9.14 P10.01 Harlequin ichthyosis case report update: questioning the need for Acitretin Topical vitamin E in the prevention of visible light induced pigmentation Robin Wiviott; Fatemeh Jafarian Alexandra Mereniuk1 Robert Bissonnette2 McGill University, Montreal, QC 1. Université de Montréal, Montreal, QC; 2. Innovaderm Research Network Inc, Montreal, QC Introduction: Harlequin Ichthyosis is a rare congenital condition in which the baby is born encased in “armour-like” plates that are separated by deep dermal fissures. Over the last two decades, treatment with oral retinoids has been associted with dramatically increased survival. We present a case of a male infant with HI who survived past the neonatal period after very early cessation of Acitretin. Though Acitretin was later resumed, it was again discontinued secondary to Pseudotumor Cerebri. Other complications will also be discussed. Methods: The baby was born with the typical phenotype of HI. Acitretin was started within the first 24 hours, but after four doses, it was discontinued in favour of supportive care. The thick plaques began to shed at nine days of life, and by day 12 the skin was much improved. The Acitretin was resumed at 1 month of life. At a routine ophthalmologic exam at 13 months, the baby was found to have papilledema. Elevated intracranial pressure was confirmed with MRI. Suspected as the cause, the Acitretin was stopped, and until now, presently 29 months, the skin has not worsenned. Subsequent examinations revealed normalized cranial pressure. To the best of our knowledge, this is the first case of pseudo tumor cerebri in harlequin ichthyosis treated with Acitretin. Conclusion: Harlequin Ichthyosis is a rare autosomal recessive condition in which Acitretin has been uesd to improve the survival. This case, however, questions the need for Acitretin since early discontinuation was still associated with accelerated shedding of the think plaques, and there was no worsening of the skin when it was later discontinued for a second time. Considering the potential side effects associated with long term usage of oral retinoids, such as pseudotumor cerebri, this case suggests that the use of Acitretin for HI should be reexamined. Learning Objective: 1) Review the pathogenesis and treatment of Harlequin Ichythyosis. 2) Examine a case of a rare condition with rare complications. Takeaway Message: This case questions the need for Acitretin in the treatment of Harlequin Ichtyosis Visible light has been shown to induce an increase in pigmentation on skin phototypes IV to VI. Studies on human skin equivalents demonstrated a potential for the use of topical antioxidants in preventing visible light induced pigmentation. We conducted a double-blind intra-subject randomized controlled trial to assess the efficacy of topical vitamin E for the prevention of pigmentation induced by visible light on skin phototypes IV and V. Ten healthy adult subjects exhibiting visible light induced pigmentation were randomized to receive a cream containing 20% vitamin E (Webber First Aid Cream) on one half of their back and control (Eucerin® Cream) on the other. Areas of 0.9 cm2 where the creams were applied were exposed to 40Jcm-2 to 640Jcm-2 of visible light using a filtered quartz halogen lamp. Study endpoints included the assessment of the mean lowest fluence inducing pigmentation 7 days after light exposure, the difference in pigmentation intensity as measured by chromameter (L*component), and the protection factor of the vitamin E cream against visible light.Visible light exposure increased skin pigmentation; the mean difference in pigmentation (L*component of chromameter) between non-exposed and exposed skin was 3.36 (p<0.005) at 320Jcm-2 and 6.85 (p<0.005) at 640Jcm-2 for skin with antioxidant, and 3.73 (p=0.005) at 320Jcm-2 and 6.23 (p<0.005) at 640Jcm-2 for skin with control. The mean lowest fluence inducing pigmentation 7 days after visible light exposure was 280Jcm-2 for skin with vitamin E against 216Jcm-2 for skin with control (p=0.182). The difference in pigmentation intensity (L*component) between skin with vitamin E and control were not statistically significant. There was no statistically significant difference in pigmentation between skin where vitamin E cream was applied and where control cream was applied prior to visible light exposure. Further studies are needed to develop effective methods to protect against visible light induced pigmentation. Learning Objective: Could topical vitamin E prevent visible light induced pigmentation in skin phototypes IV and V? Takeaway Message: The use of a 20% vitamin E cream alone did not prevent visible light induced pigmentation. A67 CDA Abstracts P10.02 Construction and validation of skin phantoms for optical modeling Diana Y. Diao1 Lioudmila Tchvialeva1 Gurbir Dhadwal1 Harvey Lui1, 2 David McLean1 Tim Lee1, 2, 3 Learning Objective: To become familiar with various types of skin phantoms and the fabrication and validation processes of the proposed rough skin phantom for modeling light propagation in skin. Takeaway Message: Our method of phantom fabrication creates durable skin phantoms that possess both controllable surface roughness and bulk optical properties that simulate human skin, and can be used in studies involving light interactions with surface and volume scattering. 1.Vancouver Coastal Health Research Institute and University of British Columbia, Department of Dermatology and Skin Science, , Photomedicine Institute,Vancouver, BC; 2. BC Cancer Agency, Departments of Cancer Control Research and Integrative Oncology,Vancouver, BC; 3. Simon Fraser University, School of Computing Science, Burnaby, BC Introduction: When laser illuminates skin, the remitted light pattern contains information on the surface and bulk properties of the skin. To study how light interacts with skin, manufactured skin phantoms are often used to model light propagation. However, existing phantoms overlook the important effect of surface roughness on light propagation patterns. Skin roughness is an important biophysical feature that is influenced by various factors, including lesion malignancy. Our team has been studying laser speckle imaging which analyzes interference patterns from light scattered from rough surfaces. This technique has shown potential for in vivo lesion differentiation and skin roughness measurement. To further improve the accuracy of this technique, we aimed to construct and validate skin phantoms that possess both controllable surface roughness and bulk optical properties suitable for modeling light interaction with skin. Methods and Results: We reviewed existing designs of phantoms and concluded that the solid phantom approach is the only viable technique for controlling both bulk optical properties and surface roughness. Silicone and silica microspheres were used to mimic the skin scattering property, while the surface roughness was created by curing the phantoms over standardized roughness metal plates. Optical profilometry and unscattering transmission (ballistic photons) were used to validate the surface and optical attenuation properties of the phantoms, respectively. Two solid phantoms with seven rough surfaces each reliably produced the desired surface roughness values in the range of normal human skin (reported literature values range between 15 and 50µm), with 10% or less variability. The measured bulk attenuation coefficients (62±4 cm-1 and 89±5 cm-1 for phantoms #1 and #2 respectively) fall within the calculated theoretical range and are in agreement with previously reported values. Conclusion: We created skin phantoms with surface roughness and bulk optical properties that simulate human skin. Construction of these phantoms will help further improve our non-invasive device for skin disease diagnosis. Initially created to study laser speckle, these phantoms can also be used for other optical modeling studies of skin. P10.03 Scleromyxedema initially mimicking diffuse cutaneous mastocytosis and improving with phototherapy Steven J. Glassman University of Ottawa, Ottawa, ON Introduction: Diffuse cutaneous mastocytosis and scleromyxedema are rare disorders that have not been reported together. Diffuse cutaneous mastocytosis represents the most extreme and rarest form of cutaneous mastocytosis, especially in adults, and despite its severity is seldom associated with systemic mastocytosis. Itch and blistering occur, with diffuse skin infiltration, leonine facies and erythroderma. Scleromyxedema is a recalcitrant disease that represents a generalized form of primary cutaneous mucinosis, often with serious systemic symptoms. It presents with myriad waxy papules and increasing skin infiltration and sclerosis mimicking systemic sclerosis. Leonine facies can be seen in scleromyxedema, which is invariably associated with a monoclonal gammopathy. Case: a previously healthy 60-year-old man presented with erythroderma following several months of intense paroxysmal pruritus, skin thickening and tightening, and occasional blisters. Examination revealed dull-red exfoliative erythroderma, diffuse skin thickening with leonine facies, leg edema and sparse bullae. Skin biopsies showed a diffuse dense dermal infiltrate of mononuclear cells compatible with mast cells (LCA+ and CD117+). Mucin was not conspicuous. Serum tryptase was elevated at 20.4ng/ml. Serum protein electrophoresis and bone marrow biopsy were normal, and c-KIT mutation in the marrow was negative. A diagnosis of diffuse cutaneous mastocytosis was entertained and he was treated with narrowband ultraviolet B for the pruritus, with surprising improvement. Erythema diminished and blistering ceased but there was persistent and increasing skin induration. Oral methotrexate was added without improvement, and his skin became increasingly sclerotic with microstomia and sclerodactyly. A papular waxy element became very prominent on the scalp, arms and legs, and repeat skin biopsy showed a proliferation of fibroblasts A68 CDA Abstracts with abundant mucin and fibrosis, consistent with scleromyxedema. Repeat serum protein electrophoresis showed a monoclonal gammopathy, but the bone marrow biopsy was unaltered. Phototherapy and methotrexate were stopped, and intravenous immunoglobulin is being considered as the next line of therapy. attending more than 10 tanning sessions (OR=1.34 [1.051.71]). Conclusion: Exposure from over 10 tanning sessions is most strongly associated with a subsequent melanoma diagnosis and there was no statistically significant difference in this association before and after 2000, suggesting that newer tanning technology is not safer than older models. Conclusion: Pruritus and erythema can be prominent early features of scleromyxedema, possibly a result of mast cell infiltration. The case also highlights the role for phototherapy in symptom control. Learning Objective: To update the dermatologist on the latest evidence of the association of melanoma and indoor tanning. Learning Objective: Examine the overlapping clinical features and treatment of diffuse cutaneous mastocytosis and scleromyxedema. Takeaway Message: Indoor tanning increases melanoma risk. We performed a meta-analysis of the literature, which observed increased risk particularly after 10 tanning sessions. Risk estimates based on number of sessions facilitates patient risk assessment and patient education. Takeaway Message: Scleromyxedema can cause severe pruritus which can be relieved with narrowband ultraviolet B phototherapy. P11.01 The association of indoor tanning and melanoma in adults: systematic review and meta-analysis Sophia A. Colantonio1 Jennifer Beecker1 Michael B. Bracken2 P11.02 Analysis of signal transducers and activators of transcription (STAT) mRNA and protein expression in Cutaneous T Cell Lymphoma (CTCL) patients and patient-derived cell lines Ivan V. Litvinov1 Brendan Cordeiro 1 Hanieh Zargham 1 MarcAndre Doré 2 Martin Gilbert2 Youwen Zhou3 Thomas S. Kupper4 Denis Sasseville 1 1. University of Ottawa, Ottawa, ON; 2. Susan Dwight Bliss Professor of Epidemiology, New Haven, CT, USA 1. McGill University, Montreal, QC; 2. Laval University, Quebec City, QC; 3. University of British Columbia,Vancouver, BC; 4. Harvard University, Boston, MA, USA Introduction: The purpose of this systematic review and meta-analysis was to determine the association of melanoma from the use of indoor tanning beds worldwide in terms of frequency of use, and use of newer tanning beds. To date, no meta-analysis had separately examined the association in geographical subgroups and in persons under the age of 25. In addition, a dose-dependent relationship between sunbed use and the association of melanoma is vaguely defined in the literature. We quantified this association in metrics that are more easily understood and personally relevant to patients. Our analysis is novel in the delineation of use of newer tanning beds, captured in the subgroup of studies from the year 2000 and onward. Methods/Results: We searched Scopus, Medline, CINAHL on August 14, 2013. We included all observational studies with melanoma patients who had indoor tanned. Thirty-one studies were included with data available on 14,956 melanoma cases and 233,106 controls. Compared to never using, the OR for melanoma associated with ever using indoor tanning beds was 1.16 [95% CI 1.05–1.28]. Similar findings were identified in recent studies with enrollment occurring in the year 2000 onwards (OR=1.22 [1.03–1.45]) and in subjects Many recent studies attempted to elucidate the pathogenesis of CTCL. Persistent activation of transcription factors of the signal transducers and activators of transcription (STAT) genes has been implicated in the pathogenesis of a variety of cancers, including CTCL. While a number of STAT signaling members including STAT3, STAT4 and STAT5 have been extensively studied, the role of other STAT proteins in CTCL remains only partially understood. Hence, we wanted to investigate the expression of STAT signaling members in CTCL patients, normal skin samples, lesional skin from benign inflammatory dermatoses and in 11 patient-derived CTCL cell lines. Our findings demonstrate that STAT1, STAT2 and STAT3 were heterogeneously expressed in CTCL lesional skin and in nonmalignant skin biopsies, STAT4 and STAT5A were preferentially expressed in CTCL samples, while STAT5B and STAT6 were primarily expressed in normal skin and in benign inflammatory dermatoses. We further report the expression of STAT mRNA and proteins in 11 patient-derived CTCL cell lines and document that such expression is upregulated by T cell stimulation treatment using PMA (phorbol 12-myristate 13-acetate) and A69 CDA Abstracts patient survival in primary melanoma (HR2.08 overall survival; HR2.39 disease-specific survival). ionomycin or magnetic beads coated with anti-CD3 and antiCD28. Learning Objective: Describe the activity of signal transducers and activators of transcription (STAT) signaling pathways in CTCL and compare it to the expression observed in benign inflammatory dermatoses. Takeaway Message: A number of STAT signaling members are preferentially expressed in CTCL, when compared to benign inflammatory dermatoses. Understanding how this cancer engages STAT signaling may lead to the discovery of novel therapeutic modalities. P11.03 Prognostic role of BRAF in melanoma disease progression and patient survival: protein expression vs. gene mutation Gholamreza Safaee Ardekani; Seyed Mehdi Jafarnejad; Shahram Khosravi; Magdalena Martinka; Li Gang;Vincent Duronio University of British Columbia,Vancouver, BC Membership: Other (PhD Candidate), Sponsor: Dr.Vincent Duronio Introduction: Alteration in braf expression and activity is the most prevalent oncogenic event in melanoma development. However, the effect of braf mutation on patient survival, as the final outcome, and its prognostic value is a matter of controversy. We investigated the effect of brafV600E mutation on patient survival and then evaluated the prognostic value of BRAF protein expression level in different stages of melanoma and its correlation with brafV600E mutation. Methods, Results: Using meta-analysis in a pool of 674 patients, we revealed that brafV600E mutation increases the risk of mortality in melanoma patients by 1.7 times (95% CI, 1.37-2.12). In addition, our investigation on 370 patient samples showed a remarkable stepwise increase in BRAF protein expression level in primary and metastatic melanoma compare with normal samples (P=1.8×10-11). High BRAF expression was significantly correlated with thicker tumors, ulceration and higher American Joint Committee on Cancer (AJCC) stages (P=1.5×10-7, 1.5×10-5, 3.6×10-13, respectively). In primary melanoma cases, patients with high BRAF expression had significantly worse overall (P=0.009) and diseasespecific five-year survival (P=0.007). While there was a trend for higher prevalence of brafV600E mutation in patients with high BRAF protein expression, no significant correlation was observed between protein expression and BRAF mutation. Furthermore, univariate Cox-regression analysis confirmed high BRAF protein expression as a strong risk factor for poor Conclusions: We showed that brafV600E mutation is an absolute risk factor for melanoma patients survival. Although, we revealed a novel prognostic value for BRAF protein expression in primary melanoma there was no significant correlation between BRAF protein expression and brafV600E mutation in our samples. Learning Objective: To get familiar with the criteria of a melanoma prognostic marker and to learn about expression pattern and prognostic value of BRAF protein in melanoma. Takeaway Message: BRAF protein expression could be used as a feasible and cheap prognostic marker in melanoma while the exact molecular mechanism behind this observation needs further investigation. P11.04 Skin cancer screening after solid organ transplantation: survey of current practices in Canada Eric Coomes1, 2 Kevin Lam1, 2 Melissa Nantel-Battista1, 2 Jessica Kitchen2 An-Wen Chan1, 2 1. University of Toronto,Toronto, ON; 2.Women’s College Hospital,Toronto, ON Non-melanoma skin cancer is the most common post-transplant malignancy. Post-transplant screening guidelines thus recommend annual skin examination. We aimed to determine current attitudes, practices, and barriers to skin cancer screening after solid organ transplantation in Canada. From July to December 2013 we performed a cross-sectional survey of all 479 Canadian post-transplant physicians and nurses. We tabulated descriptive statistics and performed multivariable logistic regression to identify factors associated with adherence to annual screening. The response rate was 48% (230/479); we excluded 46 invalid responders. Transplant personnel viewed screening as very important (median 10/10, IQR 8-10). However, only 57% of respondents ensured annual screening. Adherence to annual screening was significantly (p<0.003) associated with having a screening policy (OR 5.6, 95% CI 2.8-11) and an on-site dermatologist (OR 3.0, 95% CI 1.5-6.0). Accessibility to dermatology was moderate (median 7/10, IQR 4-9). However, 35% rated accessibility as ≤ 5/10. Centres with an on-site dermatologist had significantly higher accessibility ratings than those without (median 8/10 versus 4.5/10, p<0.0001). The primary reported barriers to access were wait A70 CDA Abstracts times (48%), excessive distance (26%), and lack of availability of transplant dermatologists (35%). Barriers to access (N=176) Excessive wait time While post-transplant skin cancer screening is perceived to be very important, there is a failure to adhere to screening guidelines. Development and implementation of formal screening policies and improved dermatologist access may improve adherence to annual screening. Table 1: Skin Cancer Screening and Access to Dermatology 84 48% No specialized transplant dermatologist 61 35% Excessive distance 46 26% Difficult to routinely refer 26 15% Lack of priority 44 25% No barriers 45 26% Screening policy (N=180) Learning Objective: To understand current attitudes, practices, and barriers to skin cancer screening after solid organ transplantation in Canada. Yes, unwritten policy 76 42% Yes, written policy 24 13% 109 63% After 12 months post-transplant 5 3% Not routinely necessary 39 23% Not sure 20 12% Frequency Interval: at least every 12 months 97 57% Frequency Interval: greater than 12 months 15 9% Not routinely necessary 44 26% Retrospective chart review of melanoma distribution diagnosed over a 5-year period in a community dermatology clinic Not sure 15 9% Daniel Wong2 Priya Maini3 Melinda J. Gooderham1 1. SKiN Centre for Dermatology, Peterborough, ON; 2. University of Western Ontario, London, ON; 3. McGill University, Montreal, QC Screening initiation (N=173) Pre-transplant or within 12 months posttransplant Screening frequency (N=171) Type of skin exam in transplant clinic (N=116) Full 40 34% Limited 76 66% Transplant Physician 99 55% Transplant Nurse 77 43% Family Physician 74 41% Dermatologist 128 71% Patient 63 35% In our medical centre 101 57% In another hospital 19 11% In the community (private clinic) 51 29% Person(s) responsible for skin exam (N=180) Most accessible dermatologist (N=176) Access to dermatologist specializing in transplant (N=178) Yes (Overall) 105 59% Yes, in our medical centre 72 40% Yes, in another hospital 13 7% Yes, in the community (private clinic) 20 11% No 63 35% Takeaway Message: 1. Only 57% of post-transplant physicians and nurses adhere to guidelines for at least annual skin cancer screening. 