Over 10,000 healthcare professionals...and you!
The conference centre in Vienna was packed with a large crowd for the second day of this major event for European dermatology. The organisers have announced an estimated turnout of 10,000 participants yesterday, which was the opening day. Dermatologists and healthcare professionals were able to choose between the wide variety of themes on the programme.
The scientific programme covers all centres of interest – even the most specialised – in fields such as paediatric dermatology, non-melanoma skin cancers, chronic inflammatory diseases, dermatological surgery, and psoriasis. The session dedicated to American dermatology was particularly popular. What an interesting opportunity to compare points of view! Again today, our two special reporters were onsite for you: read their reports from today to learn more about their experience.
Dr Véronique Chaussade
Rosacea was the focus this morning, with an interesting presentation from Brigitte Dreno. She analysed the latest studies that evaluate the effectiveness of new treatments or new dosage forms. Daily application of bromonidine gel 0.33% may be followed by a rebound effect. Oxymetazoline (alpha-2 receptor agonist) applied in the form of a 0.05% nasal solution mixed with a hydrating cream was found to reduce erythema after 1 hour, without total whitening. This cream is in clinical development, and the results have yet to be confirmed. Intradermal Botulinum toxin has been found to reduce erythema as early as the 1st month. However, the study is open to criticism, and these preliminary results have also yet to be confirmed. Laropiprant (antagonist of the prostaglandin D2 (PGD2) receptor) 100 mg/j does not seem to be effective on erythematotelangiectatic rosacea.
For papulopustular rosacea, the new 15% azelaic acid “foam” dosage reduces inflammation (approved by the FDA in July 2015). Ivermectin 1% cream has been shown to be an effective anti-parasite and anti-inflammatory for papulopustular rosacea. It seems to be more effective than other topical medicines. Dapsone 5% gel may have the same efficacy on papulopustular rosacea as topical metronidazole, but must be compared without cyclins to ivermectin. The 1st study of permethrin 5% gel has shown significant results on demodex and papulopustules, but monitoring was not conducted for long after the treatment ended. Finally, a small study shows some efficacy of the application of kanuka honey (90% + 10% glycerin). As a regular treatment, isotretinoin (at 0.25 mg/kg/day) is a second-line treatment with few side effects (2%) (J Invest Dermatol Feb. 7, 2016). A few clinical trials are being conducted using new molecules, as well as photodynamic therapy.
Finally, as a reminder, there is no single formula for treating rosacea.
In his overview regarding current issues in sexually transmitted diseases, Colm O’Mahony reminded listeners with a touch of British humour that saliva should not be used as a lubricant, because it exposes people to the risk of gonorrhoea transmission, an infection that can persist asymptomatically in the anus or pharynx. He insisted on the incidence of syphilis, which has been on the rise over the last several years. He suggested that the HPV vaccine be offered to men due to the increase in anal cancer. Finally, he emphasised the importance of an early diagnosis of primary HIV infection to quickly treat the patient and thereby avoid the risk of the contamination of partner(s), among other things. HIV screening is necessary when presented with any nonspecific outbreak.
To continue with infectious disease, Olivier Chosidow made a brilliant clarification about scabies. He pointed out the atypical clinical forms in children with frequent nodules, infection on the palms and soles of their feet, and in immunodeficient individuals with localised crusted lesions (penis, toes, ear). Scabies cannot be transmitted from animals. Oral ivermectin (200 µg/kg per dose) is a good treatment; it does not act on the eggs. A 2nd dose is critical 7 to 15 days after the 1st to destroy the adult sarcoptes that grew from the eggs that were not destroyed by the first dose. Resistance to ivermectin is a concern. Indeed, resistance has already occurred in livestock treated in great numbers for onchocerciasis. Thankfully, a new moxidectin molecule is currently under study.
