Allergies, early melanomas and amelanotic tumours, scleroderma

Here in Geneva, this autumn’s main public event is Taste Week (la Semaine du Goût), which got off to a suitably autumnal start on the shores of Lake Geneva – just like the EADV annual congress! And this 26th edition of the congress also offers a very tasty menu, with an extremely diverse and tempting programme that our special envoys at the Palexpo have been enjoying right from the very beginning.

Participants got down to work Thursday with a broad overview of current major themes in dermatology, from acne to psoriasis, pigmentation disorders and rosacea. Of the many and various sessions on offer, Professor Yordanova chose the following three: using dermascopy to monitor early melanomas, amelanotic tumours, and scleroderma. Meanwhile, Professor Tennstedt went to find out about the latest findings on allergic diseases and the most common allergens.

 

Prof. Ivelina YORDANOVA, MD, PhD

Dermatologist, Department of Dermatology and Venereology, Medical University, Pleven, Bulgaria

Early Melanomas

In the session Dermoscopy Review and Updates at 14 September 2017 Dr. Puig presented a lecture on the topic "Early Melanomas" from a dermatoscopy perspective. Dr. Susana Puig is the director of the research program of the melanoma Unit at the University Hospital Clinic of Barcelona, Barcelona, Spain. Dr. Puig is a member of the board of the International Dermoscopy Society.

At first she answered the question "What is an Early Melanoma?". She showed a few examples of simetric and non-simetric growth of the hiperpigmented halo as well as the appearence of a melanoma malignum in a pigmented nevi. She explained that it is not so easy to diagnose the "Early Melanoma" which is really a Melanoma Malignum in situ. Sometimes lesions like this remain the same and do not change in a period of few years.

In this moment for diagnosing of pigmented lesions suspected for "Early Melanoma" is used the information from two methods - Total Body Photography and Digital Dermatoscopy. When patients with pigmented lesions suspected for malignisation are being followed a Total Body Photography should be done first and after that the Dermatoscopy. Statistic researches show that in 70% of the cases the pigmented lesions, suspected for melanoma malignum, are being excised because of the evolution of the dermatoscopy picture through the following period and barely 30% of them were found with the Total Body Photography method. It takes a long time to follow and to diagnose the suspected lesions as Melanoma malignum - usually 4 follows every six months. In 50% of the cases the melanomas are being excised around 2 years after the first visit. 75% of them are established to be Melanoma Malignum in situ. This is a sub-type of the melanoma which grows very slow and needs a lot of time to reach ist potential. In cases of Lentigo Maligna in photodamaged areas of the skin the dermatoscopy criteria include white regression in the center of the lesion, increased size and deformation of the polygones in the pigmented spot. In cases of Melanoma malignum growing in a old nevus the dematoscopy criteria are different- absence of pigmented network, presence of globuses and blue-whitish veil. Dr. Christina Carera found out that there is a difference between the dermatoscopy view of photodamaged skin in patients with brighter or darker colours of the skin. She established two dermatoscopy criteria for „Early Melanoma“ of first and second phototype patients- 1. Atipical asimetric pigmented network with orange reticulations and 2. Dotted vessels. It is way easier to find the atipical asimetric pigmented network in third and fourth phototype patients. In „Early Melanoma“and Lentigo Maligna in the area of the face skin dermatoscopicaly an irregular perifollicular hiperpigmentation is established. Dr. Puig denies the term "indolent melanoma", because in the moment a first sign for Early Melanoma is found, the lesion should be exsiced and not followed for a period of 3 or 4 years until it becomes a thick melanoma. Dr. Puig researched the lesions of more than 200 patients suspected for melanoma examined by Dermatoscopy and Total Body Photography and comparing the dermatoscopic view of the melanomas found during the first visit of the patient and the malignant lesions developed in period of following. Histopatologicaly a severe cell atipy was established. Confocal microscopy showed atypical Paget-like and dentritic cells in patients with "Early Melanoma" also.