2. Development and implementation of formal screening policies and improved accessibility to dermatologists at transplant centres may improve adherence to annual screening. P11.05 Melanoma is the 8th most common cancer in Canada. It has commonly been recognized that the most frequent site for melanoma in men and women are on the back and lower legs, respectively. In a 5-year chart review from 2007-2012 of a community dermatology practice serving Peterborough, Ontario and the surrounding area, a total of 259 melanomas were diagnosed histologically via biopsy. Age, gender, site and Clark’s level were recorded. The most common site for all melanomas was the head and neck for men (40%) and the upper extremity for women (35%). However, when looking at melanomas with a stage of Clark’s level II or higher, the locations of melanoma were predictably distributed to the back (39%) and lower extremities (38%) for men and women, respectively. It was also noteworthy that the second most common site for both genders was the upper extremity (28% for men and 36% for women). From this chart review, it is important to note that a significant proportion of melanomas, either in situ or with a prognostic level of Clarks II or higher, arise from the head and neck A71 CDA Abstracts region, and the upper extremities in addition to the back and lower extremities. As a result, a lower threshold for taking a biopsy of suspicious lesions in any of these areas should be practiced to help diagnose melanomas earlier. These results also help reinforce the importance of performing full body skin exams when searching for potentially fatal skin cancers. Learning Objective: To review the anatomic distribution of melanomas in a typical community dermatology practice in Canada. To make the readers aware that head and neck, and upper extremity are also significant locations to consider a low threshold for biopsy of suspicious pigmented lesions. Takeaway Message: For melanomas of all levels, the most common location for men was head and neck, and for women was upper extremities. However, for deeper melanomas (Clark’s level II or greater) the most common locations are back for men, and lower extremities for women in agreement with previous reports. liferum, trichoblastoma, hidradenoma and numerous seborrheic keratosis. Our patient is offered a close follow-up for surgical treatment of any further appearing malignancies within the lesion. Conclusion: Occurence of multiple secondary tumors within an epidermal nevus is well known. However, malignant transformation is extremely rare. Hence, prophylactic excision is not recommended. When malignancies appear in a small, localized nevus, it should be completely excised. The extent of our patient’s nevus is inconsistent with this therapeutic measure. Our patient’s unique presentation highlights the diagnostic and therapeutic challenge associated with such a case. Learning Objective: The objective of this presentation is to report a case of multiple tumours arising in an extensive epidermal nevus and highlight the therapeutic challenge when dealing which such cases. P11.06 Takeaway Message: The possibility of a secondary cutaneous malignancy should be suspected when papule, nodule or ulcer appears within an epidermal nevus. Development of multiple tumors in an extensive epidermal nevus : a case report P11.07 Andréanne Waddell; Janie Bertrand ; Sara-Elizabeth Jean Université Laval, Québec, QC Introduction: Extensive verrucous epidermal nevus, also known as systemized epidermal nevus, is a hamartomatous proliferation of the cutaneous epithelium. Although rare, several cutaneous malignancies in association with this nevus have been reported. The malignant transformation tends to occur most frequently in middle-aged and eldery individuals. Keratoacanthoma, multifocal papillary apocrine adenoma, multiple malignant eccrine poroma, basal cell carcinoma and squamous cell carcinoma have all been described but the occurence of multiple simultaneous lesions is exeedingly uncommun. Methods and Results: We describe the case of a 55-yearold female with an extensive linear verrucous epidermal nevus localised on the right side of the body associated with unilateral lower limb hypertrophy and lymphedema. Past evaluation by an ophthalmologist, a neuropediatrician and a colleague dermatologist revealed no further associated extracuteanous manifestations. While the lesion had been stable for a long time, in the past years the patient noticed multiple suspect papules and nodules arising within the nevus. Biopsies obtained from these lesions revealed various benign and malignant cutaneous tumors within a verrucous epidermal nevus. More specifically, histopathologic evaluation demonstrated the presence of three basal cell carcinomas as well as a squamous cell carcinoma, kerathoacanthoma, syringocystadenoma papil- Predictive value of mitotic rate for sentinel lymph node positivity in malignant melanoma: a retrospective seven-year analysis Heidi Wat; Thomas G. Salopek University of Alberta, Edmonton, AB Background: The utility of sentinel lymph node biopsy (SLNB) in thin melanomas is controversial given its low positivity rate (5.6%). In 2010, the AJCC staging classification of melanoma introduced the concept of mitotic rate (MR) whereby thin melanomas (≤ 1 mm, non-ulcerated) with a high mitotic index are upstaged to T1b and are now offered SLNB. In spite of this recommendation, there is a paucity of studies to substantiate whether the finding of a single mitosis justifies this potentially morbid invasive procedure. Objective: To determine whether MR is predictive of SLNB status when stratified according to a) tumor thickness, and b) ulceration. Methods: All cases of melanoma that had undergone a SLNB at the University of Alberta between 2007-2013 were extracted from a provincial-wide surgical database. A total of 556 cases met inclusion criteria. Features that were extracted included gender, age, tumour thickness, ulceration, and MR. Variables were analyzed in a binomial logistic regression model in relation to SLN status. A72 CDA Abstracts Results: The overall SLN positivity rate was 24.5% in all melanomas regardless of thickness, however, for thin melanomas (≤ 1.0 mm) the rate was only was 4.6% (5/110). In the five cases of thin melanomas with positive SLNB, all were ≥ 0.7 mm in tumour thickness. We found that MR ≥ 1 correlated strongly with SLN positivity when analyzed as a whole irrespective of thickness (p<0.0001, odds ratio 1.874, CI 1.2102.904). When stratified by tumour thickness, only the 1.01-2.0 mm subgroup featured a significant relationship between MR and a positive SLNB (p=0.0105). Likewise, there was a significant association between MR ≥ 1 and a positive SLNB only in the ulcerated subgroup (p=0.0004). Conclusion: The incorporation of MR in staging was based on its association with long-term survival in all melanomas and not on whether it could predict good candidates for SLNB. We found that MR ≥ 1 is only useful in predicting SLNB status for patients with either intermediate thickness melanomas (1.012.0 mm) or ulcerated tumours. confirmed by a pathology report who had a melanoma diagnosis registered in OCR anytime before or up to one year after the pathological diagnosis date. Results: Of the 6,044 reports containing “melanoma”, the majority had a diagnosis of invasive melanoma (N=5,201). Overall, OCR captured 4,095 (90.5%, 95% C.I. 89.6%-91.3%) of invasive melanoma pathology reports over the 17-year period. Annual rates of 95% or higher were found for over half of the study period. The capture rate in 1993 was 82.5% and improved in subsequent years (90.9-98.1%), with the exception of 2004 (71.5%) and 2005 (58.8%). Diagnosis dates were mostly accurate, with 3,514 (86%) OCR diagnosis dates matching the pathological diagnosis date. Conclusions: The OCR capture rate for melanoma was 91% overall. There is a need for ongoing validation to ensure data remain accurate and complete in order to reliably inform research, clinical care, and policy. Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Total Learning Objective: To determine whether MR is predictive of SLNB status when stratified according to a) tumour thickness, and b) ulceration. Takeaway Message: Although MR is associated with positive SLNB in all melanomas, it does not appear to be useful in predicting who should undergo a SLNB particularly if the melanoma is thin (≤ 1 mm) or thick (>2.0 mm). In the latter thickness appears to overrides mitotic rate. P11.08 Validation of melanoma capture by the Ontario Cancer Registry Jennifer Tran5 Rodrigo Schwartz3, 4 Kinwah Fung2 Paula Rochon2, 1 An-Wen Chan2, 5 1. University of Toronto,Toronto, ON; 2.Women’s College Research Institute, Toronto, ON; 3. Dept of Dermatology, Hospital Barros Luco Trudeau, Santiago, Chile; 4. University of Chile, Santiago, Chile; 5. Division of Dermatology, University of Toronto,Toronto, ON Introduction: Monitoring of melanoma incidence over time requires accurate population-based data. The Ontario Cancer Registry (OCR) is the primary source of information on melanoma diagnoses in the province. To our knowledge, no study has directly measured the OCR capture rate of melanoma diagnoses using external data. Methods: We examined all pathology reports from a community laboratory that contained the word “melanoma” from 1993-2009. Pathology-confirmed diagnoses were linked to OCR records using health insurance numbers. Capture rates were calculated as the proportion of patients with melanoma Capture Rate 82.5% (85/103) 93.8% (105/112) 93.3% (112/120) 95.6% (153/160) 92.6% (174/188) 95.5% (233/244) 94.8% (274/289) 95.8% (248/259) 97.2% (276/284) 95.9% (234/244) 90.9% (288/317) 71.5% (256/358) 58.8% (207/352) 96.6% (309/320) 96.6% (310/321) 96.2% (378/393) 98.1% (453/462) 90.5% (4095/4526) Learning Objective: To discuss completeness of melanoma registration within the Ontario Cancer Registry, a widely-used database for epidemiological research and cancer surveillance. Takeaway Message: • The Ontario Cancer Registry, used widely for populationbased epidemiological research and cancer surveillance, has achieved high capture rates (up to 98% annually) for invasive melanoma. A73 CDA Abstracts Takeaway Message: • There is a need for ongoing validation to ensure data remain accurate and complete in order to reliably inform research, clinical care, and policy. P11.09 One-year review of the “Screen” (skin cancer post-transplant) clinic: what we have learned Sarah Baldwin2 Sheila Au1, 2 1) Our clinic identified 123 new non-melanoma skin cancers in 48 high-risk patients. 2) Caucasian males were most at risk. Squamous cell carcinoma was present in 73% of patients and over 25% of these were invasive when diagnosed. 3) Despite good awareness of the skin cancer risk, sunscreen use was poor in this population. 1. St. Paul’s Hospital and Providence Health Care,Vancouver, BC; 2. University of British Columbia Faculty of Medicine,Vancouver, BC P11.10 Introduction: The SCREEN Clinic is a new skin-cancer screening clinic that is fully integrated into the renal transplantation clinic at St. Paul’s Hospital in Vancouver, BC. The purpose of this review was to determine characteristics of patients most at risk for skin cancer, to specify types and locations of skin cancers diagnosed, and to identify areas for patient and physician education. Methods/Results: Transplant patients (primarily renal; some heart) screened by a dermatologist during a 12-month period were stratified into low, medium and high-risk groups based on detailed history and skin examination. Of 122 highrisk patients identified and followed, 48(39%) were diagnosed with new skin cancers. 72% were Caucasian, 2% were Metis and 2% were Asian. 67% were male, 53% had a previous history of skin cancer, and 85% were aware of their increased skin cancer risk. 28% reported using only 1-2 bottles of sunscreen per year. 13% never used sunscreen. Sunscreen was commonly applied to the face(51%), back(46%) and back of neck(41%), while the lips(19%) and chest(17%) were areas most neglected. 123 skin cancers were identified. Of these, 33(27%) were basal cell carcinomas and 90(73%) were squamous cell carcinomas. 27% of the squamous cell carcinomas were invasive. Common locations included arm(8%), neck(8%), hand(7%) and scalp(7%). Actinic keratosis occurred in 60%. Strategies undertaken to prevent further skin cancers included frequent patient education, liquid nitrogen, topical field cancerization therapy, reduction of immunosuppression, sirolimus, and acitretin. Seasonal and geographic trends in tanning Bez Toosi; Sunil Kalia Department of Dermatology and Skin Science, University of British Columbia, and Photomedicine Institute,Vancouver General Hospital.,Vancouver, BC Background: The incidence of skin cancer remains high and continues to rise. Tanning has been linked to causing skin cancer. Although tanning practices are assumed to be seasonal, seasonal patterns in tanning have not been systematically evaluated. This study explores seasonal and geographic trends in tanning practices in order to better understand tanning behaviors and to design timely intervention and harm reduction strategies. It utilizes internet search query data from Google Trends to test the hypothesis that tanning varies by season and contrary to general understanding peaks before the active months (June to August) of summer. Objective: To determine the seasonal and geographic effects on tanning and tanning salons search queries. Methods: Internet search query data were obtained from Google Trends. Monthly normalized search volumes (NSV’s) were determined for the term “tanning” and “tanning salons”, from January 2004 to December 2013. Using cosinor analysis, and Kruskal-Wallis one-way analysis of variance, seasonal and geographic effects were tested for data from Canada, United States and Australia. Conclusion: We have diagnosed 123 skin cancers in over 1/3 of our high-risk population. Caucasian males were found to be most at risk. As expected, squamous cell carcinoma accounted for the majority of tumours with over 25% demonstrating invasion. Although skin cancer awareness was high, sunscreen use was limited. With this information we have identified a number of potential target areas for patient and physician education. Results: Time series revealed peaks in NSV’s in March-April and troughs in October-November in Canada and the United States. The peaks and troughs in NSV’s from Australian data were out of phase by 6 month as compared to the northern hemisphere counterparts, consistent with a seasonal pattern. Cosinar analysis revealed statistically significant seasonal effects on NSV’s in all countries. The magnitude of seasonal increase in NSV’s was similar between Canada, United States and Australia. The analysis of variance showed no significant difference between the three countries. Learning Objective: To determine patient demographics, sun protection habits and skin cancer data in post-transplant patients screened over a 12-month period in Vancouver, BC. Conclusion: Currently the Canadian educational campaigns that educate people about the hazards of tanning begin in May or June. This study suggests interest in tanning practices to be A74 CDA Abstracts highest in the months preceding summer and prior to the onset of these campaigns. Further studies are needed to confirm these findings, but these results support having educational campaigns being initiated earlier during the year. P11.12 Two cases of linear basal cell carcinoma Jeewanjit Gill; Steven J. Glassman Learning Objective: Appreciate the seasonality and trends in tanning. Takeaway Message: • Interest in tanning salons is seasonal and is highest in the months preceding summer. • The Canadian educational campaigns which attempt to educate people about the hazards of tanning currently start in May or June after the interest and potential use of tanning salons have peaked. • Results support initiation of educational campaigns earlier during the year. P11.11 Primary melanoma mimicking cutaneous metastasis: a potential diagnostic pitfall following cryotherapy University of Ottawa, Ottawa, ON Introduction: Linear forms of basal cell carcinoma (BCC) are rare, with only 34 cases reported. They have been defined as straight-edged lesions with a length-to-width ratio of at least 3:1. Most cases represent nodular BCCs with a predilection for periorbital regions or the neck. Two cases at unusual locations are presented here. Case 1: 73-year-old female with incidental finding of a curious firm 2cm pearly linear lesion in the left cubital fossa, aligned within skin creases. Dermoscopy revealed arborizing telangiectases and ovoid nests, and pathology showed a pigmented nodular BCC. The lesion was excised and has not recurred 3 years later. Case 2: 74-year-old female with the incidental finding of a reddish linear 4cm lesion in the left axilla, partly aligned within skin tension lines. Dermoscopy revealed small arborizing telangiectases, and pathology showed a nodular BCC. She is awaiting excision. Conclusion: Linear BCCs can be subtle and missed because of their unusual morphology, and attributed to benign tumours or inflammatory conditions. Alignment within skin tension lines could be due to stromal interactions. Olivia V. Potok2 Muhammad N. Mahmood1 Thomas G. Salopek2 1. Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB; 2. Division of Dermatology and Cutaneous Sciences, University of Alberta, Edmonton, AB The current gold standard therapy for primary cutaneous melanoma is surgical excision with appropriate clinical and histological margins. Aside from very select cases, such as patients with lentigo maligna who are poor surgical candidates, cryotherapy is not considered an appropriate therapeutic modality for primary cutaneous melanoma. In instances where melanoma has been inadvertently treated with cryotherapy, the resultant histological changes may prove diagnostically challenging for the interpreting pathologist. Herein, we report a case of a primary cutaneous melanoma exposed to cryotherapy, thus resulting in histopathology resembling a cutaneous deposit of metastatic melanoma. Learning Objective: Antecedent procedures can alter the histology of melanoma, leading to potential diagnostic pitfalls. Takeaway Message: Liquid nitrogen cryotherapy may obliterate the entire intraepidermal component of a primary cutaneous melanoma, resulting in histology mimicking a cutaneous deposit of metastatic melanoma. Learning Objective: Recognize unusual linear forms of basal cell carcinoma. Takeaway Message: Consider basal cell carcinoma in the differential of linear lesions. A75 CDA Abstracts P12.01 The Peng flap: a great choice for nasal tip defects Emilie G. Bourgeault; Jimmy Alain Laval University, Québec, QC Introduction: The Peng flap was first described in 1987 as a variation of the linear advancement flap. Modifications by Rowe and colleagues in 1995 and Ahern and Lawrence in 2008 refined the initial design. The flap can be used as an alternative to the paramedian forehead flap in repairing larger distal nasal tip defects. To date, the technique has been effective in 75 reported cases and no flap failures have been described. We present 7 new cases of successful repair with the Peng flap and describe our novel use of Burrow’s triangle as a graft site for the construction of a new columella. Methods and Results: In our series of 7 cases, we used the Peng flap as an alternative to a forehead flap in repairing distal nasal tip defects ranging from 1.1 cm x 1.1 cm to 2.0 cm x 1.9 cm. There was no flap necrosis or complications in any of our cases, nor was there necessity for scar revision with dermabrasion. The technique allowed us to preserve the nasal profile, providing excellent cosmetic results. When necessary, we grafted Burrow’s triangle to build a new columella. Better cosmesis and minimal patient morbidity make this flap an excellent choice in the reconstruction of nasal tip defects. Learning Objective: At the end of this activity, the participant will be able to choose the Peng flap as a reliable alternative approach in repairing defects of the nasal tip and will also be able to consider grafting Burrow’s triangle for use as a new columella. Takeaway Message: Repair of the nasal tip is a difficult surgical endeavor that can be facilitated by utilizing the Peng flap. P12.02 Outcomes of contoured staged excision for Lentigo Maligna of the face and neck: a pilot study with survey of current practices Annie Liu; Alexis Botkin; An-Wen Chan University of Toronto,Toronto, ON Introduction: Treatment of lentigo maligna (LM) on the head and neck remains challenging due to subclinical tumour extension and the potential for adverse functional and cosmetic outcomes post-operatively. Standard wide excision with a 0.5cm margin remains the standard of care. However, no clinical trials exist to guide practice; case series suggest that most patients require a larger surgical margin for complete tumour clearance. Objectives: To determine the current treatment practices for lentigo maligna of the head and neck in Ontario by practicing physicians who commonly treat LM. Methods: We conducted a cross-sectional survey of all dermatologists, plastic surgeons, and otolaryngologists practising in Ontario, examining their current treatment practices for lentigo maligna of the head and neck. Conclusion: The incidence of basal cell carcinoma is increasing worldwide, the nose being the most commonly affected anatomical site. Surgical approaches offer the most effective way of achieving cure and as such the dermatological surgeon has a key role in the treatment of this disease. The bilateral rotation component of the Peng flap allows for defect repair with minimal advancement, which reduces tension at the nasal tip and maintains the shape of the nares. The single-stage nature of the flap decreases patient morbidity as opposed to the complicated two-stage process involved in the forehead flap. Results: The response rate was 35% (247/710). Treatments used for lentigo maligna included surgical excision performed themselves (45%) or by referral to another physician (46%), topical creams (20%), radiation (4.5%), cryotherapy (3.6%), and electrodessication & curettage (0.8%). Among the 75% of responders who treated lentigo maligna with standard wide excision and immediate reconstruction, 69% of physicians reported using a 0.5 cm surgical margin, while 27% report a greater than 0.5 cm margin. We will present full results (overall and by specialty type) upon completion of the analysis. Discussion: Although standard wide excision with immediate reconstruction is the most common treatment utilized for lentigo maligna of the head and neck, surgical practice varies in terms of excision technique and margin size across Ontario. Despite consensus guidelines recommending a 0.5 cm mar- A76 CDA Abstracts The majority of patients felt that over the counter antihistamines were useful in disease control although prednisone as prescribed by emergency room physicians and family practitioners were added in about a fifth of the patients. gin, there is variability in the margin size used in practice on the head and neck. Additional evidence from robust studies is needed to inform optimal treatment for this challenging tumour. Learning Objective: To learn of the current treatment practices for lentigo maligna of the head and neck in Ontario by practicing physicians who treat it commonly. Takeaway Message: Standard wide excision with immediate reconstruction is the most common treatment utilized for lentigo maligna of the head and neck, although surgical practice varies in terms of excision technique and margin size across Ontario. Despite consensus guidelines recommending a 0.5 cm margin, there is variability in the margin size used in practice on the head and neck. P13.01 Chronic spontaneous urticaria – the Saskatchewan experience and questionnaire survey Conclusion: In this follow-up questionnaire study, 30% of patients found antihistamines gave effective control. About 40% of patients may have chronic spontaneous urticaria caused by autoimmunity as assessed by the ASST. IVIG was an effective treatment for this group of patients. Learning Objective: Upon completion of this session, participants should be able to: Be familiar with successful treatments in CSU patients Be familiar with the symptoms experienced by CSU patients Takeaway Message: In approximately 50% of patients, the urticaria had resolved Quality of life is affected leading to missed work or school Majority of patients remain frustrated with the lack of efficacy of treatment Approximately 30% of participants found that antihistamines alone gave effective control for hives Natasha Gattey; Bahar Bahrani; Peter Hull University of Saskatchewan, Saskatoon, SK In the ASST (+) patients, IVIG was a highly effective treatment Background: Chronic spontaneous urticaria (CSU) is defined as urticaria persisting for more than 6 weeks with no inducible cause. An autoimmune basis is held responsible for more than half the cases. Many cases have no identifiable cause. Methotrexate was used successfully in 3 patients who did not respond to IVIG Approximately 23% of ASST (-) participants still experiencing hives found no treatment to relieve symptoms Method: 173 patients with CSU had been seen between 2003 and 2013. There were significantly more females than males (130:43). The age range was 1 year to 81. The mean age was 36 years. The average duration was 9.3 years. An autologous serum skin test (ASST) was performed on 138 patients and was positive in 58 (42.02%). P13.02 Results: A questionnaire and informed consent, approved by the Research Ethics Office, was sent to patients and replies were received from 101 participants. We were unable to contact 25 patients, and 2 patients had died. Of the respondents, 40 were ASST positive and 49 were ASST negative participants. 55.00% of ASST (+) participants and 46.80% of ASST (-) participants no longer had hives. 21 ASST positive patients who had significant quality of life issues were treated with intravenous immunoglobulin (IVIG), and 85.0% of these patients had improved quality of life with 13 of these patients now free of urticaria and no longer receiving IVIG. Patients were most bothered by pruritus, disturbed sleep, anxiety and their physical appearance including facial swelling. Many (70.4%) had missed work or school because the urticaria. Chronic Spontaneous Urticaria – an evaluation of an indirect immunofluorescence method for detecting anti-mast cell IgG antibodies Bahar Bahrani; Natasha Gattey; Peter Hull University of Saskatchewan, Saskatoon, SK An autoimmune basis is believed to be responsible for about half of all cases of chronic spontaneous urticaria (CSU) with specific IgG antibodies directed at the high affinity receptor sites for IgE on the mast cell. The autologous serum skin test (ASST) is used to identify this autoimmune form of CSU. Currently, basophil histamine release assay and basophil activation test (BAT) have been used as an alternative to the ASST. We have developed an indirect immunofluorescence method to demonstrate the presence of anti-mast cell antibodies using skin sections from a patient with severe bullous mastocytosis. Sections from paraffin embedded blocks of skin biopsied infant with bullous mastocytosis and cord-blood derived mast cells A77 CDA Abstracts were used as substrates. Serum patients with CSU was used, and fluorescein conjugated human IgG was used to label fixed antibody. Amongst the bullous mastocytosis slides, positive indirect immunofluorescence was found in 35 (46.05%) of the patients (n=76). There was a positive indirect immunofluorescence in 17 (50%) patients who had a positive ASST (n=34), 49.09% of non-IVIG treated CSU patients (n=55), and in 61.09% of IVIG treated patients (n=21). Amongst the cord-blood derived mast cell cytospin slides, positive indirect immunofluorescence was found in 29 (41.43%) of the patients (n=70). Positive indirect immunofluorescence was found in 14 (45.16%) patients who had a positive ASST (n=31), 46% of non-IVIG treated CSU patients (n=50), and in 60% of IVIG treated patients (n=20). It is possible to detect anti-mast cell IgG antibodies by indirect immunofluorescence. IgG autoantibodies could be detected in about half of CSU cases examined. Indirect immunofluorescence should be considered a more direct and credible indicator of the autoimmune form of CSU. Learning Objective: An indirect immunofluorescence method can be used to identify anti-mast cell IgG auto-antibodies. Takeaway Message: Indirect immunofluorescence should be considered a more direct and credible indicator of the autoimmune form of CSU. P14.01 may be educational - particularly for patients with difficult-tosee wounds. Importantly, this tool may motivate patients to become more involved in the management of their wounds. Learning Objective: The objectives of this study are to provide an assessment of wound photo-documentation from the patients’ perspective and to evaluate whether this could improve patients’ understanding and involvement of their wound care. Takeaway Message: • The present study provides the first assessment of the importance and perceived benefits of wound photography from the viewpoint of the patient. • Most patients have difficulty seeing their wounds and few patients monitor their wounds themselves. • There is a significant association between the ease with which a patient is able to see their wound and whether they reported subsequent memory of how the wound looked. • Patients’ ability to recall how their wounds looked in a previous clinical visit declined drastically with the time since the initial visit to the wound clinic. • The majority of patients report that taking photos of their wounds would help them track how their wound is progressing and allow them to be more involved in their own wound care regardless of whether they have difficult-to-see wounds. Patient perception of wound photography P14.02 Sheila Wang1 John Anderson1 Duncan Jones1 Robyn Evans2 1. University of Toronto,Toronto, ON; 2.Women’s College Hospital,Toronto, ON The objectives of this study are to provide an assessment of wound photo-documentation from the patients’ perspective and to evaluate whether this could improve patients’ understanding and involvement of their wound care. Our results revealed that most patients attending the wound clinic have difficult-to-see wounds (86%). Only 20% of patients monitor their wounds and rely on clinic or nurse visits to track healing progress. There was a significant association between patient’s ability to see their wound and subsequent memory for how the wound looked. This was especially true of patients who had recently attended the wound clinic. This relationship was not present in patients who visited the clinic for 3 years or more. Patients reported that inability to see their wounds made them feel that they had lost autonomy. The majority of patients reported that photographing their wounds would help them to track their wound’s progress (81%) and would afford them more involvement in their own care (58%). This study provides a current representation of wound photography from the patients’ perspective and reveals that wound photography Treatment of chronic wound staphylococcus aureus biofilms with staphylococcus epidermidis Esp protein to promote healing Christina Scali1 Mark G. Kirchhof1 Adrienne Law2 Dirk Lange2 Brian Kunimoto1 1. Department of Dermatology, University of British Columbia,Vancouver, BC; 2.The Stone Centre at Vancouver General Hospital, Department of Urologic Sciences, Jack Bell Research Centre,Vancouver, BC Biofilms are communities of bacteria attached to a surface. They are commonly found in chronic wounds, where they lead to a non-healing inflammatory phase and are associated with persistent infection. Staphylococcus aureus is one of the most common microorganisms to form biofilms and has been found to be present in 64-94% of chronic wounds. S. epidermidis strain JK16 cells and its culture supernatants have previously been shown to destroy preexisting S. aureus biofilms and inhibit the formation of new ones in vitro1. This biofilm destruction activity was found to be due to the Esp protein isolated from this S. epidermidis strain1. S. epidermidis JK16 cells as well as purified Esp can also eliminate nasal carriage of A78 CDA Abstracts S. aureus in humans1. This serine protease causes the intercellular matrix to breakdown and changes S. aureus from a sessile to a planktonic form, making it more susceptible to antibiotics and the immune system. This makes Esp an attractive candidate to use in anti-biofilm strategies. To date, Esp has not been studied in relation to chronic wound biofilms or in relation to wound healing in animals or humans. A pilot study to explore the biologic activity of S. epidermidis JK16 Esp on biofilms and healing of chronic wounds is being undertaken. The S. epidermidis JK16 Esp protein has been purified and is currently being tested in vitro on S. aureus lawns and with a spectrophotometric assay. The purified S. epidermidis Esp protein will then be compared to standard therapy in 10 patients with chronic wounds using a cross-over design. This pilot study will allow us to assess the feasibility of conducting a more definitive trial to examine the efficacy of the Esp in healing chronic wounds. 1 Iwase T, Uehara Y, Shinji H. et al. Staphylococcus epidermidis Esp inhibits Staphylococcus aureus biofilm formation and nasal colonization. Nature 2010; 465: 346-351. Learning Objective: To introduce the concept of bacterial biofilms and their role in chronic wound nonhealing and introduce a novel way to combat them. Takeaway Message: 1) Bacterial biofilms lead to chronic wound nonhealing. 2) Treatment of chronic wounds requires antibiofilm strategies to allow healing. 3) The S. epidermidis JK16 Esp protein is a potential candidate for such an antibiofilm strategy. P14.03 CD109 regulates macrophage recruitment in a mouse model of bleomycin-induced skin fibrosis Nermin R. Diab1 Anie Philip2 1. McGill University Faculty of Medicine, Montreal, QC; 2. Division of Plastic Surgery, Department of Surgery, McGill University, Montreal, QC Background: Fibrotic diseases such as hypertrophic scarring, scleroderma and keloid formation are pervasive medical problems for which there are no satisfactory treatment strategies. In addition to excessive ECM production, another hallmark of these disorders is an association with persistent inflammation. TGF-β signaling has been shown to play an important role in the initiation of inflammation in fibrotic diseases. We have reported that CD109 is an antagonist of TGF-β signaling, and that it reduces fibrotic processes during bleomycin-induced skin fibrosis. In this study, we examined whether the mecha- nism by which CD109 exerts anti-fibrotic effects involves regulation of inflammatory responses. Materials/Methods: 6 wild-type and 6 transgenic mice overexpressing CD109 in their epidermis were used. Mice were injected with either PBS or bleomycin and sacrificed at days 14, 21 or 28 post injection. Skin at the site of injection was harvested at 14, 21 or 28 days and mounted on slides. Inflammatory cells at the site of injection where quantified at each time point using immunohistochemical staining with antibodies specific for neutrophils (rat anti-mouse Ly-6G(Gr-1)) at day 14, and macrophages (rat anti-mouse F4/80-mAb) and T-cells (rat anti-mouse CD3-antibody) at all three time points. Results: No obvious neutrophil infiltration was evident at day-14 in transgenic or wild-type mice injected with bleomycin or PBS. CD109 overexpression, on the other hand, had significant effects on macrophage but not T-cell numbers as compared to wild-type mice, post-bleomycin injection. Indeed, overexpression of CD109 in the epidermis reduced the recruitment of macrophages to the dermis at days 14, 21 and 28, post-bleomycin injection. Interestingly, CD109 overexpression had no effect on T-cell numbers at days 14 and 28, post-bleomycin injection. However, T-cell numbers were significantly decreased in mice overexpressing CD109 on day-21 post-bleomycin injection when compared to wild-type mice(p<0.05). Conclusion: We conclude that macrophage numbers during bleomycin-induced skin fibrosis are reduced in CD109 overexpressing transgenic mice. Our results suggest that decreased macrophage recruitment might contribute to the reduced fibrotic responses seen in CD109 transgenic mice during bleomycin-induced skin fibrosis. Learning Objective: In the current study, we examine whether the mechanism by which CD109 exerts anti-fibrotic effects involves regulation of inflammatory responses. Takeaway Message: We conclude that macrophage numbers during bleomycin-induced skin fibrosis are reduced in CD109 overexpressing transgenic mice. Our results suggest that decreased macrophage recruitment might contribute to the reduced fibrotic responses seen in CD109 transgenic mice during bleomycin-induced skin fibrosis. A79 CDA Abstracts P15.01 Figure. ERASURE study design Secukinumab in subjects with moderateto-severe plaque psoriasis: results from the efficacy of response and safety of 2 fixed secukinumab regimens in psoriasis (ERASURE) Boni E. Elewski1 Mark Lebwohl2 Kim Papp3 Hidemi Nakagawa4 Bardur Sigurgeirsson5 Tsen-Fang Tsai6 Stephen Tyring6 Isabelle Hampele7 Alexander Karpov7 Silvia Helou8 Charis Papavassilis7 1. Department of Dermatology, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA; 2. Department of Dermatology, Mount Sinai School of Medicine, New York, NY, USA; 3. Probity Medical Research,Waterloo, ON; 4. Department of Dermatology,The Jikei University School of Medicine, Tokyo, Japan; 5. Faculty of Medicine, Department of Dermatology, University of Iceland, Reykjavik, Iceland; 6. Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine,Taipei, Taiwan; 7. Novartis Pharma AG, Basel, Switzerland; 8. Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA Learning Objective: To evaluate the efficacy of 2 doses (150 mg and 300 mg s.c.) of secukinumab (AIN457; a fully human anti-interleukin 17A monoclonal antibody) at Week 12 and to assess safety, tolerability, and long-term efficacy (up to 52 weeks) in subjects with moderate-to-severe plaque psoriasis. Objectives: To evaluate the efficacy of 2 doses (150 mg and 300 mg s.c.) of secukinumab (AIN457; a fully human anti-interleukin 17A monoclonal antibody) at Week 12 and to assess safety, tolerability, and long-term efficacy (up to 52 weeks) in subjects with moderate-to-severe plaque psoriasis. Methods: The ERASURE study (NCT01365455) was a double-blind, placebo-controlled, multicenter phase 3 trial . Subjects aged ≥18 years were equally randomized to: secukinumab 150 mg or secukinumab 300 mg once weekly for 4 weeks, then once every 4 weeks, starting at Week 4 through Week 48, or matching placebo (Figure). The co-primary objectives were to demonstrate superior efficacy of secukinumab vs placebo, based on the PASI 75 and investigator’s global assessment (IGA) 0 or 1 response rates at Week 12. Key secondary endpoints included psoriasis-related itching, pain, and scaling as measured by psoriasis diary, the PASI 90 response at Week 12, and maintenance of the PASI 75 and IGA 0 or 1 response at Week 52 in PASI 75 responders at Week 12. Safety and tolerability of secukinumab were assessed using adverse event monitoring, vital signs and other standard measures, including immunogenicity analyses. Results: 738 subjects with moderate-to-severe plaque psoriasis were randomized. Results up to Week 52 will be provided in the final presentation. Takeaway Message: Results from this study will contribute to the understanding of the short- and long-term efficacy and safety of secukinumab in subjects with moderate-tosevere plaque psoriasis. P15.02 Secukinumab compared with placebo and etanercept: the first 52-week head-to-head comparison of two biologics in a randomized, double-blind phase 3 study in subjects with moderate-to-severe plaque psoriasis (FIXTURE) Richard G. Langley1 Kristian Reich2 Christopher E. Griffiths3 Lluis Puig4 Lynda Spelman5 Enrique Rivas6 Norman Wasel7 Thomas Salko8 Marianne Notter8 Silvia Helou9 Charis Papavassilis8 1. Dalhousie University, Halifax, NS; 2. Dermatologikum Hamburg and GeorgAugust-Universität, Göttingen, Germany; 3. Dermatology Centre, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom; 4. Hospital de Sant Pau, Barcelona, Spain; 5.Veracity Clinical Research, Woolloongabba, QLD, Australia; 6. Dermos, Guatemala City, Guatemala; 7. Stratica Medical, Edmonton, AB; 8. Novartis Pharma AG, Basel, Switzerland; 9. Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA Objectives: To investigate the efficacy of secukinumab, a fully human anti-interleukin-17A monoclonal antibody, at Weeks 12 A80 CDA Abstracts (compared with placebo and etanercept) and 52 (compared with etanercept), in subjects with moderate-to-severe plaque psoriasis. P15.03 Methods: The FIXTURE (NCT01358578) study was a multicenter, double-blind, double-dummy, parallel-group, active-comparator– and placebo-controlled study consisting of a screening period (1-4 weeks) and 2 treatment periods: induction (12 weeks) and maintenance (40 weeks). Improvement in psoriasis symptoms and physical functioning with secukinumab compared with placebo and etanercept in subjects with moderate-to-severe plaque psoriasis and psoriatic arthritis: results of a subanalysis from the phase 3 fixture study Patients were randomized 1:1:1:1 to 1 of 4 s.c. treatment groups: Alice B. Gottlieb1 Richard G. Langley2 Sandra Philipp3 RLM Martin4 Charis Papavassilis4 Shephard Mpofu4 1. Secukinumab 150 mg at Baseline and Weeks 1, 2, 3, and 4, and every 4 weeks thereafter until and including Week 48. 2. Secukinumab 300 mg at Baseline and Weeks 1, 2, 3, and 4, and every 4 weeks thereafter until Week 48. 3. Placebo from Baseline to Week 11. PASI 75 responders at Week 12 continued on placebo thereafter. PASI 75 nonresponders were re-randomized 1:1 to secukinumab 150 mg or 300 mg at Weeks 12, 13, 14, 15, and 16, and every 4 weeks thereafter to Week 48. 4. Etanercept 50 mg twice per week from Baseline to Week 12, and once per week thereafter through Week 51, and secukinumab placebo at the same interval as secukinumab. The co-primary objectives were the superiority of secukinumab vs placebo in both the PASI 75 and investigator’s global assessment (IGA) 0 or 1 response at Week 12. Key secondary endpoints included demonstration of the superiority of secukinumab vs etanercept with respect to the PASI 75 and IGA 0 or 1 response at Week 12 and maintenance of response at Week 52. Safety and tolerability of secukinumab were assessed. 1.Tufts Medical Center, Boston, MA, USA; 2. Dalhousie University, Halifax, NS; 3. Charité Universitätsmedizin, Berlin, Germany; 4. Novartis Pharma AG, Basel, Switzerland Results: 1,307 subjects with moderate-to-severe plaque psoriasis were randomized. Short- and long-term efficacy and safety and 52-week maintenance of response results up to Week 52 will be provided in the final presentation. Results: In subjects with concomitant PsA (n=192), significant improvements in PASI75 response rates were observed with SEC150 mg and 300mg from week 4 and sustained to week 52. Improvements in physical functioning as measured by change from baseline in HAQ-DI score were significantly improved with SEC300mg. HAQ-DI reductions from baseline at week 12 were SEC300mg, -0.41 (P<0.01 for 300mg vs PBO); SEC150mg, -0.19; ETN,-0.29; PBO, 0.02. Reductions were sustained to week 52 and were more pronounced in subjects with greater disability (baseline scores ≥0.5). Both SEC and ETN were well tolerated with no unexpected safety findings. Learning Objective: To investigate the efficacy of secukinumab, a fully human anti-interleukin-17A monoclonal antibody, at Weeks 12 (compared with placebo and etanercept) and 52 (compared with etanercept), in subjects with moderate-to-severe plaque psoriasis. Takeaway Message: The FIXTURE study investigated short- and long-term efficacy and safety and 52-week maintenance of response with secukinumab compared with placebo and etanercept in a large cohort of subjects with moderateto-severe plaque psoriasis. Background: Secukinumab (SEC;AIN457), a fully human anti–IL-17A monoclonal antibody, demonstrated efficacy in phase 3 trials for treatment of plaque psoriasis. We report the efficacy and safety of secukinumab vs placebo and etanercept in patients with moderate-to-severe plaque psoriasis and concomitant PsA. Methods: Subjects aged ≥18yrs were randomized 1:1:1:1 to Secukinumab150 or 300mg, PBO, or ETN 50mg. Subjects received treatment at weeks 0,1,2,3, and 4 and Q4W thereafter until week 48. Subjects in the ETN arm received ETN 50mg twice per week from baseline to week 12, and 50mg weekly thereafter through week 51. The co-primary objectives were to show superiority of SEC vs PBO for PASI75 and investigator’s global assessment (IGA) 0/1 response at week 12. A pre-specified sub-analysis of PASI responses and changes from baseline in the Health Assessment Questionnaire–Disability Index (HAQ-DI) up to week 52 in subjects with concomitant PsA is reported here. Conclusion: In patients with psoriasis and concomitant PsA, Secukinumab improved skin symptoms and physical functioning vs placebo, with benefits evident from week 4 and sustained to week 52. SEC300 mg demonstrated significantly improved PASI 75/90 responses and greater reductions in HAQ-DI compared with ETN. These data strongly support continued evaluation of Secukinumab in patients with PsA. A81 CDA Abstracts Learning Objective: Secukinumab (SEC;AIN457), a fully human anti–IL-17A monoclonal antibody, demonstrated efficacy in phase 3 trials for treatment of plaque psoriasis. We report the efficacy and safety of secukinumab vs placebo and etanercept in patients with moderate-to-severe plaque psoriasis and concomitant PsA spectively). Patients with moderate to severe plaque psoriasis (28%) were more likely to visit their family physician than the control group (9 vs 3 visits per year, respectively). These patients missed more days of work than the control (11 vs 4, respectively) and recorded more work absences (2 vs 0.03 absence notes per year). Takeaway Message: In patients with psoriasis and concomitant PsA, Secukinumab improved skin symptoms and physical functioning vs placebo, with benefits evident from week 4 and sustained to week 52. SEC300 mg demonstrated significantly improved PASI 75/90 responses and greater reductions in HAQ-DI compared with ETN. These data strongly support continued evaluation of Secukinumab in patients with PsA. Conclusion: Chronic plaque psoriasis is a significant health condition and is associated with higher rates of comorbidity and use of health services in Canada, especially in patients with a moderate-severe condition. Learning Objective: To compare the comorbidities and healthcare resource utilization of chronic plaque psoriasis compared to a matched control cohort in a large, Canadian, real-world dataset. P15.04 Comorbidities and health resource use of chronic plaque psoriasis patients in Canada: a matched-cohort study Valerie Gregory1 Laura Luciani2 Martin Barbeau1 Robert J. Petrella3, 4, 5 Takeaway Message: Chronic plaque psoriasis is a significant health condition and is associated with higher rates of comorbidity and use of health services in Canada, especially in patients with a moderate-severe condition. P15.05 Characteristics of chronic plaque psoriasis in Canada: a retrospective database study 1. Novartis Pharmaceuticals Canada Inc., Dorval, QC; 2. Université de Montréal, Montréal, QC; 3.Western University, London, ON; 4. Lawson Health Research Institute, London, ON; 5. Indivisual Clinical Outcomes, London, ON Introduction: Compare the comorbidities and healthcare resource utilization of chronic plaque psoriasis compared to a matched control cohort in a large, Canadian, real-world dataset. Methods and Results: This was an observational, retrospective study of patients ≥ 18 years who, between 2008 and 2012 received a diagnosis of psoriasis and at least 1 treatment. Data were retrieved from the Southwestern Ontario (SWO) database, which is a representative primary care database of over 325,000 unique patient records in Ontario, Canada. Comorbidities and health resource utilization were recorded in the patient chart as per their healthcare provider. A matched control cohort was constructed based on age, gender and ethnicity. Differences between psoriasis and control groups were compared using paired and independent samples t-tests. A total of 7,776 patients in the SWO database (n=325,618) had a diagnosis of psoriasis and received at least 1 treatment between January 1, 2008 and December 31, 2012. Of these, 85% had chronic plaque psoriasis. Over half of patients with chronic plaque psoriasis were diagnosed with hypertension (61%, similar in the control group), 11% had diabetes (vs 7% in control group), 4% had depression and/or anxiety disorders (vs 1%), 6% had insomnia (vs 1%). Thirty-two percent (32%) were overweight and 24% were obese (vs 27% and 19%, re- Robert J. Petrella2, 3, 4 Valerie Gregory1 Laura Luciani5 Martin Barbeau1 1. Novartis Pharmaceuticals Canada Inc., Dorval, QC; 2.Western University, London, ON; 3. Lawson Health Research Institute, London, ON; 4. Indivisual Clinical Outcomes, London, ON; 5. Université de Montréal, Montréal, QC Introduction: The objective of this study was to describe the epidemiological characteristics and treatments for chronic plaque psoriasis in a large, Canadian, real-world dataset. Methods/Results: This was an observational, retrospective cohort of patients ≥ 18 years who, between 2008 and 2012 received a diagnosis of psoriasis (overall, scalp, nail, chronic plaque, pustular, palmoplantar pustulosis and guttate psoriasis) identified by ICD9-10 or text coding, and who were prescribed at least 1 treatment. Data were retrieved from the Southwestern Ontario (SWO) database, which is a representative primary care, researchable database of over 325,000 unique patient records in Ontario, Canada. Among 325,618 patients in the SWO database, 7,935 patients had a diagnosis of psoriasis between January 1, 2008 and December 31, 2012 (prevalence 2.44%). Of these, 98% (n=7,776) were treated. Chronic plaque psoriasis was the most common subtype of psoriasis (85%, n=6610), followed by scalp psoriasis (50%, n=3888) in patients receiving treatment. Among chronic plaque psoriasis patients, duration of disease ranged from 1 to 23 years. Mean age at diagnosis was 31 (sd=12) years. Patients A82 CDA Abstracts with mild disease were generally treated with topicals, most commonly corticosteroids (65%), salicylic acid (28%) and/or coal tar (19%). Phototherapy (NB-UVB, psoralen+UVA) and oral systemic agents (acitretin, cyclosporine, methotrexate) were also prescribed. Twenty eight percent (28%) of chronic plaque psoriasis patients had a moderate to severe condition. About 60% of moderate to severe patients were treated with phototherapy, whereas 33% were prescribed biologics (adalimumab, etanercept, infliximab, ustekinumab). the same productivity losses as the general population due to illness or disability, as reported by Statistics Canada. The mean number of days lost from work per year per subject owing to psoriasis-related events was 7.7 days for people with mild psoriasis and 16.3 days for those with moderate to severe psoriasis. The average annual cost per subject was CAD$1,495 for patients with mild psoriasis and CAD$3,171 for patients with moderate to severe psoriasis. Overall, the estimated total annual cost of productivity losses attributable to psoriasis in Canada reached approximately CAD$800 million, when extrapolating the cost per patient to the afflicted population. Conclusion: Psoriasis is a significant problem in primary care, affecting over 2% of the population. Of these, 85% have chronic plaque psoriasis and 28% are considered moderate to severe. These results confirm those observed in the literature. This real-world database may be used as a resource for further examination of the effectiveness of psoriasis treatment and health resource use. Conclusion: Work absenteeism attributable to psoriasis represents an important component of the burden of psoriasis in Canada. Nonetheless, there are limited data and further studies assessing productivity loss in psoriasis are required to better inform health care professionals in Canada. Learning Objective: To describe the epidemiological characteristics and treatments for chronic plaque psoriasis in a large, Canadian, real-world dataset. Learning Objective: To explore the existing evidence regarding the work productivity losses related to psoriasis, and to estimate the cost of these productivity losses in Canada. Takeaway Message: Psoriasis is a significant problem in primary care, affecting over 2% of the population. Results from this real-world database study are consistent with the existing literature, such that 85% of psoriasis patients have chronic plaque psoriasis and 28% are considered moderate to severe. Takeaway Message: Work absenteeism attributable to psoriasis represents an important component of the burden of psoriasis in Canada. P15.07 P15.06 Productivity losses related to psoriasis in Canada: a literature review Valerie Gregory1 Laura Luciani2 Martin Barbeau1 Malignancy events in the psoriasis longitudinal assessment and registry (PSOLAR) study: current status of observations Richard Langley1 Mark Lebwohl2 David Fiorentino3 Vincent Ho4 Steve Fakharzadeh5 Steve Calabro5 Wayne Langholff5 Marc Chevrier5 1. Novartis Pharmaceuticals Canada Inc., Dorval, QC; 2. Université de Montréal, Montréal, QC Introduction: Psoriasis has a significant impact on patients’ quality of life, resulting in important losses in productivity. The objective of this study was to explore the existing evidence regarding the work productivity losses related to psoriasis, and to estimate the cost of these productivity losses in Canada. 1. Dalhousie University, Halifax, NS; 2. Mount Sinai Medical Center, New York, NY, USA; 3. Stanford University, Stanford, CA, USA; 4. University of British Columbia,Vancouver, BC; 5. Janssen Scientific Affairs, LLC, Horsham, PA, USA Methods and results: A literature search was conducted in PubMed using combinations of keywords relating to psoriasis and productivity for articles published between 2000 and 2013. Twelve relevant articles identified costs or productivity losses related to psoriasis. Among these, only two articles reported work absenteeism results in the Canadian population. The number of days lost from work as a consequence of psoriasis was extracted from these two articles. Lost productivity, including only work absenteeism, was calculated based on an 8-hour work day and the Canadian mean hourly wage for full time employees. Mild psoriasis patients were estimated to have Methods/Results: PSOLAR is a multicenter, longitudinal, observational study evaluating long-term safety and clinical outcomes for patients receiving (or eligible to receive) treatment for psoriasis with biologics and/or conventional systemic agents.The accrual of malignancies excluding NMSC (ie, basal/ squamous cell carcinomas) in PSOLAR overall and by exposure sub-groups is reported. Rates of malignancy are assessed using a definition of exposure based on whether patients had ever been exposed to a given therapy at any time prior to the event. In cases of exposure to multiple therapies, malignancies are attributed to treatment groups in the order of ustekinum- Introduction: To report the accrual of malignancies excluding non-melanoma skin cancers(NMSC) in PSOLAR. A83 CDA Abstracts ab first, infliximab/golimumab second, other biologics third, and non-biologic therapy last. As of the August 23,2012 data cut, 11,900/12,000 patients had enrolled in PSOLAR (22,918 cumulative patient-years of follow up). Unadjusted rates of malignancy, excluding NMSC, across treatment groups were: ustekinumab 0.53 events per 100 patient years of observation (PYO) [95%CI:0.35, 0.76; 28/5332 PYO], infliximab/golimumab 0.70 per 100 PYO [95% CI:0.44, 1.06; 22/3136],other biologics (almost exclusively etanercept/adalimumab) 0.68 per 100 PYO[95% CI: 0.53, 0.87; 69/10093], non-biologic therapy 0.83 per 100 PYO[95%CI:0.58,1.14;36/4357], and overall 0.68 per 100 PYO[95%CI:0.57,0.79; 55/22918]. Limitations: Due to channeling of therapy, there may be differences in subgroup characteristics. Formal comparison will require statistical modeling to adjust for patient characteristics and risks, including consideration of multiple treatments. Conclusions: Although many patients exposed to biologics have been exposed to multiple prior immunosuppressive therapies, rates of malignancy appear limited overall. Unadjusted rates show a trend towards lower rates in ustekinumab-treated patients, despite the rules of event attribution, compared to other treatment groups. These are preliminary results;PSOLAR will follow patients for up to 8years, providing additional data over time. PSOLAR is a powerful resource for tracking safety events of interest among patients eligible to receive systemic therapies. Learning Objective: To report the accrual of malignancies excluding non-melanoma skin cancers(NMSC) in PSOLAR. Methods/Results: PSOLAR is a multicenter, prospective, longitudinal, observational study that will follow patients for at least 8 years in academic and community-based settings. Eligible patients are aged ≥18 years, have a diagnosis of psoriasis and are currently receiving or are candidates to receive systemic therapies for psoriasis. Demographics and medical/ family history are collected at enrollment. Collections at 6 month intervals include: adverse events, disease activity, quality of life, economic status, healthcare utilization and interval therapies. International sites in North America, Latin America, and Europe had recruited 11,900 of a target of 12,000 patients as of 23 August 2012. Baseline characteristics were as follows: median age: 49.0 years (range 12-100 years), with 61.4% of patients ≥ 45 years; 54.7% male; 83.1% white; mean body mass index (BMI) 30.9 (SD 7.2); and mean disease duration of 17.5 years (SD 13.5 years) since diagnosis. Medical history includes: 38.2% of patients with cardiovascular disorders; 14.4% with pulmonary disorders; 20.7% with psychiatric disorders; 18.8% with endocrine disorders; and 6.2% with skin cancer. Infections requiring treatment in the 3 years preceding enrollment occurred in 24.6% of patients, of which 21.6% were bacterial infections. Mean body surface area (BSA) coverage at enrollment was 12.1% (SD 17.5%), mean physicians’ global assessment (PGA) score was 2 (SD 1.2); 96.9% of patients presented with plaque type psoriasis. Psoriasis medications (current and historical) included topicals (96.9%), phototherapy (54.6%), systemic steroids (23.4%), immunomodulators (47.6%), and biologics (72.1%). Conclusions: As a disease directed registry, PSOLAR offers the ability to collect disease activity and outcomes associated with many therapies in actual clinical practice. Takeaway Message: Although many patients exposed to biologics have been exposed to multiple prior immunosuppressive therapies, rates of malignancy appear limited overall. P15.08 Psoriasis longitudinal assessment and registry (PSOLAR): global update of a multicentre, open registry of psoriasis patients Learning Objective: To report the baseline demographics and characteristics of participants enrolled in the PSOLAR study. Takeaway Message: As a disease directed registry, PSOLAR offers the ability to collect disease activity and outcomes associated with many therapies in actual clinical practice. Kim Papp1 Matthias Augustin2 Vincent Ho3 Craig Leonardi4 Alan