Reunión Anual de Dermatólogos Latinoamericanos
COVID-19 in adults
According to the oral communications of Alba Catalá (Spain)
In Dr Alba Catalá’s keynote address, “COVID-19 in Adults”, she spoke about the different patterns of skin manifestations.
Pseudo-Chilblains: She mentioned that most SARS COV-2 PCR tests are negative in children and adolescents, and noted that this is not unusual since skin lesions are normally a late manifestation that occur when viral RNA is no longer detectable. She described four of the possible physiopathogenic mechanisms that have been proposed:
1) Virus-Induced Type I Interferonopathy Hypothesis,
2) Thrombosis/Coagulopathy Hypothesis,
3) Vasculitis Hypothesis,
4) Other Factors. In biopsy samples, a thick, lichenoid, perivascular and perieccrine infiltrate is observed in the dermis; also vascular stasis, extravasation of red blood cells and focal thrombosis
mainly restricted to dispersed papillary dermal capillaries or in vessels of the reticular dermis.
Vesicular Rashes: monomorphic vesicles on the trunk and extremities, varicella-like but presenting different stages. According to Marzano et al., they are much more frequent in men, and the average age is 60 years, with an average duration of 8 days (4-15), accompanied by mild pruritis and fever (95.5%), cough (72.7%), headache (50%), asthenia (50%), dyspnoea (40.9%), hyposmia (18.2%),
hypogeusia (18.2%), odynophagia (4.5%), diarrhoea (4.5%) and myalgia (4.5%). Fernández-Nieto et al. describe an average age of 40.5 years and manifestations of mild illness in 58.3% and pneumonia in 41.7% (4.2% UTI); they also indicate a dispersed pattern in 75% of cases vs. 25% localised, and in 20.8%, appearance of the skin rash is prior to or concomitant with other COVID-19 symptoms. In biopsy samples, intraepidermal vesicles are observed with mild acantholysis and ballooning keratinocytes. PCR for SARS COV-2 vesicle content: negative. HSV and HZV PCR must be ruled out, as well as a negative Tzanck test. Some authors prefer to designate this clinical picture as “Covid-19- associated acantholytic rash” rather than varicella-like. In physiopathogeny, the literature mentions positivity for SARS Cov-2 Spike protein in the endothelium of dermal blood vessels and the epithelium of sweat glands, suggesting viral dissemination and a contribution to the development of acantholysis and dyskeratosis. Improvement of skin manifestations was observed in association with improvement of systemic symptoms.
Urticariform Rashes: on the trunk or dispersed and concomitant with other symptoms, observed equally in both sexes and all ages. 10% of cases precede, 50% accompany, and 40% occur after other symptoms. Improves when systemic symptoms improve. Biopsy is compatible with urticaria, with some characteristics of small-vessel vasculitis and microthrombi. Physiopathogeny shows complement activation and formation of ROS (reactive oxygen species) and cytokines, with aberrant activation and degranulation of mast cells, which may produce endothelial activation and micro- occlusive disease, leading to urticarial vasculitis in predisposed individuals.
Morbilliform and Maculopapular Rashes: generally the main reason for the consultation; many are also diagnosed with pneumonia. Accompanied by systemic symptoms and improves when the overall clinical picture improves. Occasional dysaesthesia and keratosis pilaris-like clinical picture. Biopsy: mild spongiosis, vacuolisation of the basal layer, mild lymphocytic infiltrate, dilated vessels in the papillary dermis and no eosinophils. SARS COV-2 PCR is negative. Important differential diagnosis to rule out – toxicodermas. In physiopathogeny: cytopathic effect induced directly on epithelial cells. A paraviral exanthem is considered to be an immunological epiphenomenon in response to the infectious pathogen. Production of endogenous circulating IFN-I can also contribute.
Purpuric and Petechial Rashes: in adults and elderly patients, observed equally in both sexes. Appear after systemic symptoms; sometimes perifollicular and predominantly in folds, with probable Koebner phenomenon and mucous membrane involvement. Biopsy: mild spongiosis, oedema of the papillar dermis, extravasation of red blood cells, perivascular and interstitial lymphocytic inflammatory infiltrate and epithelial swelling, with no signs of vasculitis. Physiopathogeny presents immune complex-mediated endothelial dysfunction.
Erythema Multiforme-Like: mostly women, average 61.5 years; 71% present with pneumonia and systemic symptoms. Post COVID-19 symptoms, with an average of 19.5 days. The physiopathogeny is apparently due to autoimmune cross-reactivity, activating keratinocytes which in turn induce production of IL 1, IFN-g and TNF-a, recruiting cytotoxic and NK cells which are believed to then target the patient’s own keratinocytes.
Pityriasis Rosea-Like: young adults, systemic symptoms, pneumonia diagnosis. The physiopathogeny suggests an activating role for SARS COV-2, triggering the reactivation of other viruses (HHV-6 and HHV-7).
Livedo Reticularis: young and middle-aged, with appearance of livedo and after a few days of systemic symptoms. In the physiopathogeny, vascular deposits of C5b-9 have been detected in affected and healthy dermis, producing endotheliitis.
Retiform Purpura and Necrosis: in ICU patients; increase in D-dimer, a product of fibrin and/or fibrinogen degradation. Biopsy shows vasculitis and occlusive arterial or deep vein thrombosis. IFD: IgM, C3 and fibrinogen deposits within the walls of the superficial or deep dermal blood vessels.
Physiopathogeny: absence of interferon signalling, extensive viral protein in the endothelium, and complement deposits with vascular thrombosis.
Finally, she mentioned that pharmacodermias are not infrequent in these patients (4.15% of the total). The incidence of skin manifestations is highly variable in the literature (from 0.2 in China to 20% in Italy), although from an analysis of the worldwide literature, it appears low: 1-2%. The dermatologist’s role is very important, since 17% of positive SARS COV-2 cases presented skin lesions as the first manifestation and in 21% as the only clinical sign.
Determining the aetiopathology of hidradenitis suppurativa
According to the oral communication of Victor Hugo Pinos León (Ecuador)
Next, in a symposium, Dr Victor Pinos discussed the physiopathology of Hidradenitis Suppurativa (HS), describing four factors: genetics, lifestyle, hormones and the role of the microbiota. With regard to genetics, 30% of patients have a family history, identifying mutations in genes that encode alpha secretase, which cleaves various transmembrane proteins in the NOTCH receptor that are involved in various signalling pathways. In terms of lifestyle, nicotine can influence bacterial propagation and biofilm formation by promoting initial adhesion and intercellular accumulation. It also increases the production of IL 10 through the activation of immune cells. In addition, 50% of patients are obese and 40% have metabolic syndrome. With regard to hormonal factors, analysis of microarrays suggests activation of the androgen receptor pathway in the skin of patients with HS. Finally, concerning the role of infectious pathogens, there are arguments against such a role (rarity of lymphangitis, septicaemia, cellulitis or regional lymphadenopathies, responds to immunomodulatory treatments and the antibiotics used have anti-inflammatory effects) and arguments for it (there is infection and inflammation together with foul-smelling suppurative drainage and abscess formation, as well long- lasting cultures shown by both commensal and pathogenic bacteria; responds to antibiotics). He concluded by noting that the immunopathogenesis appears to be complex, and that it shows characteristics of neutrophilic dermatosis, with a strong anti-inflammatory component (IL19), possible B cell participation, and a clear contribution from TH1 or TH17 cells.