Amelanotic melanomas

Prof. Giuseppe Argenziano presented a very interesting and interactive session on the topic Pink Tumors. Prof. Argenziano is the head of the Dermatology department, University of Campania Nuovo Policlinico, Napoli, Italy. The main sphere of his studies is the dermatological oncology. He is an author of many articles and books about dermoscopy as well as a new technic for developing the diagnostics of benign and malignant skin cancers. As a coordinator of the Skin Cancer section, he has built a successful, multidisciplinary center, devoted to diagnostics and treatment of patients suffering from skin cancer. Prof. Giuseppe Argenziano is a founder and former president of the International Dermoscopy Society.

Pink tumors are a group of amelanotic lesions, with soft texture such as : Spitz nevus, dermal nevus, basal cell carcinoma, squamous cell carcinoma and seborrheic keratosis. The main differential diagnosis of a amelanotic lesion is with the amelanotic melanoma. Prof. Argenziano gave many clinical examples of amelanotic lesions and demonstrated their dermatoscopy characteristics. Typical for Basal-cell carcinoma are the arborizing and serpentine vessels. Through dermatoscopy in the dermal nevus the blood vessels could be found looking like commas - comma vessels, in seborrheic keratosis comedo-like openings, milia-like cysts, hairpin vessels there are. Dermoscopy of the squamous cell carcinoma shows polymorphic atypical vessels and white colour because of the production of large amount of keratin. In many of the cases of amelanotic melanomas, the melanoma is not fully depigmented, there is a slight pigmentation. This makes the diagnostics of the amelanotic melanoma extremely difficult. Prof. Argenziano presents a conception for Management of nodular amelanotic skin lesions: in cases of ulcerated nodule it should be immediately excised, if we are sure that the lesion is a benigh amelanotic (Spitz nevus, dermal nevus) we should send the patient at home and never call him for a follow up. If we are not sure in the diagnosis of a amelanotic nodule we should excise it and send it for histopatological analysis. It has been found that 99% of the amelanotic melanomas are nodular lesions, but the other 1% is taken by the flat lesions. The dermatoscopy is very important in diagnosing flat amelanotic melanomas because thanks to this method we can see vessels and white lines which lead us to the diagnosis. Most of the acral amelanotic melanomas are presented by erosive lesions. Such lesions on the feet of patients suffering from insulin-depending diabetes mellitus are being mistakenly cured for a long time like diabetic ulcers.

 

Prof. Dominique TENNSTEDT, MD, PhD

Dermatologist, Dermatology service UCL Saint Luc, Brussels, Belgium

Clinical immunology: allergic diseases

These sessions, which covered clinical practice, therapies and fundamental research, dealt with a number of ideas, some of which are already well-known and others perhaps forgotten, but all of which are still today’s "burning" issues – or if not, they soon will be!

1. Allergic contact dermatitis:

• Most common allergen: nickel. 5 to 10 % of the general public are sensitised to it. Reactions can spread to some distance from the point of contact.
• "Toll like receptor 4" very much thought to play crucial role in development of sensitivity to nickel.
• Methylisothiazolinone (MI/MIT) has become the second most common allergen, although there has been a slight fall in the number of positive tests conducted.

This might be due to the discontinued use of MIT as a preservative in "leave on" products.

Sensitised patients should be alerted to the presence of MIT in many detergents and paints in order to avoid severe hand dermatitis or general dermatitis in cases where the allergen spreads through the air.

• A "textile mix" test should be included in the standard battery. It can sometimes be an irritant and clinical relevance should be sought, whether longstanding or recent.
• p-Phenylenediamine (PPD) is still found in the vast majority of hair dyes including those for "blondes".
• Acrylates only have a sensitising effect when used as monomers (particularly in association with UVs).

When polymerised, they no longer penetrate the tegument.

• It is crucial to read the labels on cosmetics and household cleaning products as all sorts of surprises can be lurking there!
• If a patient tests negative yet you strongly suspect an allergy, it can be useful to conduct the test on the exact spot the dermatitis appeared (once it has been cured of course!), just as you would do with a fixed drug reaction!