Menter5 Bruce Strober6 Steve Calabro7 Wayne Langholff7 Steve Fakharzadeh7 Marc Chevrier7 1. Probity Research,Waterloo, ON; 2. University Clinics of Hamburg, Hamburg, Germany; 3. University of British Columbia,Vancouver, BC; 4. Central Dermatology, St. Louis, MO, USA; 5. Baylor Research Institute, Dallas,TX, USA; 6. University of Connecticut, Farmington, CT, USA; 7. Janssen Scientific Affairs, LLC, Horsham, PA, USA Introduction: The objective of this analysis is to report the baseline demographics and characteristics of participants enrolled in the PSOLAR study. A84 CDA Abstracts P15.09 Major adverse cardiovascular events in the psoriasis longitudinal assessment and registry (PSOLAR) study: current status of observations Robert Bissonnette Alice B. Gottlieb Francisco Kerdel Luigi Naldi4 Kim Papp5 Steve Fakharzadeh6 Steve Calabro6 Wayne Langholff6 Marc Chevrier6 1 2 3 1. Innovaderm Research, Inc, Montreal, QC; 2.Tufts Medical Center, Boston, MA, USA; 3. University of Miami, Miami, FL, USA; 4. Centro Studi GISED, Ospendali Riuniti, Bergamo, Italy; 5. Probity Research,Waterloo, ON; 6. Janssen Scientific Affairs, LLC, Horsham, PA, USA Introduction: The objective of this analysis is to report the accrual of major adverse cardiovascular events(MACE) in PSOLAR. Methods/Results: PSOLAR is a multicenter, longitudinal, observational study evaluating long-term safety and clinical outcomes for patients receiving (or eligible to receive) treatment for psoriasis with biologics and/or conventional systemic agents. The accrual of MACE in PSOLAR overall and by exposure sub-groups is reported. MACE are defined as cardiovascular death, non-fatal stroke, and confirmed non-fatal myocardial infarction. MACE rates are assessed using definitions of exposure based on treatment at any time or treatment within 91 days preceding the reported event. In cases of exposure to multiple therapies, MACE are attributed to treatment groups in the order of ustekinumab first, infliximab/golimumab second, other biologics third, and non-biologic therapy last. As of the August 23,2012 data cut,11,900/12,000 patients had enrolled in PSOLAR(22,918 cumulative patient-years of follow-up). Unadjusted MACE rates, based on exposure at any time, were:ustekinumab 0.28 events per 100 years of patient observation(PYO) [95%CI:0.16,0.46;15/5332 PYO]; infliximab/ golimumab 0.32 per 100 PYO [95%CI:0.15,0.59;10/3136 PYO]; other biologics (almost exclusively etanercept and adalimumab) 0.34 per 100 PYO[95%CI: 0.23,0.47;34/10093 PYO]; nonbiologic therapy 0.55 per 100 PYO[95%CI:0.35, 0.82; 24/4357 PYO]; overall 0.36 per 100 PYO[95% CI: 0.29,0.45;83/22918 PYO]. Similar rates of MACE per 100 PYO were observed in the analysis of exposure based on treatment received within 91 days of an event. Limitations: Due to channeling of therapy, there may be differences in subgroup characteristics. Formal comparison will require statistical modeling to adjust for patient characteristics and risks,including consideration of multiple treatments. Conclusions: Although the numbers of MACE are limited,unadjusted MACE rates are generally similar across biologic treatment groups and trended higher in the no biologic group. These are preliminary results; PSOLAR will follow patients for up to 8years,providing additional data over time. PSOLAR represents a powerful resource for tracking safety events of interest,such as MACE,among patients receiving treatment for moderate to severe psoriasis. Learning Objective: To report the accrual of major adverse cardiovascular events(MACE) in PSOLAR. Takeaway Message: Although the numbers of MACE are limited,unadjusted MACE rates are generally similar across biologic treatment groups and trended higher in the no biologic group. P15.10 Major adverse cardiovascular events among initiators of biologic therapies in the psoriasis longitudinal assessment and registry (PSOLAR) study Robert Bissonnette1 Alice B. Gottlieb2 Francisco Kerdel3 Luigi Naldi4 Kim Papp5 Steve Calabro6 Wayne Langholff6 Marc Chevrier6 1. Innovaderm Research, Inc, Montreal, QC; 2.Tufts Medical Center, Boston, MA, USA; 3. University of Miami, Miami, FL, USA; 4. Centro Studi GISED, Ospendali Riuniti, Bergamo, Italy; 5. Probity Research,Waterloo, ON; 6. Janssen Scientific Affairs, LLC, Horsham, PA, USA Introduction: The objective of this analysis is to assess rates of major adverse CV events(MACE) among patients who initiated a new biologic during PSOLAR. Methods/Results: PSOLAR is a multicenter,longitudinal ,observational study evaluating long-term safety and clinical outcomes for patients receiving(or eligible to receive) treatment for psoriasis with biologics and/or conventional systemic agents. Rates of MACE(CV death,non-fatal stroke,and non-fatal myocardial infarction) among initiators of biologics in PSOLAR are summarized. As of the August 23,2012 data cut,11,900/12,000 patients enrolled in PSOLAR. 57 MACE occurred across biologic treatment groups;of these 20 MACE were reported among patients who initiated a new biologic. The proportions of patients who initiated a new biologic and had a MACE at any time after starting treatment were:adalimumab (ADA) 10/1121(0.89%, 95%CI 0.49%-1.63%), etanercept(ETA) 3/468(0.64%,95%CI 0.22%-1.87%), infliximab (IFX) 3/250(1.20%,95% CI 0.41%3.47%) and ustekinumab( UST) 4/1576(0.25%,95%CI 0.10%0.65%). Of patients with MACE, 3/1121(0.27%,95% CI 0.09%0.78%) in ADA group, 1/468(0.21%,95%CI 0.04%-1.2%) in ETA group, 0/250(0%) in IFX group and 0/1576(0%) in UST group had their MACE within 91 days of starting treatment. Baseline demographics and features were generally similar across A85 CDA Abstracts groups with some exceptions (eg.higher body mass index, and proportions of patients with psoriatic arthritis and CV disease for IFX patients).Onset of MACE after starting treatment ranged from 16-789 days for TNF-alpha inhibitor initiators and 204-814 days for UST initiators. Among the subsets of bionaïve new users,8/698 (1.15%,95%CI 0.58%-2.25%) in TNF-alpha inhibitor group and 0/352(0%) in UST group had a MACE after starting treatment. Of those in the bionaïve TNF-alpha inhibitor new user group,4 occurred within 91 days of starting treatment. Limitations:MACE among biologic initiators were limited in number and rates were not adjusted for differences among groups.CV events were confirmed by registry personnel but have not been externally adjudicated. receptor (FcERI) on the cell surface. Recently, phase 3 studies have demonstrated the safety and efficacy of omalizumab in the treatment of CSU. In these studies, treatment with 150mg and 300mg omalizumab every 4 weeks was shown to improve significantly the symptoms of the patients (itching and wheals number) in a dose dependent manner. Following this phase 3 program, a phase 3b study, OPTIMA, has been designed in order to understand further the response of CSU patients to omalizumab. The main two objectives of the study are to gather data on the impact of withdrawl and retreatment with omalizumab in CSU patients initially responding to treatment and efficacy of optimizing the dose from 150mg to 300mg in patients not achieving a UAS7<6 after 6 months of treatment. Conclusions: At this time,no distinct patterns of MACE have been observed after initiation of biologic therapies among PSOLAR patients.Further analyses adjusting for demographic features,CV risk factors and biologic exposure are planned. Methods/Results: This study will be a: 320 patients, international, multi-center, randomized, open labeled trial. Efficacy of omalizumab 150mg or 300mg doses administered every 4 weeks will be monitored by using the UAS7 score and quality of life questionnaires. The study design will be presented here. Learning Objective: To assess rates of major adverse CV events(MACE) among patients who initiated a new biologic during PSOLAR. Takeaway Message: At this time,no distinct patterns of MACE have been observed after initiation of biologic therapies among PSOLAR patients. P15.11 Optima: an ongoing phase 3b study to evaluate the efficacy of optimized retreatment and step-up therapy with omalizumab in patients with chronic spontaneous urticaria refractory to standard of care Charles Lynde2 Gordon Sussman4 Wayne Gulliver3 William Yang6 Jacques Hébert5 Sam Khalil1 Olivier Chambenoit1 1. Novartis Pharma Canada, Dorval, QC; 2. Mediprobe Research, London, ON; 3. Memorial University of Newfoundland/NewLab Clinical Research Inc, St John’s, NL; 4.The university of Toronto,Toronto, ON; 5. Centre de Recherche Appliquée en Allergie de Québec, Québec, Québec, QC; 6. Ottawa Allergy Research Corporation, Ottawa, ON Introduction: Chronic spontaneous urticaria (CSU), also called chronic idiopathic urticaria (CIU), is a condition where patients experience frequent pruritic hives with associated erythema and/or episodes of angioedema that have no apparent external trigger and which last for at least 6 weeks. Mast cells are a key effector cells in this condition. Omalizumab is a humanized neutralizing anti-IgE indicated for moderate to severe persistent asthma in Canada. Omalizumab has a direct impact on mast cells by reducing the density IgE high affinity Conclusion: This will be the first phase IIIb study worldwide to evaluate the efficacy of optimized re-treatment and step-up Therapy with Omalizumab in patients with Chronic Spontaneous Urticaria. Learning Objective: Chronic spontaneous urticaria (CSU), also called chronic idiopathic urticaria (CIU), is a condition where patients experience frequent pruritic hives with associated erythema and/or episodes of angioedema that have no apparent external trigger and which last for at least 6 weeks. Mast cells are a key effector cells in this condition. Omalizumab is a humanized neutralizing anti-IgE indicated for moderate to severe persistent asthma in Canada. Omalizumab has a direct impact on mast cells by reducing the density IgE high affinity receptor (FcERI) on the cell surface. Recently, phase 3 studies have demonstrated the safety and efficacy of omalizumab in the treatment of CSU. In these studies, treatment with 150mg and 300mg omalizumab every 4 weeks was shown to improve significantly the symptoms of the patients (itching and wheals number) in a dose dependent manner. Following this phase 3 program, a phase 3b study, OPTIMA, has been designed in order to understand further the response of CSU patients to omalizumab. The main two objectives of the study are to gather data on the impact of withdrawl and retreatment with omalizumab in CSU patients initially responding to treatment and efficacy of optimizing the dose from 150mg to 300mg in patients not achieving a UAS7<6 after 6 months of treatment. Takeaway Message: This will be the first phase IIIb study worldwide to evaluate the efficacy of optimized re-treatment and step-up Therapy with Omalizumab in patients with Chronic Spontaneous Urticaria. A86 CDA Abstracts P16.01 Allergic contact dermatitis to black rubber milking equipment in a dairy farmer P16.02 The most common co/cross reactants in p-phenylenediamine allergic patients and the impact on available alternative hair dyes Tiffany Chen2 Melanie D. Pratt1 Gurbir Dhadwal; Gillian de Gannes 1. Division of Dermatology, University of Ottawa, Ottawa, ON; 2. University of Toronto,Toronto, ON Introduction: Paraphenylenediamine (PPD) is a colouring agent known to cause severe allergic contact dermatitis. Traditionally, hair dye has been the primary route of exposure to PPD; however, new patterns of occupational exposure to PPD and cross-reacting substances are emerging. Black rubber mix is used to colour rubber black or grey and is found in several common industrial and household products. It contains isopropyl paraphenylenediamine, a chemical that has been associated with cross-reactivity to PPD. Methods and Results: We describe the case of a 33 yearold dairy farmer who presented with a severe allergic contact dermatitis on the dorsal aspects of his hands and forearms. The patient stated that he often employed a black rubber milking device when milking cows that would directly contact his dorsal thumb and forearm. Additional history revealed that many years earlier, the patient had developed a severe allergic contact dermatitis several days after receiving a temporary henna tattoo. The patient was patch-tested with the North American Contact Dermatitis Group series, the rubber series, and various other rubber accelerators. Patch testing results revealed strong positive reactions to PPD, black rubber mix, and mecaptobenzothiazol. Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC Background: P-phenylenediamine (PPD) is a common component of hair dyes and is also a common contact sensitizer. Rates of sensitization to PPD, amongst patients presenting for patch testing, range between 2%-12%. Given the rates of sensitization, hair dyes containing alternatives to PPD have been developed. Here we attempt to determine if contact sensitization to the co/cross reactants found in these alternative hair dyes limit their use by PPD allergic patients. Methods/Results: We retrospectively reviewed all patch test results of patients presenting to the UBC Contact Dermatitis Clinic between January 2008 and June 2013. All patients were patch tested with a screening series of 65-80 allergens as well as supplemental allergens as clinically indicated. The American Contact Dermatitis Society Contact Allergen Management Program (CAMP) database was queried for hair dyes without PPD and each of the most common co/cross reactants. Of the 95 patients found to be patch test positive to PPD, 74(78%) had at least one other positive reaction. The most common co/cross reactants, constituting statistically significantly greater than 1% of PPD positive patients, were nickel(24%), ammonium persulfate(18%), cobalt (16%), p-toluenediamine sulfate(15%), 4-aminophenol(14%), fragrance mix I(12%), toluenediamine base(9%), fragrance mix II(7%), myroxylon pereirae resin(7%), glyceryl thioglycolate(7%), 3-aminophenol(6%), black rubber mix(6%), thiuram mix(6%) and carba mix(6%). The CAMP database contained 17 PPD free dyes. Co/ cross reacting to nickel, cobalt, ammonium persulfate, glyceryl thioglycolate, p-toluenediamine sulfate/base, black rubber mix, thiuram mix or carba mix did not further restrict the number of dyes. Cross reacting to 4-aminophenol restricted available dyes to 16. Positivity to any of the fragrances restricted patients to 1 non-permanent dye. Conclusions: This case highlights an uncommon yet important source of exposure to a substance known to crossreact with PPD in the occupational setting. Our patient likely became sensitized to PPD at the time of his prior henna tattoo. Subsequent exposure to the black rubber milking device resulted in his current presentation. Given the increasing number of products containing PPD and related chemicals found in the workplace, an awareness of such products and the occupational implications of reactions to these products is warranted. Learning Objective: To highlight the cross-reactions that can occur with PPD and related chemicals. To describe the occupational implications of a PPD allergy. Takeaway Message: Given the increasing number of products containing PPD and related chemicals found in the workplace, an awareness of such products and the occupational implications of reactions to these products is warranted. Conclusions: Patients who are allergic to PPD are commonly allergic to other chemicals found in hair dyes. Patients that are PPD allergic and also react to fragrances are severely restricted in their choices of hair dye. Learning Objective: To understand if chemicals, that PPD sensitized patients commonly co/cross react to, restrict their choice of hair dyes. A87 CDA Abstracts Takeaway Message: Patients that are PPD allergic and also react to fragrances are severely restricted in their choices of hair dye. Takeaway Message: Lauryl glucoside is an important marker for allergenicity and serves as a marker for cross-reactions to a wide group of compounds found in many products. P16.03 P16.05 Lauryl glucoside - a valuable marker of cross reactions during patch testing Lessons learned in occupational dermatology from Australia Jeewanjit S. Gill1 Laurie M. Parsons2 Tiffany Kwok1 Rosemary Nixon2 1. University of Ottawa, Ottawa, ON; 2. University of Calgary, Calgary, AB 1. Division of Dermatology & Cutaneous Sciences, University of Alberta, Edmonton, AB; 2. Skin and Cancer Foundation, Melbourne,VIC, Australia Background: Lauryl glucoside is a common compound found in a variety of products that include shampoos, soaps, deodarants, toilet wipes, baby wipes, and cosmetics. It often functions as a surfactant and/or emulsion stabilizer. Cross reactivity of this compound during patch testing has been reported but a comprehensive search has not been conducted to date. Objective: To discuss emerging trends and lessons learned during an occupational contact dermatitis mentorship elective in Australia. Methods: Three case vignettes of cutaneous allergy seen in the Occupational Dermatology Clinic at the Skin and Cancer Foundation in Melbourne, Australia will be presented. Methods: A comprehensive literature search was conducted using Medline, Scopus, Google Scholar, and individual dermatology journals. Key words included “lauryl glucoside”, “contact dermatitis”, and “patch testing”. An analysis of similar glucoside compounds was also done. Results: A total of 12 articles were found. Even though lauryl glucosides have been suggested to cross react with alkyl glucosides, the specificity and range of these moieties is immense. They can include hydrocarbon chains (C10-C22), cyclical rings, as well as aromatic groups. The list of compounds commonly encountered include arachidyl glucoside, butyl glucoside, caprylyl/capryl glucoside, cetearyl glucoside, coco glucoside, ethyl glucoside, hexadecyl glucoside, isostearyl glucoside, myristyl glucoside, octadecyl glucoside, octyldodecyl glucoside, undecyl glucoside, glucose homopolymers, dodecylether, and glucopyranose. Interestingly, the glucoside base is a hexose structure and diastereomers may also be implicated in cross reactivity. Conclusion: Lauryl glucoside is an important marker for allergenicity and serves as a marker for cross-reactions to a wide group of compounds found in many products. Learning Objective: To demonstrate the importance of lauryl glucoside as a marker for patch testing. Results: A 47-year old automotive emissions worker with hand dermatitis was patch test positive to methylchloroisothiazolinone/methylisothiazolinone (MCI/MI) and methylisothiazolinone (MI), found in a hand cleaner at work as well as in numerous personal care products. A 46 year-old endoscopy technician developed respiratory symptoms as well as an eruption on the hands within minutes of entering the endoscopy suite, and was found to be prick test (but not patch test) positive to chlorhexidine. A 31 year-old nuclear medicine technologist had severe atopic dermatitis on her body which cleared with conventional treatment, but her hand dermatitis persisted. Patch testing was positive for coconut diethanolamide in her hand cleanser at work. Conclusions: 1) Contact dermatitis to MCI/MI and MI alone is found in numerous occupational and non-occupational exposures and has become increasingly relevant in Australia. The Australian Baseline Series has expanded to include methylisothiazolinone as an allergen on its own. 2) It is important to delineate between immediate and delayed hypersensitivity reactions, based on patient history. 3) Consider patch testing all atopics recalcitrant to treatment. Acknowledgements: American Contact Dermatitis Society Mentoring Award, Canadian Dermatology Foundation Frederick Kalz Bursary Learning Objective: To discuss emerging trends and lessons learned during an occupational contact dermatitis mentorship elective in Australia. A88 CDA Abstracts Takeaway Message: 1) Contact dermatitis to MCI/MI and MI alone is found in numerous occupational and non-occupational exposures and has become increasingly relevant in Australia. The Australian Baseline Series has expanded to include methylisothiazolinone as an allergen on its own. 2) It is important to delineate between immediate and delayed hypersensitivity reactions, based on patient history. 