The role of ultrasound in hidradenitis suppurativa
According to the oral communication of Ximena Wortsman (Chili)
Dr Ximena Wortsman discussed The Role of Ultrasound in HS.
Ultrasound is a useful tool in correct staging and subsequent monitoring of treatment. It has been shown in multiple studies that clinical staging (Hurley stages) often underestimates the severity of the case due to subclinical lesions detected with the SOS-HS score. This is also a prognostic factor, since stages 2 and 3 respond poorly to systemic treatment due to the high degree of fibrosis. She showed its importance as a guide in invasive treatments like corticosteroid injections, and in preparing a guide plan for surgical treatments. Dr Wortsman recommended basal Colour Doppler Ultrasound for good diagnosis and staging, then for follow-up according to the severity of the case and the patient’s progress, and for monitoring and a possible treatment guide.
Non-surgical treatment options for hidradenitis suppurativa
According to the oral communication of Rita Pichardo (USA)
Next, Dr Rita Pichardo talked about Non-Surgical Treatment Options, and explained that while there is no effective cure for HS, there are metabolic, medical and surgical strategies which vary with the type of lesions, Hurley stages, frequency of flare-ups and the patient’s goals/expectations.
STAGE I: Clindamycin 1% lotion, silver sulfadiazine 1% cream and benzoyl peroxide 10% cleanser. Doxycycline, minocycline 100 mg / twice daily or amoxicillin / clavulanic acid or clindamycin 150 mg twice daily. She also suggests zinc 90 mg/day and interlesional triamcinolone 10 mg/cc.
STAGE II: Clindamycin 300 mg twice daily plus rifampicin 300 mg twice daily for 3 months, or dapsone 50-100 mg/day and triamcinolone and zinc in this stage as well. In refractory Stage II cases: Adalimumab 40 mg/week (the only one approved by the FDA), or infliximab 5 mg/kg IV every 8 weeks; spironolactone 50-100 mg/day and as rescue therapy, metronidazole 500 mg twice daily, rifampicin 300 mg twice daily and moxifloxacin 400 mg/day.
For STAGE III: Clindamycin 300 mg twice daily plus rifampicin 300 mg twice daily; prednisone 0.5 - 1mg/kg/day. Cyclosporine. TNF-alpha inhibitors and others. As adjuvant therapy: quit tobacco use and reduce weight, pain management and treatment of secondary bacterial infection. She highlighted the importance of multidisciplinary teamwork.
Hidradenitis suppurativa: surgical options
According to the oral communication of Mark Davis (USA)
To bring this busy day to a close, Dr Mark Davis spoke about Surgical Treatment of HS. He emphasised that incision and drainage of lesions should be avoided, except to alleviate intense pain from an abscess due to frequent recurrence. He recommended punch debridement, deroofing of sinus tracts or abscesses and excision, depending on severity. Other tips included W-plasty, discontinuous undermining, V-Y advancement flaps and split-thickness auto-skin grafts which do not include the pilosebaceous units. In conclusion, he presents surgical treatment as safe and effective, with low complication rates.
The utility of skin ultrasound in diagnosis and treatment of dermatological pathology
According to the oral communication of Carmen Rodríguez Cerdeira (Spain)
In her keynote address, Dr Carmen Rodríguez Cerdeira discussed the Utility of Skin Ultrasound in the Diagnosis and Treatment of Dermatological Pathology. She spoke about skin ultrasound as a non- invasive technique (both ultrasound and confocal microscopy) that is safe, inexpensive, and immediately accessible, and that provides additional anatomical and physiological information. In addition, it helps in the diagnosis, management and monitoring of different dermatological processes (inflammatory, tumoural and aesthetic). She mentioned that the images are hyperechoic in the epidermis, interlobular septa, fascia, bone/calcifications, extracutaneous hair, nail plate and foreign bodies; hypoechoic in fat lobules, the nail bed, cartilage and muscle; and anechoic in air and water.
The Doppler technique allows us to study the vascular structures and identify physiopathological phenomena like inflammation via increases in skin vascularisation. She reviewed the artefacts that can lead to erroneous diagnoses (reverberation, posterior and lateral acoustic shadowing, posterior acoustic enhancement, and mirror images).
Among Benign Tumours, the added value for Seborrhoeic Keratoses is very limited because of their epidermal location; with Lipomas, ultrasound allows us to determine supra-, intra- or inframuscular location, and with Angiomas, the Doppler shows its increased flow in the dermis/hypodermis.
Epidermoid Cysts are anechoic with posterior enhancement and with no increased vascularisation, and Pilomatricoma presents an anechogenic halo with hyperechogenic foci in the centre (calcifications) and increased vascularisation at the periphery.
With Malignant Tumours, Non-Melanoma Cancers: BCC, estimation of depth and diameter to delimit surgical margins, examination of peritumoural vessels, adjacent structures and evaluation of response to non-surgical treatments and recurrences. It appears as a solid hypoechoic tumour, with irregular but well-defined edges and with characteristic hyperechoic spots and a moderate increase in intra- and peritumoural vascularisation. SCC: a less characteristic pattern which appears as a more or less homogeneous, irregular hypoechoic lesion, often vascularised with both peripheral and intratumoural neovessels; helps to rule out invasion of adjacent structures and in measuring tumour thickness.
Melanoma presents a clearly delimited, “potato-shaped” hypoechoic lesion that allows for estimation of tumour thickness; however, ultrasound does not distinguish pigment, making it less useful than Confocal Microscopy, and it offers limited help with thick melanomas. Cutaneous MTS of Melanoma appear as fairly homogeneous dermo-hypodermic nodules, with edges that are sometimes irregular or polycyclic, with necrotic areas with an anechoic appearance and increased vascularisation on the Doppler, although these are not so significant in lesions smaller than 7 mm.