2. Atopic dermatitis (AD):

• AD is still dermatology’s "poor relation", particularly in comparison with its “eternal rival”, psoriasis!! Nevertheless, things are changing in terms of both physiopathology and therapies. Regarding epidermal anomalies, filaggrin deficiency is still very much present, but it is not alone – other deficiencies are involved, such as loricrin, involucrin and cutaneous lipids...At the same time, interleukins play a central role in the anomalies causing AD: IL 4,IL 13,IL 31,IL 33, etc.
• Moreover, AD is increasingly being seen as an auto-immune disease.
• Malassezia sympodialis plays a major role in head and neck dermatitis.
• AD therapies are still based on emollients, and local anti-inflammatories (topical corticoids and topical calcineurin inhibitors), both of which are crucial. In severe forms of the disease, ciclosporins and UVB phototherapy can be useful.
• Therapeutic education should not be neglected – in fact it is to be encouraged.
• Major new biological products are going to completely change the outlook for patients suffering from severe AD: Dupilumab (anti IL4-IL13R), Tralokinumab (anti IL13), Nevolizumab (anti IL31R) and no doubt many more in the (very) near future!

Currently, Dupilumab is the only one available, on the American market only (since March, 2017), but it should soon be available in Europe too. These future biological products appear to be relatively safe, but that needs to be confirmed at a later date!

The price of these biological products will have to be evaluated and discussed!

 

Prof. Ivelina YORDANOVA, MD, PhD

Dermatologist, Department of Dermatology and Venereology, Medical University, Pleven, Bulgaria 

Systemic sclerosis and scleroderma-like diseases

Prof. Dr. Lidia Rudnicka from Poland presented a plenary lecture on the topic Systemic sclerosis and scleroderma-like diseases. Scleroderma is a rare disease which is presented by hardening of the skin in the acral areas, proximal skin sclerosis or diffuse affection of the whole body surface. In order all of the clinical symptoms to be understood, Prof. Dr. Lidia Rudnicka explained the pathogenesis of the disease first. It includes injury of the microcirculation in the small blood vessels, damage of the fibroblasts and endothelial cells, as well as a severe autoimmune activation which affects the T- and B- lymphocytes. All this stimulates the production of collagen and skin fibrosis. Prof. Dr. Lidia Rudnicka presented the skin changes which are characterized in the beginning with oedema of the hands, followed by hardening, contactures, appearance of ulcers on the tips of the fingers which can not be healed and lead to autoamputations of the distal phalangs. The disease usually affects the feet and the face also. The internal organs of the patients can be affected also - kidney, heart, lungs. One of the first signs of the disease is Reynaud phenomenon which is manifested mostly in the winter by vasoconstriction of the blood vessels. After the vasoconstriction a dilatation follows which make the patients feel like their hand are dipped in hot water. The changes of the vessels caused by the systemic scleroderma can be diagnosed with the method capillaroscopy. Specific immunological markers in Systemic sclerosis are antinuclear antibodies and anti-SCL 70 antibodies in the serum. Systemic sclerosis decreased extremely the quality of life of the patients. Treatment can be made mainly with cytostatics Methotrexate, Cyclosporine or high doses of crystal Penicillin which significantly decreased the skin sclerosis and vasodilatators - Iloprost. Lately hopes in the systemic treatment of scleroderma are laid on the treatment with Rituximabе which is an anti CD-20 monoclonal antibody with powerful effect, but it is still in Phase 2 of the clinical trial. Systemic sclerosis can not be treated with corticosteroids.

Scleroderma-like diseases are characterized with diffuse skin hardening although the immune markers are negative in absence of Raynaud phenomenon and no internal organ affection. Sclerodema, also known as scleroderma of Buschke, and scleroderma adultorum, is a self-limiting skin condition which affect usually the areas of the upper back, neck, shoulders and face. It is characterized clinically by induration and hardening of the skin that results from excessive mucin deposition between thickened collagen bundles in the dermis. There are three clinical forms which are classified by their associated condition. Scleroderma may be associated with a history of a bacterial infection (type 1), a blood dyscrasia (type 2), or diabetes mellitus (type 3). Each of these clinical forms has a different history, course and prognosis. Sometimes it precedes or accompanies hematologic diseases like monoclonal gamopathy and mieloma disease. The treatment is conducted with intavenous immunoglobulin IVIG for a period of 6 months.