EDITOR’S PICK OF THE YEAR
Report by Prof Anna ZALEWSKA-JANOWSKA (Dermatologist, Poland)
EDITOR’S PICK OF THE YEAR
This very interesting and informative session is already a tradition at the EADV. Editors from 4 leading dermatology journals presented their editorial choices of the last year published articles.
BEST PAPERS OF THE YEAR FROM JAAD
According to the oral communication ofDirk Elston (Charleston, USA)
Dirk Elston presented “Best papers of the year from Journal of the American Academy of Dermatology (JAAD)”.
The editor introduced the audience to diagnosis and management of pemphigus as updated recommendations of an international panel of experts (JAAD 82,3, 575-85). Important issues of this work included new treatment options (anti CD-20 antibodies – rituximab and ofatumumab), IVIG with attention of patients with IgA deficiency who should receive IgA-depleted IVIG, and also pointed out at careful medical history taking with special attention to causes of drug induced pemphigus (D-penicillamine, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, cephalosporins).
Another paper from JAAD was on drug reaction with eosinophilia and systemic symptoms which may occur within 2 weeks of drug exposure and underlined importance of this disease diagnostic criteria revision (JAAD 82,3;606-611 and 573-4).
Another paper on comorbid diseases of vitiligo pointed out at new disease associations including multiple sclerosis, idiopathic thrombocytopenic purpura and lymphoma, next to already reported associations such as hypothyroidism and rheumatoid arthritis (JAAD 82, 3, 628-33).
Further interesting paper was focused on silicone oil added to most commercial syringes as lubricant that can contaminate injected solutions (JAAD 82, 3, 747-9). This problem was well-reported in ophthalmologic literature. As for dermatology use of silicone oil lubricated syringes should be re-evaluated.
A very interested technique of molluscum bodies extraction with angled forceps was presented (JAAD 82,3,e79-e80) and illustrated with very informative photographs.
On importance a very helpful treatment ladder of prurigo nodularis was demonstrated including corticosteroids, TCIs; capsaicin, gabapentinoids and antidepressants; cyclosporine, MTX; naltrexone; aprepitant; dupilumab (JAAD 2020, 82: 460-8).
CME series (JAAD 2020, 82) presented extended dermatomyositis antibodies panel which seem to be very useful in diagnostic process of this disease and its prognosis.
PICK OF THE YEAR FROM JDS
According to the oral communication of Riichiro Abe
Editors’ pick of the year from Journal of Dermatological Science (JDS) presented by Riichiro Abe included observations of widely used preservative – thiomersal induction of skin pseudo-allergic reaction via Mas-related G-protein coupled with receptor B2 (MRGPRX2), namely by direct stimulation of mast cells upon first encounter (JDS 2019,95, 99-106). Another topic from JDS focused on detection of autoantibodies against alpha-2-macroglobulin-like 1 in paraneoplastic pemphigus sera by novel green fluorescent protein-based immunoassays (JDS 2020,98, 173-8).
Further interesting topics are the following dysfunctional autophagy and alopecia areata (JDS 2020, August 18), effect of irradiance on UVA-induces skin aging (JDS 2019,94,220-28) and efficacy and safety of dupilumab monotherapy in adults with moderate-to-severe atopic dermatitis presented as poled analysis of two phase 3 randomized trials (LIBERTY AS SOLO 1 and LIBERTY AD SOLO 2) (JDS 2019,94,266-75).
PICK OF THE YEAR FROM BJD
According to the oral communication of Neil Rajan
Neil Rajan representing British Journal of Dermatology (BJD) focused on series of most interesting papers on cutaneous signs of SARS-Cov-2 infection including famous chilblains. Inevitably this new coronavirus is in the centre of interest of the whole world and almost exclusively this topic is treated as fast truck.