Autoinflammatory syndromes: cases I’ve learned from
According to the oral communication of Antonio Torrelo (Spain)
A very interesting Symposium on Autoinflammatory Diseases, a group of uncommon diseases characterised by acute and recurring inflammatory episodes with overproduction and release of proinflammatory mediators. Genetic and molecular defects responsible for these diseases have been discovered in the last 25 years. Dr Antonio Torrelo spoke about “Cases I’ve Learned From”; he reviewed his clinical cases over the years, many of which had diagnoses for years which described the skin involvement very well but did not explain the systemic problem. One of them was a girl with a diagnosis of Generalized Pustular Psoriasis in whom a Deficiency of IL-36 Receptor Antagonist was discovered after many years, finally allowing a DITRA to be diagnosed. Another patient was diagnosed with Chronic Lichenoid Keratosis; in this patient, a Germline NLRP1 mutation was eventually detected, which is also responsible for Chronic Myeloproliferative Syndromes. A boy diagnosed with Generalised Progressive Symmetric Erythrokeratodermia turned out to have a hyperfunctioning CARD14 mutation, resulting in CAMPS (CARD14-Mediated Psoriasis). The same mutation is seen in patients with a diagnosis of Familial Pityriasis Rubra Pilaris associated with Psoriasis. A diagnosis of Perforating Neutrophilic and Granulomatous Dermatitis in a patient with a near-total absence of Ig and B lymphocytes was ultimately found to have a PLCG2 (phospholipase C gamma 2) mutation, leading to a diagnosis of APLAID (Autoinflammation and PLAID, i.e. PLCG2 associated antibody deficiency and immune dysregulation).
Mucocutaneous ulcers and urticarial lesions: when should an autoinflammatory syndrome be suspected?
According to the oral communication of Rosalba Elizabeth Riveros Rivarola (Paraguay)
Dr Rosalba Riveros Rivarola discussed “Cutaneous ulcers: when should an autoinflammatory syndrome be suspected?” She classified them according to their clinicopathological dermatological context into SYNDROMES WITH MUCOCUTANEOUS ULCERATIONS (Marshall’s Syndrome, PFIT Syndrome, Behcet-Like Autoinflammatory Syndrome and Behcet’s Syndrome) and URTICARIFORM SYNDROMES, for which she described the CRYOPYRINOPATHIES (FCAS, Muckle-Wells Syndrome, and NOMID), and PERIODIC FEVERS (FMF, TRAPS, HIDS, PLAID/APLAID Syndrome,
AISLE Syndrome, NLRP1-Associated Auto-Inflammation with Arthritis and Dyskeratosis). In conclusion, she stated that it’s important to think of autoinflammatory lesions when we encounter urticariform or ulcerous lesions associated with 3 recurrent episodes of moderate fever and arthritis in patients under 20 years of age and with high CRP/acute phase reactants, in the absence of pathogens, circulating autoantibodies or antigen-specific T lymphocytes, which differentiates them from autoimmune diseases.
Hidradenitis suppurativa: a systemic disease
According to the oral communication of Alberto J. Lavieri (Argentina)
Dr Alberto Lavieri discussed Hidradenitis Suppurativa as a systemic disease and presented an analysis in which he describes the comorbidities already known to be associated with HS (HBP, dyslipidaemia, diabetes, rheumatic diseases; PCOS, IBD, tumours with lymphoma, SCC, mucinous adenocarcinoma, and psychiatric disorders like depression and anxiety), but places the focus on statistical analysis to determine in which cases it is actually necessary to perform a screening and thus achieve early identification of those at risk of disease, understand the pathogenesis and establish new evidence-based therapeutic targets, since correlation does not imply causation, ruling out mere co-occurrence. It is known for certain that the 1/3 male-female ratio, tobacco use, obesity, age (18-29 years) and low socio-economic status are demographic data. In summary, screening is recommended for patients with a risk of metabolic syndrome (diabetes/obesity/dyslipidaemia/HBP/cardiovascular disease), psoriasis (shares the same comorbidities as HS), polycystic ovary syndrome (strongly associated with obesity and metabolic syndrome), inflammatory bowel disease, rheumatic diseases (axial and peripheral arthritis, sacroiliitis, spondyloarthropathy, enthesitis, dactylitis), uveitis, SCC (4%) and psychiatric diseases (major depression, anxiety, use of intoxicants and suicidal ideation). On the other hand, statistics have shown that, in cases of thyroid dysfunction, non-alcoholic fatty liver and malignancies, screening would not be recommended.
New non-freezing technique in post-herpetic neuralgia and vulvodynia
According to the oral communication of Liliana Calandria (Uruguay)
In the Cryotherapy Workshop, Dr Liliana Calandria spoke about a New Non-Freezing Technique for Post-Herpetic Neuralgia and Vulvodynia, using N2 without freezing, at about 15 cm away and perpendicular to the site, using circular movements covering the whole area like a cloud for 30 seconds or more; in general, 6 cycles are performed, one per week. The procedure activates internal reactions that alleviate pain, with partial restoration of the affected nerve fibres and sheaths. Use of Abbocath 14 or without a point is recommended, and the patient will feel very intense cold for minutes or hours. The changes are subjectively subtle at first, and it helps to have the patient fill out a worksheet to record pain intensity, type, duration, etc. Better results are observed when the procedure is started early, and it has also been observed that in patients who did not show a good response, it also helped to reduce their post-herpetic neuralgia medication. For vulvodynia, 2 to 10 sessions are suggested, with clear improvement from the outset and with no recurrence. This technique contributes a bloodless approach with promising results, prioritising dermatologists’ role in difficult-to-resolve cases.
Precancer: Cryosurgical management and clinical-dermatoscopic correlation
According to the oral communication of Eduardo Silva Lizama (Guatemala)
Dr Eduardo Silva Lizama discussed Cryosurgery in Skin Precancer, proposing an open spray technique for actinic keratosis, Bowen’s disease and early invasive squamous cell carcinoma, in 2 cycles of no more than 20 seconds of application and 30 to 45 seconds in clearly differentiated SCC, always with 5 mm margins in the last three cases. Immunocryosurgery for actinic keratosis and Bowen’s disease is performed with Imiquimod 5%; for AK on alternating days for 3 weeks with cryosurgery application in week 2, and for Bowen’s, 5 weeks of daily application with cryosurgery in week 2 as well. Later, Imiquimod is stopped. This can also be done with 5FU and Diclofenac, but he does not use these as much.
The world of basal-cell carcinoma cryosurgery
According to the oral communication of Eduardo Silva Lizama (Guatemala)
He then spoke about the World of BCC Cryosurgery, with fast freezing and slow thawing at a minimum temperature of -25° and in 2 cycles, with pigmented, ulcerated, nodular BCCs smaller than 1 cm, and secured in cartilage. (Relative) contraindication in BCCs larger than 1 cm; with poorly- defined edges or post-radiotherapy recurrence; located in nasolabial or preauricular regions or on the scalp, nasal alar crease, lower limbs, lateral faces of the tongue, or cubital fossa; or in sclerodermiform or metatypical variants. Cure rate is 95 to 98% of cases, except in embryonic fusion zones, where the recurrence rate is twice that of other locations. He recommends a closed technique with a test tube or open spray; margins of 5 mm and 3-5 deep. Palliative Cryosurgery is used for elderly patients with large lesions, starting from the centre to reduce the size and then the periphery in a separate session, at least 2 times. Finally, he recommends using a combination with dermatoscopy as a complementary technique.