3) Consider patch testing all atopics recalcitrant to treatment. contact dermatitis with re-exposure to unpolymerized acrylates. P16.06 Acrylate systemic contact dermatitis Maxwell B. Sauder1 Melanie D. Pratt1, 2 1. University of Ottawa, Ottawa, ON; 2. North American Contact Dermatitis Group, Ottawa, ON Background: Acrylates, the 2012 American Contact Dermatitis Society allergen of the year, are found in a range of industries and products including the absorbent materials contained within feminine pads. When fully polymerized, acrylates are non-immunogenic; however, if not completely cured the monomers can be potent allergens resulting in delayed-type hypersensitivity reactions (type IV allergic reaction). Objective: A 28 year old female is presented that had her teeth varnished with Septodont’s Isodan that contains 2-hydroxyethyl methacrylate (HEMA) with no initial reaction. Approximately 1 month later, the patient developed a genital dermatitis secondary to her feminine pads. The initial reaction resolved but 5 month’s later the patient developed a systemic contact dermatitis after receiving a second varnishing. Methods: The patient was patch tested to the North American Contact Dermatitis standard screening series, select acrylates, select vehicles and preservatives, sunscreen series, flavours and fragrances series and the patient’s own pads both wet and dry pieces from various layers. Patch test readings were performed at 48 and 96 hours. Results: The patient was dramatically patch test positive to many acrylates: methylmethacrylate, hydroxyethyl methacrylate, butyl methacrylate, hydroxypropyl methacrylate, ethylene glycol dimethacrylate, triethylene glycol dimethacrylate, butanediol dimethacrylate, urethane dimethacrylate, hexanediol diacrylate, tetrahydrofurfuryl methacrylate, triethylene glycol dimethacrylate, dimethyl ethyl methacrylate, tripropylene glycol diacrylate and trimethylolpropane triacrylate. Learning Objective: To present a case demonstrating: 1. Allergic contact dermatitis to unpolymerized acrylates 2. Cross sensitization to various other acrylates 3. Systemic contact dermatitis from acrylates Takeaway Message: This case demonstrates a reaction to unpolymerized acrylates within a feminine pad as well as broad cross sensitization to acrylates and the potential for systemic contact dermatitis with re-exposure to unpolymerized acrylates. Conclusion: This case demonstrates a reaction to unpolymerized acrylates within a feminine pad as well as broad cross sensitization to acrylates and the potential for systemic A89 CDA Abstracts P17.01 An array of mobile apps in dermatological surgery Joshua M. Mercer University of Alberta, Edmonton, AB As of June 2013, there were 19619 and 8,209 medical applications (apps) available for the Apple and Android platforms, respectively. Hence, finding useful dermatology apps by physicians, residents and medical students can be overwhelming. Therefore, I decided to methodically review hundreds of apps obtained by using the following keywords: dermatology, medications, skin cancer, skin surgery and melanoma; in an attempt to create a short list of credible apps, organized into functional categories, that would be clinically relevant for dermatological surgeons or their patients. Learning Objective: To create a short list of credible apps, organized into functional categories, that would be clinically relevant for dermatological surgeons or their patients. Takeaway Message: • Recent developments in technology, including mobile apps and teledermatology, are shaping the way in which the practice of Dermatology is being conducted. • Currently there are hundreds of Dermatology apps and counting, some of which can be useful in your daily practice or for your patients. • Caution must be used regarding patient confidentiality, data storage and the accountability of some apps. P18.01 Hot-spots of CTCL cases in Houston and Texas: a comparison of the MD Anderson and Texas Cancer Registries Ivan V. Litvinov1 Michael T. Tetzlaff2 Elham Rahme1 Pamela Gangar2 Michelle A. Jennings2 Kevin Pehr1 Denis Sasseville1 Madeleine Duvic2 1. McGill University, Montreal, QC; 2.The University of Texas MD Anderson Cancer Center, Houston,TX, USA Background: Cutaneous T-Cell Lymphomas (Mycosis Fungoides and the leukemic variant, Sézary Syndrome) are rare cancers with a documented incidence of ~4-8 cases per million individuals per year. Currently, the pathogenesis of CTCL remains only partially understood. Reports of incidence of Mycosis Fungoides in married couples and families raise a possibility that there might be an important environmental trigger for this disease. However, to date no unequivocal geographic hotspots have been documented for this cancer. Methods: We analyzed by region, zip code, age and ethnicity the demographic data of 1047 patients from Texas, who were seen in a CTCL clinic at the MD Anderson Cancer Center (MDACC) during 2000-2012 using the MDACC database. In addition de-identified data on CTCL incidence was requested from the Texas Cancer Registry (TCR) database and similar analyses were performed on 1970 patients with MF and SS that were registered in that database between 1995-2010. Subsequently both data sets were cross analyzed and compared. Results: Our findings, based on the MDACC database results, document geographic clustering of patients in three communities within the Houston metropolitan area, in which the CTCL incidence rates were 10-50 times higher than the expected population rate. Moreover, analysis of incidence rates in these communities over time suggests a significant increase in the disease after ~2006. The data results from the TCR database defined the CTCL population rate for the state to be 5.57 [CI 5.34; 5.83] cases per million per year. Furthermore, the TCR database confirmed the above findings and further highlighted 4 additional putative geographic hotspots for CTCL within the state of Texas, but outside the Houston metropolitan area. In addition, in this work we summarize disease incidence patterns based on sex, age and race across the state of Texas using both databases. Learning Objective: Describe clustering of CTCL cases in the state of Texas using the MD Anderson and Texas Cancer Registry databases. Takeaway Message: Identification of geographic clustering for CTCL argues for existence of yet unknown external causes in triggering this rare cancer. Identification of additional CTCL hotspots around the world will potentially help identify these triggers and will bring us closer to preventing this disease. P18.02 Investigating the role of CD133 in melanoma stem cell niche morphogenesis Anthony B. Mak1, 2 Caroline Schnegg1 Chiou-Yan Lai3 Jason Moffat2 Mei-Yu Hsu1, 3 1. Department of Dermatology, Boston University Medical Centre, Boston, MA, USA; 2. Banting and Best Department of Medical Research, University of Toronto,Toronto, ON; 3. Department of Pathology, Brigham and Women’s Hospital, Boston, MA, USA Our battle with melanoma continues to be complicated by frequent metastasis, therapeutic resistances and clinical relapse. A90 CDA Abstracts These complications may be explained by the cancer stem cell (CSC) model, which has revolutionized the strategic considerations for modern melanoma treatment. However, melanoma stem cell (MSC) targeted therapy may be non-efficacious due to an increase in tumor plasticity (i.e. the ability to induce MSCs from differentiated melanoma cells through environmental cues in the niche) relative to certain other cancers. Thus, MSC targeting requires multipronged approaches that are not only directed to the MSCs themselves but also to their niche. We previously demonstrated that MSCs expressing the pentaspan transmembrane glycoprotein CD133 reside in a complex vascular niche comprising of authentic endotheliumlined blood vessels, tumour-derived vasculogenic mimicry (VM) channels, and mosaic vessels. Importantly, silencing of the CSC marker CD133 in melanoma cells results in reduced tumorigenicity and depletion of MSCs, as well as the inhibition of VM and niche morphogenesis in vivo. To elucidate the molecular mechanisms responsible for CD133-dependent MSC niche morphogenesis, we performed gene expression profiling using PCR-based pathway-specific arrays on a melanoma cell line and melanoma tumour xenografts transduced with lentiviral short-hairpin RNA (shRNA) interference vectors targeting either CD133 or a control transcript. A validated gene hit termed brain angiogenesis inhibitor 1 (BAI1) is significantly downregulated in CD133expressing melanoma cells and xenografts transduced with the control shRNA, suggesting it has a role as a negative regulator for MSC niche establishment and maintenance. Studies are underway to evaluate the potential of targeting CD133 and/ or upregulating BAI1 as novel niche-targeting strategies for therapy in melanoma. Learning Objective: CD133+ melanoma stem cells reside and depend on a complex vascular niche in tumours. Takeaway Message: Inhibiting CD133 to target melanoma stem cells and their niche is a promising approach for melanoma treatment. 18.03 Evaluating morbidity and association with autoimmune thyroiditis of chronic urticaria in children 50 % of spontaneous CU cases. The pathogenesis of CU and its effect on quality of life (QoL) are not well established in children. We aimed to establish a registry of CU in children to assess autoimmunity, QoL and factors affecting QoL. Between January 2013 and 2014, we recruited 35 children. Participants were queried on demographics, clinical history and QoL (CUQ2oL) through a validated questionnaire. In addition, participants filled the urticaria activity score (UAS). Blood tests were drawn to assess basophile activation, thyroid autoimmunity and confirmatory tests were performed when applicable to diagnose inducible forms. The Wilcoxon Rank Sum test and multivariate regression analysis were used to assess autoimmunity and factors associated with impaired QoL respectively. Our findings reveal that the majority of children were males (57%) presenting at a median age of 8 years (IQR: 3.75-12.0). Thyroiditis was reported in 17.1% of family members, but TSH and anti-thyroid peroxidase were normal in all patients. Physical forms occurred in 17.1 % of patients. Mean CD63 expression was 5.3% and was comparable to CD63 levels in controls. The mean weekly quality of life (UAS) score over 3 months was 6.5 on a scale of 42, which indicates a mild disease. Increased age at onset (OR=2.2, 95%CI) was associated with decreased QoL in the functionality domain and higher UAS (OR=2.16) with worse sleep domain. In conclusion, CU in children was not associated with thyroiditis or autoimmunity. Older age of onset and higher UAS may affect the quality of life in pediatric population. Our cohort will be followed for 10 years to study the natural history of CU. Learning Objective: • To understand the role of autoimmunity in the pathogenesis of chronic urticaria in children. • To determine the impact of CU on the quality of life in pediatric population. • To assess factors affecting the quality of life in children. Takeaway Message: • Compared to adults, the implication of autoimmunity and thyroiditis seems to be less important in pediatric CU. • Most children have a mild disease and good control with anti-histamines only. • Older age of onset and higher urticarial activity score may affect the quality of life in pediatric population. Elena Netchiporouk McGill University, Montreal, QC Chronic urticaria (CU) is defined when hives occur for at least 6 weeks. Recent studies suggest that autoimmunity including targeting either the mast cell IgE receptor, the IgE molecule or auto-antigens (i.g. thyroid antigens) may account for almost A91 CDA Abstracts P19.01 Effective management of eccrine angiomatous hamartoma using pulsed dye laser Joseph Doumit; Allison Vidimos Cleveland Clinic, Cleveland, OH, USA Eccrine angiomatous hamartoma (EAH) is a rare condition which presents itself as a benign tumor known to typically affect the pediatric population but may infrequently be seen in adulthood. Defining features of the condition include increased eccrine and vascular glands. Albeit clinical manifestations are variable, true diagnosis is confirmed by histological examination. There have been reports of associated hyperhidrosis and pain although the condition tends to be asymptomatic. No systemic conditions have yet been associated with EAH but in our experience we have noted concomitant onset of diabetes mellitus with our adult patients. There is no gold standard treatment for EAH but current literature has reported the following treatment options: surgical excision, pulsed-dye laser, Nd:YAG laser, botulinum toxin, and certain sclerosing agents depending on the size and symptoms of the condition. In our experience, pulsed-dye laser has provided effective treatment amongst current options. We present a case series where pulsed-dye laser proved to be a successful approach in this condition. Learning Objective: To educate the benefits of using a pulsed-dye laser for the treatment of Eccrine angiomatous hamartoma. Takeaway Message: The pulsed-dye laser is an effective modality in the treatment of Eccrine angiomatous hamartoma P20.01 Drup price listing as a requirement for meeting speakers and drug marketing displays Robert N. Richards North York General Hospital, University of Toronto,Toronto, ON Results: The media, insurance companies, governments , and the public express concerns about prescription costs. Drug company marketers recognize the physicians’ prescribing role and they collectively spend billions of dollars on physician persuasion. Marketers are full time experts. Physicians may not be fully prepared to deal with their persuasive expertise. A CBC report noted (too strongly?):-- “Doctors, who are bombarded with marketing materials promoting brand names, simply do not consider the cost burden---when they write prescriptions.” Physicians often believe that they know drug prices but, unfortunately, observational studies indicate otherwise. However, numerous studies demonstrate that physician knowledge of drug costs leads to more economical prescribing. An ideal venue to educate physicians about costs is at scientific meetings. If all educational presentations and marketing displays were required to provide drug costs at all meetings;---then physicians would be more aware of drug costs. This innovative educational practice would help dispel the common perception that there is too close a relationship between physicians and ‘big pharma’ . Some universities recommend this educational practise, but we could not identify any that required it. Conclusions: Physician knowledge of drug costs leads to more economical prescribing. The requirement to list drug prices in educational presentations and marketing displays would assist in educating physicians about drug costs. The CDA, if it decided to mandate drug price listings, would be in the forefront of drug cost education;-- as well as sending a message to the public that our first responsibility is patients. Learning Objective: Learning objective: To demonstrate that the compulsory listing of drug prices in all scientific meeting presentations, posters, and marketing displays would result in better physician education about drugs and would lead to more cost efficient prescribing. Takeaway Message: Takeaway message: Physician knowledge about drug costs results in more cost efficient prescriptions. Mandating the listing of drug prices in all scientific meeting presentations, posters, and marketing displays would be an ideal and innovative way to educate physicians about drug costs. Introduction: Drug prices are a major determinant in total health care costs. Increased physician awareness of drug costs would assist in cost efficient prescribing. Physician knowledge about drug costs would be increased if all meeting presentations and marketing displays were required to give the prices of all drugs discussed. Methods: Medline search, media review. Colleague and patient discussions. A92 CDA Abstracts P20.02 Dermatolgy drug sampling: educational and other considerations Robert N. Richards Takeaway Message: Physicians receiving drug samples should remember that everyone is affected by marketing and that sampling often leads to higher costs for patients. When possible, physician education should be received from independent sources and not from samples. North York General Hospital, University of Toronto,Toronto, ON Introduction: Product sampling is a well entrenched marketing tool. Educators and ethicists often disapprove, but physicians often approve. Educational aspects and pros and cons reviewed. Methods: Medline search. Observation of samples in our group office and hospital clinics. Colleague discussions. Results: Physicians receiving samples may feel obligated to a company and grant their representative preferential access;-resulting in greater biased prescribing of their product. Particularly true if the samples are for self or family use. Dispensed samples which are expired can reflect adversely upon the physician. Samples may benefit the patient short- term but usually cost them more later, because ordinarily, only expensive products are sampled. Samples are often of the ‘me too’ type and price is rarely given. ie: Olux-E foam: $168 whereas generic clobetasol: $20.35. Companies ONLY give samples because they are proven to increase physician prescribing. Physician education obtained from drug samples is biased. Drug education is better obtained from independent educational sources:---professional meetings, colleagues, journals, and ‘Medical Letter” type reviews. Physicians requiring topical testers to determine patient tolerance can buy them, or without obligation, contact the company for a sample without representative marketing. Expensive office and hospital space is better used for requisitions and patient educational materials than for storing overflowing samples, drug literature and discount coupons. Expensive staff and physician time is required to store and monitor samples. Abundant ‘me-too’ samples can be confusing. Educators state: “Know a few drugs and know them well.” Observational studies show that resident access to drug samples influences them to use more expensive advertised products. Conclusions: Drug sampling marketing is designed to influence physician prescribing and often leads to product bias and higher drug costs. Samples can be useful for patient testing, physician education, and occasionally for patients without funds. However independent options are usually available and should be pursued. Learning Objective: Learning objectives: Physicians accepting drug samples have a significant risk of receiving a biased drug education and of being persuaded to prescribe higher cost drugs. A93 CDA Abstracts Author Index Abbas, Mariam........................................................................................... A41 Afifi, Tarek.................................................................................................. A35 Ahluwalia, Renita...................................................................................... A37 Al-Rajaibi, Raqiya...................................................................................... A48 Alain, Jimmy............................................................................................... A76 Alavi, Afsaneh............................................................A9, A10, A12, A21, A34 Albrecht, Lorne......................................................................................... A27 Alhusayen, Raed............................................................................... A10, A55 Almohideb, Mohammad A....................................................................... A47 Anderson, John......................................................................................... A78 Anooshirvani, Niloofar..................................................................... A9, A10 Arbour, N................................................................................................... A13 Arthurs, Bryan.......................................................................................... A62 Asai,Yuka ................................................................................................ AA1 Au, Sheila........................................................................................... A24, A74 Augustin, Matthias.................................................................................... A84 Bahrani, Bahar .......................................................................................... A77 Baibergenova, Akerke.................................................................... AA1, A10 Bailey, Kristy.............................................................................................. A34 Baldwin, Sarah........................................................................................... A74 Barbeau, Martin............................................................................... A82, A83 Barber, Duane........................................................................................... A39 Barber, Kirk................................................................................................ A26 Beauregard, Solange................................................................................. A47 Beecker, Jennifer.............................................................................. A38, A69 Bélisle, Annie....................................................................................... A4, A21 Bell, Chaim................................................................................................. A60 Benohanian, Antranik................................................................................. A8 Bertrand, Janie ......................................................................................... A72 Bhogal, Meetu............................................................................................ A20 Billick, Robin.............................................................................................. A50 Bissonnette, Robert............................................. A13, A26, A58, A67, A85 Bocz, Heather........................................................................................... A31 Boggild, Andrea................................................................................ A34, A35 Bolduc, Chantal......................................................................................... A58 Botkin, Alexis A.................................................................................. A9, A76 Boull, Christina ........................................................................................ A42 Bourcier, Marc........................................................................................... A26 Bourgeault, Emilie G................................................................................ A76 Bracken, Michael B.................................................................................. A69 Brassard, Alain........................................................................... A5, A11, A12 Burns, Ariel................................................................................................ A46 Calabro, Steve......................................................................... A83, A84, A85 Cartotto, Robert...................................................................................... A42 Chalabi,Youb............................................................................................. A26 Chambenoit, Olivier................................................................................ A86 Champagne, Trevor ................................................................................. A37 Chan, An-Wen...................................................................A9, A70, A73, A76 Chandrakumar, Shivani F.......................................................................... A41 Chandran,Vinod......................................................................................... A3 Chaplin, Anna C........................................................................................ A38 Chen, Tiffany.............................................................................................. A87 Cheung, Loretta........................................................................................ A54 Chevrier, Marc......................................................................... A83, A84, A85 Chia, Justin................................................................................................. A25 Chimenti, Sergio.............................................................................. A22, A27 Cohen, Stacy ............................................................................................ A48 Colantonio, Sophia A................................................................................ A69 Coomes, Eric............................................................................................. A70 Corbo, Michael D...................................................................................... A61 Cordeiro , Brendan.................................................................. A7, A14, A69 Côté, Benoît....................................................................................... A4, A21 Coulombe, Jérôme................................................................... A3, A63, A66 Cowger, Jeffery ........................................................................................ A16 Crawford, Richard I.................................................................................... A6 Dahl, Alice.................................................................................................. A46 Danylo, Alexis............................................................................................ A34 Day, Robert M................................................................................ A22, A27 de Gannes, Gillian.................................................................. A11, A56, A87 Denburg, Judah A...................................................................................... A31 Desjardins, Danielle................................................................................. A41 Dhadwal, Gurbir.............................................................................. A68, A87 Diab, Nermin R......................................................................................... A79 Diao, Diana Y.............................................................................................. A68 Dodiuk-Gad, Roni P.................................................................................. A42 Donovan, Jeff............................................................................................. A44 Doré, Marc-Andre ........................................................................... A7, A69 Doucette, Steve............................................................................... A17, A60 Doumit, Joseph....................................................................... A36, A45, A92 Doumit, Marc............................................................................................ A19 Duronio,Vincent....................................................................................... A70 Dutil, M...................................................................................................... AA1 Dutz, Jan..................................................................................................... A43 Duvic, Madeleine............................................................................. A15, A90 Dytoc, Marlene......................................................................................... A52 Eder, Lihi....................................................................................................... A3 Ejaz, Aiza..................................................................................................... A55 El-Hadi, Hadal.............................................................................................. A2 Elewski, Boni E........................................................................................... A80 Eminger, Lindsay........................................................................................ A48 Erickson , Janelle ...................................................................................... A26 Evans, Robyn.............................................................................................. A78 Fakharzadeh, Steve................................................................. A83, A84, A85 Fausto de Souza, Dominique................................................................. A54 Ferringer, Tammie..................................................................................... A48 Fiorentino, David...................................................................................... A83 Fish, Joel...................................................................................................... A42 Fitzpatrick, Richard E............................................................................... A19 Fleming, Patrick......................................................................................... A55 Foley, Peter ...................................................................................... A22, A27 Fowler, Robert ......................................................................................... A50 A94 CDA Abstracts Fredholm, Simon....................................................................................... A14 Fung, Kinwah............................................................................................. A73 Gang, Li....................................................................................................... A70 Gangar, Pamela................................................................................. A15, A90 Gattey, Natasha......................................................................................... A77 Geduld, Jennifer........................................................................................ A35 Ghassemi, Farhad..................................................................................... A10 Ghesquiere, Wayne.................................................................................. A35 Ghiasi, Nazli................................................................................................. A7 Gilbert, Martin................................................................................... A7, A69 Gill, Jeewanjit S........................................................................ A36, A75, A88 Gill, Pavandeep.......................................................................................... A13 Gladman, Dafna D....................................................................................... A3 Glassman, Steven J.................................................................. A54, A68, A75 Goldberg, Hanna...................................................................................... A60 Gomez, Pilar.............................................................................................. A52 Gooderham, Melinda J............................................................................. A71 Gottlieb, Alice B............................................................................... A81, A85 Greenspoon, Jill........................................................................................ A40 Gregory,Valerie...................................................................... A23, A82, A83 Grenier, Pierre-Olivier............................................................................ A49 Griffiths, Christopher E......................................................... A22, A27, A80 Grobler, Andre............................................................................................ A2 Groff, William............................................................................................ A19 Guenther, Lyn................................................................................... A24, A44 Gulliver, Wayne.......................... A23, A29, A30, A31, A32, A33, A50, A86 Gupta, Ambika............................................................................................. A2 Habel,Youssef............................................................................................ A15 Haber, Richard M...................................................................................... A64 Haddad, Amir............................................................................................... A3 Hajek, Jan.................................................................................................... A35 Halton, Jacqueline .................................................................................... A16 Hampele, Isabelle...................................................................................... A80 Harris-Janz, Sydney................................................................................... A16 Hatami, Afshin........................................................................... A3, A63, A66 Hébert, Jacques......................................................................................... A86 Heffernan , Michael ................................................................................. A26 Helou, Silvia............................................................................................... A80 Hickey, John............................................................................................... A46 Ho, Nhung......................................................................................... A62, A63 Ho,Vincent........................................... A29, A30, A31, A32, A33, A83, A84 Holfeld, Karen.................................................................................... A2, A41 Hook, Kristen............................................................................................ A42 Hsu, Mei-Yu................................................................................................ A90 Hu, ChiaChi...................................................................................... A22, A27 Huang,Yuanshen................................................................................ A7, A14 Hull, Peter........................................................................................ AA1, A77 Humphrey, Shannon.................................................................AA1, A6, A58 Hunt, Anne-Marie..................................................................................... A49 Hylwa, Sara ............................................................................................... A42 Ibrahim, Omar........................................................................................... A45 Jack, Carolyn..................................................................................... A13, A50 Jafarian, Fatemeh.............................................................................. A65, A67 Jafarnejad, Seyed Mehdi........................................................................... A70 Jean, Sara-Elizabeth................................................................................... A72 Jennings, Michelle A......................................................................... A15, A90 Jeschke, Marc............................................................................................. A42 Johnston, Donna ...................................................................................... A16 Jones, Duncan............................................................................................ A78 Juda, Ari....................................................................................................... A56 Kain, Kevin C............................................................................................. A35 Kalia, Sunil ........................................................................................ A13, A74 Kanigsberg, Nordau........................................................................ A16, A65 Karpov, Alexander ................................................................................... A80 Katchadourian, Karine............................................................................. A61 Kerdel, Francisco...................................................................................... A85 Keystone, Jay S........................................................................................... A34 Khalil, Sam......................................................................................... A23, A86 Khosravi, Shahram.................................................................................... A70 Kim, Whan B.................................................................................... A21, A53 Kirchhof, Mark........................................................................ A11, A43, A78 Kircik, Leon ..................................................................................... A22, A27 Kirshen, Carly........................................................................................... A16 Kitchen, Jessica.......................................................................................... A70 Klekotka, Paul................................................................................... A27, A28 Kokta,Victor.............................................................................................. A64 Komierowski, Beata................................................................................. A57 Kraft, John.................................................................................................. A56 Kraft, John N................................................................................................ A2 Kricorian, Greg......................................................................................... A28 Kuhn, Susan................................................................................................ A35 Kunimoto, Brian........................................................................................ A78 Kupper, Thomas S..................................................................... A7, A14, A69 Kurian, Anil................................................................................................. A19 Kuzel, Paul.................................................................................................. A12 Kwok, Tiffany............................................................................................. A88 Lacroix, Julie............................................................................................... A38 Lai, Chiou-Yan........................................................................................... A90 Lam, Diana................................................................................................. A58 Lam, Joseph................................................................................................ A61 Lam, Kevin.................................................................................................. A70 Lam, Lauren............................................................................................... A39 Lange, Dirk................................................................................................. A78 Langholff, Wayne..................................................................... A83, A84, A85 Langley, Richard G.................................................................. A80, A81, A83 Lara-Corrales, Irene........................................................................ A33, A62 Lau, Davina................................................................................................. A60 Law, Adrienne............................................................................................ A78 Lebwohl, Mark.................................................................................. A80, A83 Lee, Tim...................................................................................................... A68 Leonardi, Craig............................................................... A22, A26, A27, A84 Leung, Jordan............................................................................................. A12 Levy, Jonathan............................................................................................ A11 Li, Monica K............................................................................. A17, A57, A60 A95 CDA Abstracts Libman, Michael........................................................................................ A35 Lima, Hermenio C........................................................................... A16, A31 Litvinov, Ivan V..........................................................A7, A14, A15, A69, A90 Liu, Annie............................................................................................. A9, A76 Lovegrove, Fiona....................................................................................... A18 Luciani, Laura.................................................................................... A82, A83 Lui, Harvey................................................................................................. A68 Lynde, Charles W...............................................................A1, A2, A26, A86 Maari, Catherine....................................................................................... A58 Mahmood, Muhammad..................................................................... A5, A75 Maibach, Howard...................................................................................... A12 Maini, Priya................................................................................................. A71 Mak, Anthony B......................................................................................... A90 Malaiyandi,Viba......................................................................................... A55 Malhotra, Neel.......................................................................................... A61 Mallya, Usha............................................................................................... A23 Marcil, Isabelle ............................................................................................ A8 Marcoux, Danielle.................................................................................... A66 Marinas, Joseph E...................................................................................... A16 Martin, RLM............................................................................................... A81 Martinka, Michal................................................................................. A6, A70 Mashiko, S................................................................................................... A13 Mathieu, Steve........................................................................................... A47 McCarthy, Anne........................................................................................ A35 McCourt, Collette.................................................................................... A24 McEvoy, Alana C........................................................................................ A65 McLean, David........................................................................................... A68 Menter, Alan............................................................................. A27, A28, A84 Mercer, Joshua M....................................................................................... A90 Mereniuk, Alexandra................................................................................ A67 Metzger, Daniel......................................................................................... A61 Miedzybrodzki, Barbara........................................................................... A47 Miliszewski, Monica.................................................................................. A43 Miller-Monthrope,Yvette........................................................................ A38 Miller, Robert................................................................................... A20, A46 Milmont, Cassandra E..................................................................... A27, A28 Mioduszewski, Margaret J....................................................................... A57 Mistry, Nisha.............................................................................................. A21 Moffat, Jason.............................................................................................. A90 Mpofu, Shephard....................................................................................... A81 Murray, Christian........................................................................................ A9 Mussani, Farheen............................................................................. A33, A52 Mydlarski, P. Régine ........................................................................ A25, A57 Nakagawa, Hidemi .................................................................................. A80 Naldi, Luigi................................................................................................. A85 Nantel-Battista, Mélissa.................................................................... A8, A70 Neagoe, Christine ................................................................................... A54 Netchiporouk, Elena....................................................................... A15, A91 Nguyen, Khue................................................................................... A47, A50 Nguyen,Van-Hung.................................................................................... A65 Nigen, Simon............................................................................................. A58 Nirula, Ajay........................................................................................ A27, A28 Nixon, Rosemary..................................................................................... A88 Noiles, Kristin L.............................................................................. A56, A58 Notter, Marianne...................................................................................... A80 O’Toole, Ashley C............................................................................ A38, A54 Odum, Niels.............................................................................................. A14 Olynych, Tim.............................................................................................. A31 Ortonne, Jean-Paul.......................................................................... A27, A28 Pannu, Mohammad................................................................................... A35 Papavassilis, Charis.......................................................................... A80, A81 Papp, Anthony............................................................................................ A43 Papp, Kim....................................................... A22, A26, A27, A28, A29, A30 ........................................................................ A31, A32, A33, A80, A84, A85 Parsons, Laurie M.......................................................... A17, A43, A60, A88 Pehr, Kevin.................................................................................. A7, A15, A90 Petrella, Robert J....................................................................................... A82 Philip, Anie.................................................................................................. A79 Philipp, Sandra........................................................................................... A81 Poelman, Susan.......................................................................................... A39 Polcari, Ingrid............................................................................................. A42 Pope, Elena................................................................................................. A63 Posso-De Los Rios, Claudia J................................................................. A62 Potok, Olivia V............................................................................................ A75 Poulin-Costello, Melanie......................................................................... A26 Poulin,Yves..........................................AA1, A26, A29, A30, A31, A32, A33 Powell, Julie................................................................................ A3, A64, A66 Pratt, Melanie D.............................................................. A38, A59, A87, A89 Pratt, Michelle .......................................................................................... A50 Prieto,Victor G......................................................................................... A15 Puig, Lluis ................................................................................................... A80 Rahme, Elham................................................................................... A15, A90 Ramien, Michele........................................................................ A3, A63, A66 Reich, Kristian ........................................................................ A22, A27, A80 Resneck, Jr., Jack........................................................................................ A60 Richards, Robert N......................................................................... A92, A93 Richer,Vincent.................................................................................... A8, A21 Risser, David R........................................................................................... A15 Rivas, Enrique............................................................................................ A80 Rochon, Paula............................................................................................ A73 Rockwell, Gloria....................................................................................... A19 Rohekar, Sherry........................................................................................ A44 Rosen, Cheryl F.....................................................................................A1, A3 Roshdy, Osama A............................................................................. A48, A54 Roszell, Eric E............................................................................................ A24 Safaee Ardekani, Gholamreza................................................................ A70 Sajic, Dusan ............................................................................................... A42 Salko, Thomas............................................................................................ A80 Salopek, Thomas G.......................................................................... A72, A75 Samycia, Michael ...................................................................................... A24 Sandre, Matthew....................................................................................... A44 Sapra, Priya................................................................................................... A1 Sarfati, M..................................................................................................... A13 Sasseville , Denis......................................................A7, A14, A15, A69, A90 A96 CDA Abstracts Sauder, Maxwell B............................................................................ A65, A89 Saxena, Anjali............................................................................................. A48 Scali, Christina........................................................................................... A78 Schachter, Jordana.................................................................................... A62 Schnegg, Caroline..................................................................................... A90 Schwartz, Rodrigo.................................................................................... A73 Shah, Kamal................................................................................................ A27 Shaw, James................................................................................................ A55 Shear, Neil H........................................AA1, A29, A30, A31, A32, A33, A42 Shelton, Jennifer........................................................................................ A26 Shoimer, Ilya............................................................................................... A64 Shojania, Kam............................................................................................ A24 Sibbald, Cathryn...................................................................... A21, A34, A63 Sibbald, R Gary.................................................................A9, A12, A21, A34 Siddha, Sanjay.........................................................................................A1, A2 Sigurgeirsson, Bardur............................................................................... A80 Sikora, Sheena........................................................................................... A43 Silver, Shane...................................................................................... A22, A35 Simone, Andrew A........................................................................... A36, A51 Sissons, Wendy.......................................................................................... A65 Skotnicki, Sandy............................................................................... A12, A52 Solish, Nowell.............................................................................................. A9 Sotoodian, Bahman........................................................................... A6, A49 Spelman, Lynda.......................................................................................... A80 Srolovitz, Herbert.................................................................................... A54 Stevens, Michael S..................................................................................... A35 Stevens, Randall M.......................................................................... A22, A27 Strober, Bruce........................................................................................... A84 Strober, Bruce........................................................................................... A28 Sussman, Gordon..................................................................................... A86 Szakacs, Tom.............................................................................................. A40 Tan, Jerry.......................................................................................... AA1, A58 Tchvialeva, Lioudmila............................................................................... A68 Tetzlaff, Michael T............................................................................. A15, A90 Thavaneswaran, Arane............................................................................... A3 Thibeault, Marie-Marthe......................................................................... A46 Thompson, Elizabeth H.................................................................. A27, A28 Thuraisingam , Thusanth......................................................................... A47 Tolar, Jakub................................................................................................. A42 Toole, Jack........................................................................................ AA1, A26 Toosi, Bez................................................................................................... A74 Tran, Jennifer.............................................................................................. A73 Trentin, Grace........................................................................................... A20 Trotter, Martin J......................................................................................... A43 Tsai, Tsen-Fang.......................................................................................... A80 Tsang, Roger Y............................................................................................ A43 Turmel, Stéphanie..................................................................................... A47 Tyring, Stephen ........................................................................................ A80 Vadeboncoeur, Sophie...................................................................... A4, A64 Vale, Rachel ............................................................................................... A59 Van De Velde, Rochelle............................................................................ A35 Veillette, Hélène ...................................................................................... A49 Veilleux, Mylène S..................................................................................... A46 Velsher, Lea................................................................................................ A59 Vender, Ronald B....................................................................................... A53 Vidimos, Allison......................................................................................... A92 Vieira, Andrew........................................................................................... A26 Villeneuve-Tang, Catherine..................................................................... A21 Vincelette, Jean.......................................................................................... A35 Vo, Anthony................................................................................................ A19 Waddell, Andréanne................................................................................. A72 Wadden, Patricia....................................................................................... A50 Wagner, John............................................................................................. A42 Walsh, Noreen.......................................................................................... A46 Walsh, Scott........................................................................................ A7, A18 Wang, Sheila............................................................................................... A78 Ward, Brian .............................................................................................. A35 Wasel, Norman......................................................................................... A80 Wat, Heidi.................................................................................. A5, A52, A72 Watters, A. Kevin...................................................................................... A47 Weinstein, Miriam........................................................................... A62, A63 Wiviott, Robin........................................................................................... A67 Woetmann, Anders.................................................................................. A14 Wong, Daniel............................................................................................. A71 Wong, Noelle Y.......................................................................................... A43 Wu, Douglas....................................................................................... A5, A19 Wu, Jane............................................................................................ A18, A37 Xing, Lin...................................................................................................... A59 Yadav, Geeta.............................................................................................. A60 Yang, William.............................................................................................. A86 Yeung, Jensen............................................................................................. A41 Zahedi Niaki, Omid................................................................................. A65 Zargham, Hanieh............................................................................... A7, A69 Zargham, Ramin........................................................................................ A65 Zhang, Alexandra............................................................................. A36, A45 Zhou,Youwen............................................................................ A7, A14, A69 Zimmer, June............................................................................................. A41 Zip, C......................................................................................................... AA1 A97