PICK OF THE YEAR FROM JEADV
According to the oral communication of Johannes Ring
Johannes Ring presented Journal of the European Academy of Dermatology and Venereology (JEADV) pick including a lot of most interesting and useful guidelines on topical photodynamic therapy, lichen planus, anogenitial warts, pemphigus vulgaris and foliaceous, extracorporeal photophoresis, systemic treatment of psoriasis. Very important papers by Schuster et al (JEADV 2020, 34, 1331-9) on happiness that can be measured as a marker of burden of disease and is significantly decreased in psoriasis and atopic dermatitis and another one by Demirtas et al (JEADV 2020, 34, 1280-5) demonstrating that music intervention is effective against itch and act better than emollients add to our armamentarium of therapies.
SPOTLIGHT 1A
UPDATE IN DERMATOSURGERY
Report by Dr. Laura BOUCHARD (Dermatologist, Finland)
SPOTLIGHT 1A
UPDATE IN DERMATOSURGERY
According to the oral communication of Prof John Paoli (Gothenburg, Sweden)
Professor Paoli from Sweden reviewed recent literature in dermatosurgery on tumor recurrence after surgical treatment.
It has been a debate for years whether partial excision of melanoma at first increases the risk of worse prognosis and metastasis.
Moscarella et al. (JEADV 2020; 34: 279-84) from Italy did a meta-analysis on the influence of partial biopsy of primary melanoma on disease recurrence and patient survival. Five different studies were included with 3249 patients of whom 1121 (34.5%) were part of the partial biopsy group. 4 of the 5 studies looked at recurrence-free survival and found that the risk-ratio (RR) was 1.15, which was insignificant. 4 studies looked at melanoma-related survival and found a RR of 1.5, which was also insignificant. Thus, there is still no evidence that partial biopsy of melanoma prior to surgery would influence the levels of recurrence or mortality.
Zoutendijk et al. (BJD 2019; 181: 383-4) from the Netherlands analysed a material of 283 lentigo malignas (LM) of which 9.9 % were treated initially with imiquimod or laser instead of the first-hand alternative surgery. 255 cases were excised with surgery. Out of these, 23 (9 %) were reclassified as lentigo maligna melanoma (LMM). Partial biopsy of LM thus incurs a significant risk of missing a LMM and non-surgical treatment can lead to recurrency or metastasis.
Van Lee et al. (BJD 2019; 181: 233-4) also from the Netherlands did a retrospective cohort study on recurrence of cutaneous squamous cell carcinoma of the head and neck after Mohs micrographic surgery (MMS) versus standard excision (SE).
Cumulative incidence of recurrence Mohs Surgery vs Std Excision
The cumulative incidence of recurrence was 3 % in the MMS group versus 8 % in the SE group. In addition, tumors in the MMS group were higher risk (size, differentiation etc) that in the SE group. There is a clear benefit of using MMS in these high-risk SCCs of the head and neck.
Svensson et al. (Acta Derm Venereol 2020; 100) from Prof Paoli’s group in Sweden did a retrospective study to identify clinicopathological factors associated with incomplete excision of SCCs in Swedish patients. 691 cases from a 2-year period (2014-2015) were included in the study and 81 (11.7 %) were incompletely excised. Body site, tumor differentiation, tumor size, clinical surgical margins, specialty and experience level of the physician were included in a multiple regression analysis. Body site in the head and neck area (15 % incompletely excised), lower grade of tumor differentiation (18 %), tumor size over 15 mm (17.3 %) and specialty (general practitioner 20 %) affected the outcome. However, only large tumor size and excisions carried out by general practitioners (GP) significantly affected rates of incomplete excision in multiple regression analysis.
Kappelin et al. (JEADV 2020; Mar 2. Epub ahead of print) from Sweden looked at risk factors for incomplete excision of basal cell carcinoma (BCC) in a prospective study during 2008 to 2015. 4.6% of 3911 BCC tumors were incompletely excised. The face, especially the nose and ear were risk areas for incomplete excision with 20.3 % and 23.7 % for the nose and ear respectively. BCC morpheiform subtype was incompletely excised in 26.5 % of cases and infiltrating in 7.5 %. In morpheiform tumors of the nose, the incomplete excision rate was as high as 61.5 % and 50 % in morpheiform BCCs of the ear. In conclusion, Mohs surgery is strongly recommended for at least morpheiform tumors of the nose and ear.
