Melanoma, psoriasis, certolizumab and bullous autoimmune disorders, key themes of this first day of EADV

For this first day of the congress, there is still a summer ambiance lingering in Vienna. In this city at the crossroads of the past and future, meetings are being held at the stately Austria Center Vienna, an impressive complex of modern buildings just a stone's throw from the Danube. But the programme is packed and there is simply no time to take a walk along the water!

While Wednesday was dedicated to dermatological companies from various countries, the sessions from the official programme started today. The day was kicked off by a presentation by Dr Stephen Katz, an eminent immunology and skin expert who set out his vision of the future of dermatology. For this first day, Laboratoire BIODERMA's two special reporters, Dr Véronique Chaussade and Professor Frédéric Caux, decided to focus on the latest scientific developments related to Melanoma, psoriasis, certolizumab and bullous autoimmune disorders. Here are their reports. Happy reading!

Dr Véronique Chaussade

International leaders in dermoscopy attend the EADV Iris Zalaudek brought up some key points for analysing non-pigmented pink-coloured lesions. The 1st step is to analyse the morphology of the vessels. Any polymorphic aspect identifies a malignant tumour. Based on their morphology, they signal a dermal nevus (comma), a malignant spitzoid tumour (clusters), a melanoma (irregular lines), a keratinocytic tumour (hairpin), Bowen's disease (glomerular), or a basal cell carcinoma (branching). The 2nd step is to describe the arrangement of these vessels: regular for a malignant spitzoid tumour, in strings for a clear cell acanthoma, in clusters for Bowen's disease, radiating for a squamous cell carcinoma, in tree branches for a BCC, irregular for a malignant tumour, etc. The 3rd step is to focus on the specific morphologies (shiny unstructured red zones, cloudy red globules, yellow zones with a circle of peripheral vessels, a “strawberry” aspect, unstructured pink-coloured zones with multiple erosions, etc.). It is important not to miss the diagnosis of achromatic melanoma, which can mimic all benign tumours. One should be immediately suspicious when presented with a tumour that is firm, palpable and in continual growth (approximately 0.5 mm/month), in a man, generally over 60 years old, without lentigines or nevi. It is very rare for there not to be a bit of residual pigmentation, only visible with a dermoscope. Polymorphic microvessels are used to distinguish it from a basal cell carcinoma. For these rose-coloured tumours, it is best to use a polarized light dermoscope, because it does not exert pressure, which would obscure the vessels. It also allows observers to view the shiny white streaks (chrysaloid) that are not visible with the immersion dermoscope.

For Giusseppe Argenziano, 80% of pigmented melanomas are easy to identify after clinical and dermoscopic examination. For the rest, follow simple rules: examine all of the nevi, and know how to monitor them. In the case of an uncertain diagnosis and in particular in the case of a modular tumour, no monitoring: it should be excised.

Several sessions covered melanomas

C. Hoeller presented current data on stage I and II melanomas. This is a heterogeneous group in terms of prognosis. The current indications for sentinel lymph node biopsy are Breslow melanomas that are ≥1 mm. Breslow melanomas from 0.75 to 0.99 mm can also be concerned, but only in case of ulceration, or angiolymphatic invasion, in young subjects (< 40 years old), with a mitotic index of ≥ 1/mm2, or a positive margin after a shave biopsy. This is the most powerful prognostic factor. Margins of resection are 0.5 mm for melanomas in situ, 1 cm for Breslow melanomas that are ≤ 2 mm, and 2 cm for Breslow melanomas that are > 2 mm. Monitoring allows for detection of a recurrence (80% take place in the 3 years following the excision) and/or another melanoma (2nd melanoma in 8-10% of the cases during the next two years). Interferon alpha is the only adjuvant treatment that can be offered for a Breslow melanoma that is > 1.5 mm.

Bertrand Richert gave an interesting talk on nail lichen planus. It is rare (1%) and only accompanied in 10% of cases by cutaneous or mucous signs. The cutaneous signs depend on the site of inflammation and are primarily longitudinal striae (90%), annular erythema (30%), fissures, thinning down or flattening, pterygium, or anonychia. The changes take place progressively, towards nail atrophy which no longer responds to treatment. It must therefore treat it early with triamcinolone acetonide IM (0.5-1 mg/kg) 1 time/month or intralesional (10 mg/ml) if it affects only one or few fingers. 2/3 of patients respond to the treatment. However, 2/3 have a recurrence after 1 year, without a predictive factor for recurrence.

Pr Frédéric Caux

In the field of psoriasis, the arrival of new proven therapies raises the question of their safety, especially over the long term. One poster analyses the tolerance of apremilast, an oral phosphodiesterase 4 inhibitor (P2052). The poster reviewed five clinical studies conducted during the development phase of apremilast and reanalysed its side effects and long-term tolerance. 2,242 patients were evaluated for side effects, and 1,905 patients were evaluated for long-term tolerance, with more 575 of them studied for more than 3 years. The most frequent side effects were diarrhoea (15%), nausea (13%), headaches (6%), and upper respiratory tract infections (7%). These side effects diminished over time. Digestive problems led to an average 1.6 kg weight loss, with 25% losing over 4.5 kg. Only 3 patients interrupted administration of apremilast due to weight loss. There were no complications with use of the biotherapies, and there was no increased risk of severe cardiovascular events, cancer or tuberculosis.

Another study reported on the long-term effectiveness of certolizumab, a PEGylated anti-TNFα currently indicated for psoriatic arthritis. Development of the drug for cutaneous psoriasis is underway: A phase 3, double-blind study was conducted with an initial placebo group of 409 patients observed for 4 years. Patients taking certolizumab saw long-lasting improvements in their inflammatory arthritis. Patients with cutaneous psoriasis over more than 3% of their body in addition to joint pain also saw an improvement in skin lesions (at 4 years, 80% of patients had attained PASI 75 and 40% had attained PASI 100). There were 6 deaths, including 1 from lymphoma and 1 from breast cancer. The authors of the work did not discuss the link between these deaths and certolizumab (P0445).

One poster reported the lack of transport of certolizumab across the placenta (P0442). Multiple in vitro techniques showed that the PEGylated anti-TNFα drug does not cross the placenta. In 10 women with Crohn’s disease treated with certolizumab, the medicine was not detectable in the baby’s blood at birth, contrary to what was observed in 11 women treated with infliximab and 10 women treated with adalimumab.

In the field of bullous autoimmune disorders, one case of pemphigus was reported, induced by supplements taken by a bodybuilder. A 25-year-old Turkish man took supplements containing ginger, cumin, wheat, creatine, and glutamine and subsequently developed typical pemphigus vulgaris, confirmed by histology and immunofluorescence. As a reminder, the authors state that medicines containing thiol radicals, like D-penicillamine and captopril, are known inducers of pemphigus and that some foods high in thiol functions, including garlic and leeks, can also act as inducers. Foods high in tannins may cause pemphigus as well, and ginger and cumin are high in tannins. In a country where pemphigus is endemic, this single clinical case is not proof positive that such supplements cause pemphigus, but it does illustrate that supplements, even plant-based ones, are not always harmless. This observation may be compared to a poster presented at the AAD on the triggering of outbreaks of late-onset cutaneous porphyria by natural chlorophyll beverages consumed for “detoxification.”