Cryosurgery as coadjuvant treatment
According to the oral communication of Gustavo Segura (Mexico)
To wind up this very full day, Dr Gustavo Segura Morena spoke about Cryosurgery as Coadjuvant Treatment and discussed immunocryosurgery, cryobiopsy in which it has been shown that the tissue is not damaged for further histopathological study, coadjuvancy with intralesional triamcinolone in keloid scars and in association with terbinafine for sporotrichosis.
Topical caffeine for androgenetic alopecia, more useful tools
According to the oral communication of John H. Gaviria Calderon (Colombia)
In the Therapeutics Course, which took the whole morning today, Prof. John Gaviria Calderón spoke about the Efficacy of Topical 1.5% Caffeine in a compounded formulation using nanotechnology for androgenetic alopecia, with a high growth rate due to its action on hair follicles, noting that its efficacy is equivalent to 5% Minoxidil. He recommended combined use of 1.5% Caffeine in the morning, giving the formulation in distilled water to avoid making the hair greasy, and 5% Minoxidil at night, and demonstrated the success of the treatment at 3 months with Fotofinder trichoscopy.
Therapeutic Updates in Alopecia Areata
According to the oral communication of Ariel Bernardo Sethman (Argentina)
Dr Ariel Sethman gave an update on treatments for alopecia areata.
He reviewed clinical symptoms, comorbidities and aetiopathogenesis and showed the wide range of treatments available, and suggested that each treatment should be used for at least 6 months before seeking a new alternative if no response is seen. Due to the autoimmune nature of AA, two therapeutic approaches have proven to be effective: corticosteroids and topical sensitisers; the former (topical or intralesional and systemic) reduce T CD4+, NK and Langerhans cells and increase T CD 8+, thereby inverting the CD4/CD8 ratio. Topical sensitisers (particularly diphencyprone) increase non-specific suppressor T clones to reduce the immune response to auto-antigens, induce a new T population to eliminate auto-antigens in affected areas of the hair and thus induce antigenic competition. With regard to topical and oral Minoxidil, the mechanism by which it stimulates the hair follicle has not been explained, but it induces and prolongs the anagen phase, increases the thickness and length of the new hair, transforming the vellus hair into terminal hair. Depending on extent (less or more than 50%) and age (less or more than 10 years), he proposes 5% Minoxidil + medium-strength topical corticosteroid twice daily for patients under 10 years old; for patients over 10, but with less than 50% extent, intralesional corticosteroids plus 5% Minoxidil / 5% Minoxidil + clobetasol twice daily. And for patients over 10 years old with more than 50% extent, diphencyprone twice weekly for 24 weeks / 5% Minoxidil + clobetasol. New: JAK inhibitors may be effective (topical and oral tofacitinib, ruxolitinib and baricitinib) with variable results; although relapses occur when they are stopped, they should be considered as an alternative for localised AA in case of adverse effects from oral treatments or with paediatric patients. Also PRP, which promotes growth and differentiation of the hair follicle in the promontory area, and follicle cells express receptors for the factors released by the platelets (PDGF, TGFB, VEGF and FGF), stimulating cell proliferation and stimulating hair growth with 1 monthly application for 6 months. Emerging treatments: dupilumab, ustekinumab and abatacept. Simbastatin/Ezetimibe has shown limited and controversial results. In conclusion, he suggested multidisciplinary management with medical specialisations, psychodermatology, and patient associations.
Ivermectin in Dermatology
According to the oral communication of José María Ollague Torres (Ecuador)
Dr José Ollague discussed Ivermectin in Dermatology, reviewing the history of the multiple uses to which it has been put since 1983 as a powerful antiparasitic, starting with nodular migratory eosinophilic panniculitis, and later scabies, rosacea, pediculosis pubis, demodecidosis, larva migrans, crusted scabies, phthiriasis palpebrarum, tungiasis, caridiasis and trichuriasis, swimmer’s itch, onchocerciasis, and strongyloidiasis. It has shown antiparasitic, anti-inflammatory, antimicrobial, antineoplastic and antiviral effects, although Dr Ollague classifies many of the publications on SARS SOV-2 as anecdotal.
Treatment of ANCA-positive vasculitides
According to the oral communication of Gustavo Camino (Peru)
Dr Gustavo Camino spoke about the Treatment of ANCA-Positive Vasculitides.
In his discussion of the physiopathology, he placed a particular emphasis on B-lymphocyte CD20, which is targeted by current first-generation treatments like rituximab and second-generation treatments like ocrelizumab, obinutuzumab, veltuzumab and ofatumumab. Treatment in the INDUCTION PHASE uses oral corticosteroids or pulses followed by oral administration, and oral cyclophosphamide or pulses followed by maintenance with oral administration. Rituximab with initial dose of 1g IV day 0 and 14 or 375 mg/m2/week for 4 weeks, then maintenance 4 to 6 months after induction. Also Ig IV in refractory cases and plasmapheresis in refractory cases and patients with ANCA and anti-GBM antibodies (Goodpasture syndrome). In 75 to 90% of cases, total or partial remission in 6 months. MAINTENANCE PHASE: AZT, MTX, rituximab, mepolizumab and MMF; this stage extends to 12-24 months or 36 months in case of severe PR3 ANCA; in non-severe MPO ANCA, observation.
Therapeutic Secrets from the Mayo Clinic
According to the oral communication of Mark Davis (United States)
Dr Mark Davis presented Top-Secret Therapeutic Tips and Clinical Pearls from Mayo Clinic.
For CTCL, the clinic has used low-dose, hypofractionated superficial radiotherapy (electron beam) with resounding success for difficult-to-manage lesions. For erythromelalgia, he discussed the efficacy of lidocaine patches, which were also used for postherpetic neuralgia and for recovery from painful ulcers. For brachioradial pruritis, and with erythromelalgia and perineal, genital and rectal pain and other forms of localised pain, good results were achieved with a combination of 2% amitryptiline and 0.5% ketamine in cream form. For calciphylaxis, besides conventional treatments, he mentioned oral anticoagulants in comparison with the performance of AMI. For oral lichen planus and canker sores, use of high-potency corticosteroids or tacrolimus ointment applied with a cotton swab. For burning mouth syndrome, lidocaine gel or clonazepam applied directly to the lesion, then withdrawn without swallowing; also keep the mouth hydrated, bland diet, gentle brushing and avoid oral habits like biting one’s tongue. As a systemic treatment, alpha-lipoic acid, gabapentin and pregabalin. To conclude, he mentioned moist dressings after applying low- to moderate-potency creams for rapid control of pruritis in a wide variety of pruriginous dermatoses in children and adults.
