During my dermatology training I have become interested, for many reasons, in specialising in medical dermatology. Firstly, I enjoy the challenge of complex cases, especially caring for patients with skin diseases with systemic manifestations. Secondly, I find the management of serious, potentially fatal, skin disease, with the use of systemic and biologic treatments, stimulating and immensely rewarding. I recognise the significant physical and psychological impact of these conditions. Finally, I enjoy the collaboration that this subspecialty offers with other specialties. I therefore was very grateful for the opportunity provided by the British Society for Medical Dermatology to attend specialist clinics after being successful in my application for the Trainee award. In particular, I wished to increase my understanding of bullous disorders (immunological, inherited and reactive), improve my diagnostic skills and learn from experts about managing patients with bullous disease, from basic nursing care to novel treatments.

Unfortunately it was another 18 months, and much anticipation, before I could attend tertiary clinics in London due to necessary Covid-19 travel and hospital restrictions. I finally attended the following clinics and course:

1. Immunobullous clinic at Guy’s and St Thomas’ Hospitals, London, supervised by Dr Emma Benton

I really enjoyed this busy clinic, which commenced with an MDT discussion of complex patients and cases of diagnostic uncertainty. I observed cases of pemphigus foliaceus, epidermolysis bullosa acquisita and other autoimmune bullous diseases. I learnt about the use of rituximab for patients with pemphigus and the clinical correlation with measurement of circulating antibodies, easily obtainable via the immunodermatology laboratory, but perhaps not routinely used in other parts of the country.

2. Oral dermatology clinic at Guy’s and St Thomas’ Hospitals, London, supervised by Professor Jane Setterfield.

I really enjoyed attending Prof Setterfield’s clinic on a couple of occasions. The mouth has felt daunting to me as a trainee. Starting with the basics I was shown a systematic, thorough examination of the oral cavity and, by discussing the Oral Disease Severity Score (ODSS) for each patient, I have vastly increased my confidence using this in my practice going forward. I observed cases of pemphigus vulgaris, vulvovaginal gingival lichen planus, mucous membrane pemphigoid and orofacial granulomatosis, and begun to appreciate nuances in the oral signs. I benefited from discussing the topical treatments used for oral disease and the use of systemics with Prof Setterfield who is a wealth of knowledge and experience.

3. Cutaneous sarcoidosis clinic at King’s College Hospital, London, supervised by Dr Sarah Walsh

Given the diverse population in London, this clinic provided a brilliant opportunity to see many patients with cutaneous sarcoidosis and Dr Walsh was a really enthusiastic teacher. It was useful to discuss management and the involvement of other specialties. Dr Walsh also had some interesting cases to show me of patients with alternative diagnoses such as superficial granulomatous pyoderma gangrenosum and granulomatosis with polyangiitis (Wegener’s).

4. Hidradenitis suppurativa clinic at Guy’s and St Thomas’ Hospitals, London, supervised by Dr Ruth Lamb

It was really helpful to observe how this subspecialty clinic has been established with the hugely beneficial addition of surgical, microbiology and psychology involvement. I met a number of extreme and complex cases which require a multidisciplinary approach to management. It was useful to have a consultant microbiologist join the clinic as antibiotic suggestions were important including the use of IV ertepenam as a bridging treatment. I also appreciated that the collaboration with plastic surgeons, colorectal surgeons and urology/gynaecology was paramount in these cases.  It has inspired me to consider setting up a similar HS clinic in my current consultant job.

5. Lymphovascular clinic, St George’s Hospital, London, supervised by Dr Kristiana Gordon

I was warmly welcomed into the team at St George’s Hospital for a couple of days to join the lymphoedema service. Dr Gordon really helped me develop my ability to assess patients during her lymphatic diagnostic clinic, including the use of lymphoscintigraphy.We encountered patients with secondary lymphoedema, lipoedema and primary lymphoedema and lymphovascular malformations. I spent some time with the fantastic lymphoedema specialist nurses learning about and observing the 4 elements of decongestive lymphatic therapy including compression bandaging and the options available for patients. The primary genetic lymphoedema clinic, with a clinical geneticist, was really interesting and their published classification and diagnostic algorithm pathway is a helpful guide for these complex cases.

6. International Pemphigus and Pemphigoid Foundation Scientific Symposium, Virtual, September 2021

This three-day meeting was really informative and covered recent advances in our knowledge of the immune pathogenesis and management of pemphigus and pemphigoid. I learnt more about the association of bullous pemphigoid with neurological diseases and also potential culprit medications.

Due to ongoing Covid-19 restrictions I have not yet managed to attend adult and paediatric epidermolysis bullosa clinics but look forward to this in the near future.

I would like to thank my supervisors and the BSMD committee for providing such a fantastic opportunity for me to pursue my personal interests and inspire me to continue to develop a subspecialty interest in medical dermatology. I have thoroughly enjoyed learning from such great clinicians in the field and this experience has been invaluable as I embark on the start of the steep learning curve as a consultant in the NHS. I am sure the professional contacts I have made during the Trainee award will be hugely beneficial for my own development and for patient care.