To conclude, Pascal Reygagne shared with us his convictions and perspectives concerning the treatment of androgenic alopecia. Minoxidil 5% lotion is more effective and fast-acting than the 2% version on men, but this has not been shown in women. Minoxidil 5% foam can be prescribed 2 times/day for men, and 1 time/day for women. Its dosage is more pleasant. Finasteride (selective 5-alpha-reductase type II inhibitor) 1 mg/day per os is used only for men. The post-finasteride syndrome (appearance of depression, pain, asthenia, reduced libido, suicide, etc., following treatment): does it really exist? The number of suicides reported in the population is not convincing. The injection of platelet-rich plasma is not authorised in this indication in France. Biofibre artificial hair can expose patients to a risk of infection. There are studies on PDG2 or E4. Finally, there are still studies under way on dutasteride (inhibitor of 2 type I and type II isozymes).
Pr Frédéric Caux
Regarding autoimmune bullous diseases, Nicolas Kluger, a French dermatologist working in Helsinki, reported an observation of bullous pemphigoid induced by dynamic phototherapy (P0324). The patient was an 88-year-old male who had Bowen's disease in the preauricular area for which two dynamic phototherapy sessions were held. Four months later, a large area of erosion appeared in the treated zone that was interpreted as a non-specific lesion; a factitious dermatitis was then suspected. The diagnosis was adjusted four months later when rare bullae appeared on the back and one hand. Immunofluorescence was positive at the dermal-epidermal junction and antibodies directed against the NC16a domain of BP180 were present. In the literature, there is only one other observation of localised bullous pemphigoid after dynamic phototherapy. The same author also reported a case of bullous pemphigoid induced by radiotherapy (P0331). This inducing factor is better known since approximately 40 observations have been described, primarily after radiotherapy for breast cancer. The bullous disease is usually localised and limited to the zone treated by radiotherapy. The presumed mechanism is antigen retrieval after alteration of the basement membrane by radiotherapy.
A symposium reviewed the latest molecules under development for atopic dermatitis. Multiple avenues are being explored to try to find new treatments for this disease. They primarily aim to block various cytokines and biotherapies directed against interleukins IL12/IL23, IL4/IL13, IL13, IL17A or IL22 are in the early evaluation phase. Interleukin receptors are also targeted, for example with nemolizumab directed against interleukin receptor 31. Some molecules directed against substances involved in pruritus have also been developed including tradipitant, which is a neurokinin 1 antagonist. The role of molecules directed against IgE such as omalizumab and ligelizumab should also be evaluated. From a clinical standpoint, the molecule for which the most information is available is dupilumab, which appears highly promising. Five studies have been undertaken in the United States, Europe and Japan in patients with severe, widespread and chronic atopic dermatitis. For a dose of 300 mg of dupilumab per week, clinical improvement in the 12th week was observed for 73% of the patients with at the same time a decrease in pruritus and insomnia. There were no notable side effects. Nemolizumab was evaluated in a study including 36 patients with atopic dermatitis: a decrease in pruritus (-50%), insomnia and the quantity of dermocorticoids used was observed after only one injection at eight weeks. Lastly, ustekinumab, which had occasionally demonstrated efficacy in atopic dermatitis, was evaluated in a double-blind, placebo-controlled study of 33 patients. Biological improvements with skin biopsies were observed but no significant difference in clinical scores was found at the dose of ustekinumab used. It should be noted that all these clinical studies were undertaken in atopic adults but not in children.
Lastly, a poster presented by a Brazilian dermatologist from Porto Alegre highlighted the contribution of Pr. Philippe Ricord's work in the area of sexually transmitted diseases. This dermatologist, born in Baltimore in 1800 to French parents who had fled the French Revolution, returned to France at the age of 20. After starting his medical degree in New York and completing it in Paris, he studied at Hôtel Dieu under Dupuytren. He became the doctor of several eminent figures, including Napoleon III. He created several medical instruments and developed the vaginal speculum. He worked on sexual diseases at a time when most people thought syphilis and gonorrhoea were different manifestations of the same disease. He was against this classical theory and defended his opinion in his "Traité pratique des Maladies Vénériennes ou Recherches critiques et expérimentales sur l’inoculation appliquée à l’étude de ces maladies" (Practical handbook on venereal diseases or critical and experimental research into inoculation applied to the study of these diseases) published in 1838. However, he was initially against the existence of chancroid but publicly acknowledged his mistake, quoting the poet Auguste Marseille Barthélémy: “The absurd man is he who never changes”.