Sinx et al. (JAAD 2020; 83: 469-76) from the Netherlands assessed the effectiveness of nodular basal cell carcinoma (nBCC) treatment with curettage and imiquimod cream compared with surgical excision in a non-inferiority, randomized, controlled study. They allowed a pre-specified inferiority of 8 %. 145 nBCCs were randomized in a one-year follow-up. The proportion of patients free of recurrence after 12 months was 86.3% (63/73) for the curettage and imiquimod group and 100% (72/72) for the surgical excision group with a difference in efficacy of 13.7% (p = .0004). In addition, a lot of recurrences occur later than one year. Surgical excision is the preferred method of treatment for nBCCs; especially on the face.
Last, Nghiem et al. (JAMA Dermatol 2019; Sep 4. Online ahead of print) from the US wrote a Viewpoint for less toxic, more effective treatment of Merkel Cell Carcinoma (MCC): “From Wide Margins to Wise Margins, Integrating Irradiation”. He has recently published their results of a retrospective study of 188 cases (JAAD 2020, Online July 22.). The idea is to prioritize surgery with margins as large as possible, while allowing primary closure if radiotherapy is included (90 % of their cases). Adjuvant radiotherapy can be added on sooner when longer healing time of a skin graft is avoided.
HOW TO DEAL WITH THE FOREST OF BIOLOGICS IN PSORIASIS?
According to the oral communication of Prof Christopher Griffiths (Manchester, United Kingdom)
Professor Griffiths went through things to be considered when choosing the biologic treatment for psoriasis. There are four groups of biologic medications to choose from:
The National Institute for Health and Care Excellence (NICE) has issued its guidance for use of biologics in the treatment of severe plaque psoriasis in England: all apart from infliximab PASI ≥ 10, DLQI > 10; infliximab PASI ≥ 20, DLQI > 18.
Factors to take into consideration when prescribing biologics are:
• TB
• Weight
• Psoriatic arthritis
• Demyelination (periferal and central)
• Cardiac Failure
• Pregnancy
• Inflammatory Bowel Disease (IBD)
• Lupus
• Anti-Drug Antibodies (ADA)
• Cost
There is most data about anti-TNFs biologics. Anti-TNF biologics should not be used if the patient has a history of cardiac failure, TB or demyelination. The risk of infection is biggest with this group (serious more likely with infliximab), but it is unusual. ADAs may develop with all anti-TNFs except etanercept, most common with infliximab. There is good data about certolizumab during pregnancy and it can be used throughout. Weight gain is associated with this group of biologics (average 0.9-2.4 kg). Biosimilars offer more affordable treatment for severe disease and TNF-inhibitors have so far been considered the treatment of choice for psoriatic arthritis (secukinumab).
Anti-IL-17 biologics are associated with a high response rate (PASI 90: 70%, PASI 100: 40%) even after anti-TNF -inhibitor failure. They are effective for spondylarthropathy and psoriatic arthritis. However, exacerbation of IBD has been described and they should not be used for patients with a history of IBD. There is a small increase of candida infections responsive to normal candida treatments with anti-IL-17 treatment. Neutropenia is a rare side effect with the majority of cases of neutropenia mild, transient, and reversible. An uncertain association of suicidality with brodalumab has been reported.
Ustekinumab is used in two different doses according to body weight (45 mg < 100 kg and 90 mg > 100 kg). The weight group between 90-100 kg has the poorest response and the lecturer suggests prescribing the higher dose already at 90 kg. The risk of TB is low with ustekinumab and drug survival is very good.
Anti-IL-23p19 biologics are approved for moderate-to-severe plaque psoriasis. There is no real-world evidence yet. Short-term, the risk for TB is low and no candidiasis or exacerbation of IBD has been described.
Considerations for prescribing are mainly clinical at present. Psoriasis Stratification to Optimise Relevant Therapy (PSORT) is a UK consortium that has been created is to better understand determinants of response to biologic therapies and deliver an algorithm to guide psoriasis management based on clinical, genetic and immunological data.
In conclusion, the immunology of psoriasis is complex, but understanding this has led to biologics and transformational change for patients.
Real world data from registries are vital for safety and response assessment.
In the future, stratification will allow right biologic first time and minimal effective dosing.