Secondary Effects of Chemotherapy Drugs
According to the oral communication of Iván Jara Padilla (Chile)
Next, Dr Iván Jara Padilla presented a review of Secondary Cutaneous Effects of Chemotherapy Drugs: mucositis, toxic erythema, onychodystrophy, hyperpigmentation, alopecia. The new targeted therapies show secondary effects, like EGF receptor inhibitors which produce papulopustular/acneiform rashes in 50-90% of patients, monomorphic and in seborrhoeic areas after the second week of chemo. In the nails: paronychia, distal onycholysis, pyogenic granuloma; in hair, changes in texture. Also xerosis, photosensitivity, hyperpigmentation, SJS/TEN. Small tyrosine kinase receptor inhibitor molecules can produce periorbital facial oedema, induration and visual disturbances (60%), morbilliform rash, localised or diffuse pigment changes, alopecia and exacerbation of pre- existing dermatoses like psoriasis, lichenoid reactions, TEN. Also hand-foot syndrome, splinter haemorrhages, and seborrhoea-like dermatitis. RAS/BRAF/MEK/ERK intracellular pathway inhibitors produce morbilliform rash, verrucous keratosis, keratoacanthoma, transformation of naevi into melanoma (evaluation every 3 months) and hyperkeratosis of the hands, feet and areas subject to friction; these secondary effects are less common when combined therapy with BRAF INH + MEK INH is used.
Pemphigus Vulgaris Update
According to the oral communication of Julio Cesar Empinotti (Brazil)
Dr Julio Empinotti gave a Pemphigus Vulgaris Update, dividing the treatment into Induction to Remission with corticosteroids and Remission Maintenance with the goal of a low dose of prednisone (10mg/day) and adjuvants like AZT, MTX, cyclophosphamide, plasmapheresis, high-dose Ig IV and rituximab, which achieves 89% complete remission when combined with prednisone vs. prednisone alone. He suggests the RA protocol in the ICU, with a pulse of 1 g IV repeated every 15 days, leading in many cases to stopping the corticosteroid. Emerging therapies: Anti-B-cell immunobiologicals (veltuzumab, obinutuzumab, ofatumumab, FcRn, BTK inhibitor, anti-BAFF and anti-BAFF-R, among others).
Breaking Paradigms in Understanding Skin Diseases
In the afternoon, in New Trends, Breaking Paradigms in Understanding Skin Diseases, the Colombian Psoriasis and Immunodermatology Group (COLPSOR), consisting of Dr Juan Castro Ayarza, Dr Angela Londoño, Dr César González Ardila and Dr Manuel Franco, accompanied by Dr Gabriel Magariños, provided an interesting perspective on psoriasis from the past, present and future. To give a brief snapshot, they organised it as follows:
the treatments NOT USED were: efalizumab, alefacept, TMS + SMX, cyclosporine for more than 2 years, and dapsone.
In LIMITED USE: dithranol, fumaric acid esters, tazarotene, calcipotriol in monotherapy and infliximab. In CURRENT USE: MTX, efficient, economical, safe and with a protective effect in patients with psoriasis and metabolic syndrome (subcutaneous use is recommended).
WHAT’S COMING NEXT: Neuropeptides like onabotulinum toxin A, botulinum toxins in localised plaques to achieve 40% reduction of erythema, desquamation and infiltration. Calcitonin gene-related peptide (CGRP), a mediator for pain, growth factor and keratinocyte proliferation. Nerve growth factor (NGF), which activates and recruits mast cells, keratinocyte proliferation. Substance P, which induces skin inflammation, proliferation of T lymphocytes. As for technology, notable tools include the excimer laser and the FotoFinder which is used to determine PASI scores, but both are very expensive and operator-dependent; apps like ReumApp and Psioriasis Calc; and use of the Internet.
WHAT THE FUTURE HOLDS: there is currently a staggering of doses to avoid the loss of efficacy in anti-drug antibodies (ADAs), so their identification is important. There are also ongoing studies in rats of anti-cytokine and anti-microbial vaccines and immunotherapies (anti-IL17), biomarkers like HLA- C06 which will make it possible to predict responses to treatment, which have been observed in “superresponder” patients and serum N-glycomics. Finally, artificial intelligence will enable recognition of lesions and monitoring of responses to particular treatments; some such studies already exist in skin cancer, psoriasis (ECLIPSE), atopic dermatitis and onychomycosis.
In conclusion, the identification of ADAs and serum levels of biologic drugs turn out to be important tools in selecting treatments. “Superresponders” present a challenge with regard to their identification and the possibility of spacing out drug doses. Artificial intelligence can help to identify situations and to make decisions which will improve patients’ quality of life.
Clash of the Titans
According to the oral communications of Arnaldo Aldama (Paraguay), Marcello Menta Simonensen (Brazil), Juan C. Diez de Medina (Bolivia), Juan Chalela Mantilla (Colombia), Silvio Alencar Marques (Brazil), Margarita Larralde (Argentina) and Gustavo Camino (Peru)
In the classic and always enlightening Clash of the Titans session, clinical cases were discussed based on the vast experience of the participating professors, who offered their diagnostic impressions, and on colleagues’ contributions through the live chat in which they shared their own impressions.
Dr Arnaldo Aldama presented the case of a 51-year-old woman sent from the Surgery Department for evaluation of abdominal scarring who had had operations on both breasts (4 years prior, then 2 years) with a presumptive diagnosis of breast cancer, observing fat necrosis and acute inflammatory infiltrate, and then, on a second occasion, liquefactive necrosis, fibrosis and necrosis of the mammary parenchyma. At a consultation the year before, she had presented an abscess in the abdominal wall (RIF), with histopathology again reporting an acute inflammatory process with necrosis of the fibroadipose tissue. In her second consultation, she presented a painful lesion in the remaining right breast with 4 days of evolution, initially erythematous and then blackish in colour, with necrotic crust and suppurative submammary ulceration. Presumptive diagnoses were proposed, such as cryoglobulinaemia, panniculitis, antiphospholipid syndrome, dermatomyositis, and vasculitis. A new biopsy was performed. Moderate neutrophilic infiltrate and hyaline material in the light, with subtle changes that pointed to cryoglobulinaemia. The Department of Internal Medicine suspected dermatomyositis due to slight muscle weakness, alopecia and Raynaud’s (reported by the patient but not confirmed), in addition to an ESR of 71, slightly elevated C4 and anti-Ro+ antibodies; everything else normal. MTX was started and the patient consulted at another Centre, where she finally reached her objective, namely excision of the remaining mammary tissue. Two years later, she was admitted to the emergency room with a diagnosis of thoracic cellulitis and received appropriate treatment for it, and a biopsy was again performed with presumptive diagnoses of APS vs. cryoglobulinaemia vs. panniculitis vs. dermatitis artefacta. ATB were stopped and prednisone was started. Biological parameters continued to be normal with no return to the ER until she went to the hospital in her city for “a fall from her own height” and heavy bleeding from a lesion on the left breast scar which led to a surgical intervention with transfusion of 2 units of blood, and the extraction of a ballpoint pen from the mammary region with abundant surrounding scar tissue, thus leading to a final diagnosis of dermatitis artefacta. The patient could not be convinced to accept this evaluation and enter psychiatric treatment.
Dr Marcello Menta Simonensen presented the case of a 30-year-old woman with intensely pruriginous lesions on her face with 5 days of evolution; presumptive diagnoses of syringomas, flat warts, granulomatous rosacea, and sarcoidosis. The biopsy showed a lichenoid dermatitis with mild spongiosis, but the symptoms spontaneously regressed in 21 days. With the valuable support of Prof. Casas, who observed keratinocyte necrosis that had not been seen previously, they were able to arrive at a diagnosis of flat wart regression phenomenon, with the Hp showing Ly-Mn infiltration in the upper dermis with invasion of the epidermis, vacuolar degeneration of the basal cells, spongiosis, microvesiculation, exocytosis and keratinocyte necrosis.
Dr Juan C. Diez de Medina presented the case of a 52-year-old patient with a nodular erythematous lesion in the left nasolabial region, asymptomatic, with rapid growth over 8 months. The presumptive diagnoses were: BCC, solitary trichoepithelioma, trichofolliculoma and leiomyoma. The dermatoscopy technicians were strongly inclined toward a BCC diagnosis, so the lesion was excised and it turned out to be a foreign body granuloma.
Dr Juan Chalela Mantilla presented the case of a 23-year-old man with significant cheilitis with 18 months of evolution, following treatment of acne with isotretinoin in the context of atopy. The lesions began during treatment and never improved when it was stopped after completing the appropriate dose. Emollients and topical corticosteroids were indicated; lab results were normal, except for IgE.
Mycology was negative and bacteriology showed a wide range of germs for which he received all types of antibiotics without any response. Upon seeking a second opinion, ATB were suspended, thalidomide was initiated and had to be stopped due to sleepiness, and the patient was switched to DDS and Vit. C in addition to gentle hygiene and moisturisation. The patient improved and there is still no diagnosis.
Dr Silvio Alencar Marques presented the case of a 75-year-old patient with a history of “cancer” 5 years previously (unknown type), who presented a pericicatricial tumoural lesion at 3 months of evolution with a satellite lesion at 1 month of evolution, preauricular, with no palpable ADP and in good general condition. Presumptive diagnoses of Merkel cell carcinoma, angiosarcoma, SCC and metastasis of SCC. The biopsy showed a clear neoplastic lesion, with IHC results showing AE1/AE3+, EMA+, BerEP4-, KI67 80%; adipophilin and androgen receptor were not checked. A diagnosis of extraocular sebaceous carcinoma was established, ruling out Muir-Torre syndrome.
Dr Margarita Larralde presented 2 paediatric cases with the same pathology. The 11-year-old girl had been treated with IV antibiotics for infective cellulitis on 2 occasions for erythema in the neckline region at age 4, and was still seeking a diagnosis. With presumptive diagnoses of cellulitis, tufted angioma, eccrine angiomatous hamartoma, KHE complicated with KMS or connective tissue dieases, a biopsy was performed which allowed for a diagnosis of tufted angioma with characteristic cannonball-like cells and IHC showing Glu-, WT1+ and D2-40(+/-). Recall the association with Kasabach-Merritt syndrome and chronic coagulopathy without thrombocytopenia. Discussion as to whether TA and KHE are distinct entities or a spectrum of the same entity.
Finally, Dr Gustavo Camino presented the case of a 68-year-old patient with a lesion that she referred to as a “callus” on the back of her hand with sudden growth. A lozenge biopsy was performed, leading to a conclusion of keratoacanthoma, recurring at 8 months with a very large lesion. A new lozenge was taken, and again the biopsy showed keratoacanthoma (with free edges in both cases). When it recurred again, the colleague who had been seeing her referred her to a hand specialist for an intervention, and at that point Dr Camino saw her with pericicatricial papular lesions. This time, the biopsy allowed them to come to a diagnosis of myrmecia verrucae, with no new lesions appearing at a check-up 1 year later.
We hope you have enjoyed RADLA 2021!
Fillers and skin biostimulators
Fillers for the lower third: harmonising volumes
According to the oral communication of Sergio O. Escobar (Argentina)
In his presentation, Dr Sergio O. Escobar discussed how to improve the lower third of the face with collagen-boosting fillers. Drooping of the superficial buccal fat over the mandibular ramus leads to the much-feared “jowls”, also known as the “bulldog look”. The doctor presents a filler technique that uses calcium hydroxyapatite in a 1:2.5 dilution with PSS and lidocaine 2%. According to the doctor, the key is to fill in the masseter and premental area just on either side of the drooping area. In addition, it is
important to make a vertical pillar in the gonion area. Using a cannula in this area makes it possible to avoid damage to facial arteries.
Fillers for the mid and upper third
According to the oral communication of Veronica Muchnik (Argentina)
Dr Veronica Muchnik spoke about repositioning of the middle third of the face. The lines on the face in this area are relevant because they help us to detect the ligaments. The orbital ligament and the lower front zygomatic ligament are the most relevant here. There are both superficial and deep fat compartments. In general, the superficial ones primarily fall at the lateral level and the deep ones at the medial level in what is known as medial SOOF (medial suborbicularis oculis fat). The most superficial area is usually filled with a cannula in vectors, while the deep area is filled in boluses. The fillers must be chosen appropriately for the area, using higher G’ at the deep level. For the temporal area, the ideal is to fill no more than 1 cm below the temporal crest, and no further than 1 cm laterally from the orbital rim, to avoid the superficial temporal and deep temporal arteries.
According to the oral communication of Cristina Pascutto (Argentina)
The presentation on biostimulators by Dr Cristina Pascutto reviewed the new type of dermal and subdermal fillers with the ability to stimulate collagen synthesis and provide effects that go beyond just adding volume. Hyaluronic acid not only provides support, it also has a biological stimulating effect on both dermal and epidermal tissue. This effect is mainly achieved with non-reticulated hyaluronic acid. This type of hyaluronic acid must have a molecular weight between 1 and 3 million kDa, with different concentrations and low G’. In many cases, they are mixed with amino acids, stimulating peptides, etc. Superficial intradermal application is most common, although deep application is also possible. The other major product for facial biostimulation is calcium hydroxyapatite, which is marketed as calcium hydroxyapatite microspheres in a carboxymethylcellulose matrix. The G’ value is high, with high viscosity. Its effects are angiogenic and induce neocollagenesis, and it can be used for tightening, definition of the facial contour and collagen stimulation in any area of the face. It is usually used with dilutions to make it more economical to use the product in larger areas. In addition, recent studies show that it produces better synthesis of collagen types I-III and elastin when diluted. It should not be applied to the glabella or the lips. An alternative to synthetic fillers is autologous plasma, which has the advantage of using multiple non-exogenous growth factors. Plasma has multiple indications beyond wrinkles or tightening.
Dyschromias: What colour determines in the skin?
Histopathology of dyschromias
According to the oral communication of José Antonio Plaza (USA)
One highlight in the session on dyschromias was Dr José Antonio Plaza’s presentation on the histopathology of alterations in skin pigmentation. The doctor emphasised that all of these pathologies are very non-specific with the usual stains, hence the clinical-pathological correlation.