DERMOSCOPY
COMMON NEVUS PATTERNS
Report by Dr Adrian ALEGRE SÁNCHEZ (Dermatologist, Spain)
DERMOSCOPY
COMMON NEVUS PATTERNS
According to the oral communication of Dr Olivier Gaide
In the dermoscopy session, Dr Olivier Gaide reviewed the life cycle of nevi, in which nevus cells proliferate from early childhood until 30-35 years of age, at which point they begin to decline. He reviewed the common nevus patterns: pigmented reticulum, patchy pattern, central hypopigmentation, central hyperpigmentation, globular or cobblestone, and symmetrical peripheral globular. The most important thing is to know that common nevi will have these types of patterns, but we should suspect another lesion type if other patterns or structures are present.
CHARACTERISTICS OF AMELANOTIC LESIONS
According to the oral communication of Dr Bengu Nisa Akay
Dr Bengu Nisa Akay reviewed the characteristics of amelanotic lesions, which do not have melanin.
The first thing to consider is that lesions of this type should be biopsied when ulceration or white structures (white lines, keratin scales, etc.) are present. Recall that surface ulceration can be seen as globules or orange spots. If there is no ulceration or white structures, we must evaluate the vascular pattern. Patterns with gaps or dotted vascular patterns are considered benign. Other benign patterns are the centred, serpiginous or reticular patterns (not branching or arboriform).
The speaker also recalled the basic rule of biopsying or excising any pink papulonodular lesion.
AMELANOTIC MELANOMAS
According to the oral communication of Dr Giuseppe Argenziano
Also in the context of amelanotic lesions, Dr Giuseppe Argenziano presented his remarks on amelanotic melanomas. The doctor commented on the need to apply 3 rules with raised pink lesions of unknown nature:
1. Combine clinical and dermoscopy,
2. Look for the primary characteristic of the lesion, and
3. Never do monitoring (excise if in doubt).
EARLY-STAGE MELANOMAS AND THEIR CLOSEST IMITATORS
According to the oral communication of Dr Monika Arenbergerova
Dr Monika Arenbergerova spoke on early-stage melanomas and their closest imitators.
In this case, she talked about melanomas at stage T1a (0.8 mm thick with no ulceration) and stage T1b (0.8 – 1 mm thick). These early-stage melanomas show the same patterns as advanced melanomas, but tend to lack an inverse reticulated pattern, blue-grey structures and regression zones. Some of the lesions that can imitate these early melanomas are seborrhoeic keratoses, thrombosed haemangiomas, Spitz nevi, angiosarcomas, pigmented basal cell lesions, etc.
BASAL CELL CARCINOMA
Report by Dr Adrian ALEGRE SÁNCHEZ (Dermatologist, Spain)
BASAL CELL CARCINOMA
Non-melanoma skin cancer
This session on basal cell carcinoma (BCC) reviewed innovative aspects in the diagnosis and therapeutic management and monitoring of the most common type of epithelioma.
DIAGNOSING BASAL CELL CARCINOMA
According to the oral communication of Dr Piergiacomo Calvazara-Pinton
In the first session, Dr Piergiacomo Calvazara-Pinton reminded us that, while visual inspection has a sensitivity of up to 79% for diagnosing BCC, histology remains the gold standard. However, an ideal diagnostic technique must be non-invasive; such techniques include dermoscopy, ultrasound, or reflectance confocal microscopy. Dermoscopy has been shown to increase the specificity and sensitivity of visual diagnosis. With regard to confocal microscopy, it has been shown that this technique can further increase sensitivity when combined with dermoscopy. In addition, one of the advantages of confocal microscopy is that it can be used as a monitoring tool with non-surgical treatments. With high-frequency ultrasound, there is a problem with definition that complicates assessment of the margins. OCT (optical coherence tomography) provides cross-sections very similar to those from histology, but with less depth. It represents a tool with great potential, but few published studies to date.
MANAGING HIGH-RISK OR COMPLEX BASAL CELL CARCINOMA
According to the oral communication of Dr Nicole Kelleners-Smeets
With regard to the therapeutic management of BCCs, Dr Nicole Kelleners-Smeets gave us some guidelines for managing high-risk or complex BCCs. Complex BCCs include those that are locally advanced, in difficult locations or of large size, recurrent BCCs, those occurring in radiotherapy areas, and those occurring in patients with comorbidities.