Initially focusing on hypopigmentations or achromias, MITF-1 is useful with vitiligo as a nuclear marker that stains melanocytes in a very specific way. Fontana-Masson staining is also helpful in diagnosing vitiligo. In the case of guttate hypomelanosis, epidermal atrophy, flattening of ridges and patchy loss of melanocytes, but not total absence. Postinflammatory hypopigmentation is another common condition resulting from many other causes such as morphea, psoriasis, leprosy, pityriasis versicolor, syphilis, etc. Histologically, we typically see melanophages in the dermis, which help with diagnosis.
One situation in which pathology does help is with hypopigmented mycosis fungoides: cytotoxic CD8+ phenotype, epidermotropic lymphocytosis, inflammatory infiltrate.
Turning to hyperpigmentations, there are certain specific cases with more or less typical characteristics. Confluent and reticulated papillomatosis of Gougerot and Carteaud presents the following characteristics: wavy epidermis, squat papillomatosis and elongation of ridges. The histology of macular amyloidosis presents deposits of amyloid material in the basal membrane or in the superficial portion of the papillar dermis, some acanthosis and generally inflammatory infiltrate. It usually requires specific stains. Erythema dyschromicum perstans shows vacuolar interface changes, with pigment in the dermis in the earliest stages; but it loses specificity when it is more advanced, showing only melanophages. Postinflammatory hyperpigmentation also includes melanophages, and it is essential to look for characteristics that will help us to find the initial pathology that caused this hyperpigmentation.
Laser and IPL
Lasers in dermatological treatment
According to the oral communication of Alvaro Andrés Luque Acevedo (Colombia)
In the symposium on laser light therapy and intense pulsed light (IPL), Dr Álvaro Andrés Luque introduced us to basic aspects of lasers. The wavelength (colour) of the laser determines its affinity for different chromophores (targets) in the skin. In turn, the size of the treatment target determines the thermal relaxation time of the tissue to be treated, and thus the length of the pulses used to treat that target (shorter pulses for smaller sizes). Extremely short pulses can generate photoacoustic effects, which go beyond the photothermal effects. In dermatological terms, indications for laser treatment can include capillary malformations, spider veins or rosacea. For pigmentation, lasers can be used to treat hyperpigmented lesions such as lentigos, café au lait spots, tattoos, etc. In skin rejuvenation, the field of application is even broader, with ablative and non-ablative fractional lasers.
Applications of intense pulsed light (IPL) in dermatology
According to the oral communication of Susana Misticone (Venezuela)
The presentation on Intense Pulsed Light was provided by Dr Susana Misticone, who reminded us that while, strictly speaking, pulsed light is not a laser, the principles by which it operates are still based on selective photothermolysis. Its primary advantage is its versatility: it can be used to treat vascular lesions, pigmented lesions, and also for photorejuvenation. It can be a good option for superficial pigmented lesions, using short wavelengths starting from 510 nm. It should not be used with tattoos due to the risk of burns. Dr Luque recommended combining pulsed light with vascular filters for melasma, followed later by low-intensity pigment laser. For vascular lesions, it is recommended to use 550, 560 or 570-nm filters, which can yield results nearly as effective as purely vascular lasers. Another advantage is the ability to perform multi-chromophore treatments with photothermal and photobiological effects in cases of acne. The primary complications typically seen are pigment alterations from the use of short filters with dark phototypes and possible interactions with melanin.
CO2 laser and its many indications
According to the oral communication of Daniel Galimberti (Argentina)
Dr Daniel Galimberti presented his experience and new developments in CO2 laser therapy. The indications vary widely, and these lasers can be used for actinic cheilitis, rhinophyma, laser resurfacing, etc. They can be used in fractional mode to perform resurfacing with quick recovery times compared to traditional treatments. Dr Galimberti also presented his experience in treating lower- extremity ulcers with CO2 laser via vaporisation of fibrin and fractionation in the peripheral area.
Another relevant surgical treatment is perforation of the bone of the cranial vault in secondary healing after oncological surgery to accelerate the healing of defects.
Pulsed dye laser (PDL) with vascular lesions: our experience
According to the oral communication of Florencia Galdeano (Argentina)
Dr Florencia Galdeano told us about the effectiveness of pulsed dye lasers for the treatment of capillary malformations, using purpuric settings, and achieving efficacy rates between 50 and 90% in most patients. In addition, with infantile hemangiomas, pulsed dye laser can allow for the use of lower doses of propranolol and shorter treatment periods.
Facial rejuvenation: combining technologies to optimise results
According to the oral communication of Fátima Agüero De Zaputovich (Paraguay)
Dr Fatima Agüero de Zaputovich presented her experience in combining techniques to optimise results with rejuvenation. One of the most interesting combinations that the doctor presented was botulinum toxin 10-15 days prior to CO2 resurfacing. Using mini-doses of isotretinoin together with CO2 is also effective for patients with hyperseborrhoea or rhinophyma. Fractional CO2 lasers can also be used to generate channels so that we can later deliver plasma and accelerate healing. She presented what appears to be a particularly effective combination for acne scars, using a CO2 laser in continuous mode for deep scars and radio frequency microneedling for the surrounding skin, combined with topical platelet-rich plasma.
The symposium on hair restoration presented different aspects of this technique, for which both demand and the range of offerings are booming.
Preparation, evaluation and monitoring of patients with scarring alopecias
According to the oral communication of Jorge Larrondo (Chile)
With regard to scarring alopecias, Dr Jorge Larrondo presented aspects to keep in mind for preparing and monitoring treatment. It is especially important to know when we can consider performing hair transplants. We need to bear in mind that a high percentage of patients with scarring alopecias show psychological disturbances and significant distress in their quality of life, and that many times we cannot offer them surgical improvement. In addition, cases have been described of scarring alopecias appearing due to surgical treatments including transplants and others, even cases as simple as a nevus excision. When planning a surgery, we need to consider the need to provide good medical treatment. This is essential before, during and after the surgery – adapting it to each case, since the available options and responses are highly varied. The goal is to control the pathological activity, although there is no gold standard for monitoring. When planning a surgery, recommendations vary between one year and 2-5 years. We have the option to assess the clinical history in order to choose data that show where there is activity. However, we must keep in mind that with some pathologies, we observe signs of histopathological or trichoscopic activity for which the clinical history alone is not sufficient. Therefore, trichoscopic evaluation will be essential in order to see subclinical affectation, and to help us choose biopsy zones if the need arises. Ultrasound is also starting to be used to assess pathological areas less invasively, by enabling us to see the hair and vascularisation.
Surgical results often do not show the quality that is observed in transplants with non-scarring pathologies, but supported by other treatments like hair fibres or micropigmentation, it is possible to achieve high-quality results for patients.
Dr Larrondo comments that cases of lupus appear to be achieving better results. Dr Acosta comments that in some patients, when follicles are taken from a donor region that appears healthy, there are subclinical abnormalities that probably affect the erratic development of these transplants, leading to reduced results.