Factors that influence the risk of metastasis include location in the head or neck, size > 4 cm, and invasion to the subcutaneous cellular tissue.
Mohs surgery remains the treatment of choice for high-risk carcinomas. Radiotherapy continues to be the best second-line option when surgery is contraindicated or when a complete excision has not been performed and cannot be performed. In addition, the use of neoadjuvant vismodegib has been shown to be effective in preserving facial structures like the orbit and the periocular area with high-risk BCCs in this area. Another possible combination is the use of vismodegib prior to palliative radiotherapy.
SYSTEMIC TREATMENTS FOR ADVANCED BASAL CELL CARCINOMA
According to the oral communication of Dr Nicole Basset-Seguin
Regarding systemic treatments for advanced BCC, Dr Nicole Basset-Seguin’s presentation provided useful information.
She noted that, fortunately, advanced BCCs represent less than 20% of cases. In addition, BCCs of this type can in turn be subclassified according to their characteristics. Treatments which inhibit the hedgehog pathway are effective because practically 100% of BCCs involve hyperactivation of this pathway (>90% are inactivating mutations of PTCH1 and <10% are activating mutations of SMO). This means that it is not necessary to perform genotyping prior to treatment. There are a series of adverse effects like ageusia, fatigue, alopecia and muscle cramps that tend to constrain long-term treatment. Currently available options are vismodegib (150 mg daily) and sonidegib (150 mg daily). Half-life is greater with sonidegib, at 28 days, versus 4 days for vismodegib. In terms of efficacy, they are very similar when we look at overall response, whereas sonidegib seems to have more partial responses. The same is true when we look at long-term responses. With regard to tolerability, sonidegib has been shown to have up to 10% less adverse reactions and probably a later start. In both cases, temporary interruptions of treatment do not compromise efficacy. It must be borne in mind that studies of post-treatment survival show relapse rates around 60% when treatment is discontinued after a complete response. Immunotherapy may represent an interesting alternative in cases of resistance to hedgehog inhibitors.
INFANTILE HAEMANGIOMA
Report by Dr Adrian ALEGRE SÁNCHEZ (Dermatologist, Spain)
INFANTILE HAEMANGIOMA
Vascular malformations
Infantile haemangioma represents the most common vascular tumour in infancy. Fortunately, propranolol has ushered in a veritable revolution in the treatment of these tumours over the past decade. Our knowledge of how to use it correctly and monitor this treatment continues to increase.
THERAPEUTIC OPTIONS FOR THIS TYPE OF VASCULAR TUMOUR
According to the oral communication of Dr Julie Powell
In the session on vascular malformations, Dr Julie Powell presented different therapeutic options for this type of vascular tumour.
We should understand that treatment in the first 2 months of life will reduce complications and long-term effects, and that early referral to a dermatologist is therefore key to achieving this goal. The COVID pandemic has presented a real challenge in this regard, due to the need to quickly detect high-risk haemangiomas to set guidelines for treatment.
High-risk haemangiomas include large or multifocal haemangiomas, those in high-risk locations (lumbosacral, perineal, mammary in women, periocular, nasal tip, oral), and any ulcerated form. It is currently believed that excessive monitoring during treatment with propranolol may be unnecessary.
The doctors suggests the possibility of online check-ins with these patients in selected cases, if they meet the usual health criteria. Propranolol treatment is started at 0. mg/kg/day in 2 individual doses, increasing by 0.5 mg/kg/day every 3-4 days up to the target dose of 2-3 mg/kg/day.
In addition, a simple questionnaire is proposed for paediatric units: the IHReS questionnaire (Infantile Hemangioma Referral Score), which can be used to evaluate the need to refer paediatric patients with haemangiomas. This questionnaire includes a score based on the presence of risk indicators (symptoms, location, size, etc.) and has proven useful in ensuring that these patients get treatment with propranolol as soon as possible, thereby avoiding potential complications arising from late treatment.