Surgical treatment of scarring alopecias
According to the oral communication of Alex Ginzburg (Israel)
Dr Alex Ginzburg presented the surgical technique as such. Up to 5% of alopecias currently being treated are of the scarring type. In these cases, the hair follicle is replaced by scar tissue. Surgical treatments are divided into two types: reduction of scarred skin via excision, with or without prior use of expanders. Hair transplants are also an option. In transplants with scarring alopecias, it appears that the best results are seen in cases of lichen planopilaris, as well as lupus, whereas patients with frontal fibrosing alopecia show worse progress.
Scarring alopecias caused by inflammatory diseases have lower survival of hair follicles than in other pathologies, about 60-70%. It is also essential to allow time for progress without activity before considering the transplant.
When transplanting scar tissue that causes acquired alopecia, better results are achieved, although even so, survival rates will be better than in healthy skin.
The following tips are proposed: adapt the technique by spacing out the distance between grafts; decrease the adrenaline dose; if the area is very large, do it in two surgeries to allow for vascularisation (the more central area first, then the periphery later). Finally, in case of doubt, a trial surgery is recommended.
Autoinflammatory syndromes: cases I’ve learned from
According to the oral communication of Antonio Torrelo (Spain)
In this symposium, the doctors reminded us that while autoinflammatory diseases are uncommon, there are characteristics from which any dermatologist should at least be able to offer a suspected diagnosis. In general, they are clinically characterised by periodic and recurrent episodes of fever and acute inflammation, with early onset and multisystemic disorders. They can be grouped into monogenic and polygenic diseases. In addition, they can be clinically classified as cases with mucocutaneous ulcerations or urticariform syndromes. Urticariform syndromes include cryopyrinopathies and periodic fevers. Unfortunately, managing these syndromes is complex. Dr Antonio Torrelo masterfully explained the discovery and description of a specific syndrome: CANDLE syndrome (chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature). The physiopathological basis of CANDLE syndrome is a proteasome disorder that presents with recurring fever, oedemas on the face and eyelids, lipodystrophy, joint inflammation, evanescent purpuric lesions and growth disorders.
Hidradenitis suppurativa: a systemic disease
According to the oral communication of Alberto J. Lavieri (Argentina)
Dr Alberto Lavieri spoke to us about hidradenitis suppurativa as the most well-known example of a disease with an autoinflammatory-autoimmune profile. Its pathogeny includes a combination of related factors (genetic, immune disorders, tobacco-use exposome, obesity, etc.). Clinical management usually combines antibiotics, biologicals and surgical techniques. In recent years, the focus has turned to its possible comorbidities, notably diabetes mellitus, metabolic syndrome, hypertriglyceridaemia, obesity, rheumatic diseases, polycystic ovaries, and psychiatric and tumour diseases (especially squamous cell carcinoma). Knowing these associations allows us to put screening mechanisms in place to rule them out early and prevent future complications. We must keep in mind that there has been shown to be a significant risks of ischaemic stroke and acute myocardial infarction, and that this risk is greater than in patients with severe psoriasis.
Cosmetic dermatology for men: A long-awaited revolution
Cosmeceuticals for men: dawn-to-dusk care
According to the oral communication of Rosa Maria Olivera (Mexico)
In this interesting session, speakers commented on the exponential growth seen in recent years in aesthetic and cosmetic medicine for men. As Dr Rosa María Olivera reminds us, the term “cosmeceutical” was originally coined by Kligman for a type of product with an aesthetic purpose, intended to improve the attractiveness and appearance of the skin. These cosmetics have evolved over the decades to include antioxidants, photoprotectors, hydroxy acids, retinoid derivatives, depigmentation treatments, etc. The doctor reminded us that, despite not being drugs, cosmetics can also trigger adverse reactions like allergic dermatitis, photodermatitis, dyschromias, etc. There are products aimed at men, with less greasy bases, and in general containing active ingredients with seboregulating, hydrating and anti-ageing properties. When it comes to selling these products, the AAD (American Academy of Dermatology) provides a series of guidelines which generally include putting the patient’s interests first and not prescribing products that have not been proven effective.
Male facial rejuvenation. Laser treatment, combined techniques
According to the oral communication of Esmeralda Teran (Ecuador)
Dr Esmeralda Terán told us about the particularities of laser and light treatments specifically for male patients. In this regard, she informed us that the same principles of selective photothermolysis apply for both sexes. Among the most common indications for men are sequelae of acne, such as marks and scars. Also, vascular treatments like telangiectasia in the nose or cheek area due to rosacea.
Venous lakes are another fairly common indication in the lip area, which can be treated with a neodymium laser. As for pigmented lesions, tattoo removal is common in men, but also removal of spots like lentigos or deeper lesions like naevi of Ito or Ota. Men are increasingly asking for general rejuvenation treatments, which can be performed using techniques like intense pulsed light or ablative or non-ablative fractional lasers.
Dermatoses in skin of colour
Hyperpigmentation in different skin types
According to the oral communication of Maria Vitale (Argentina)
In the session on dermatoses in skin of colour, speakers discussed particularities and new developments relating to dermatoses in dark skin. Dr María Vitale started her talk by discussing Fitzpatrick’s classification of phototypes. Each phototype in the sequence has a higher melanin content and a lower minimal erythema dose. There are new classifications, like the so-called genetico-racial classification, which include characteristics relating to geographic location, genetics and response to different treatments like peels or laser treatments. This is interesting when trying to predict the possible development of post-inflammatory hyperpigmentation. Dr Obagi has her own classification in which she refers to original colours (no racial blending), divergent colour (some blending) or complex colour (with lots of racial and ethnic blending). With divergent or complex colours, topical treatment is recommended before and after treatments to avoid post-inflammatory hyperpigmentation. Therefore, we must keep all of these factors in mind when performing procedures and indicating treatments.
An important point involving pigmentation is the initial activation of melanocytes. This activation is mediated by intrinsic and extrinsic factors. The intrinsic factors include genetic and endocrine factors, while the extrinsic ones include a complex group of factors that make up the exposome. One particularly interesting concept is that of light pollution: visible light, UVA and UVB radiation. It’s important to note that visible light has a synergistic effect with UVA radiation that generates hyperpigmentation. For this reason, Dr Vitale said that it would be useful to protect ourselves from this type of light as well. Its biological effects are mediated by chromophores, notably including opsins.
Most importantly, high-energy blue light activates Ops3, which induces melanin synthesis. In addition, visible light appears to induce more pigmentation in dark skin than in light skin, generating even longer-lasting pigmentation than that caused by UVA. This concept is important because high-energy visible light (high-energy blue light) can be emitted not only by the sun, but by electronic devices, and its effect on hyperpigmentation has been demonstrated. It’s true that the damage from solar radiation is more significant than that from digital illumination, but the effect is additive. As if that weren’t enough, it has been confirmed that the effect of light pollution is multiplied by that of the ordinary pollution to which we are exposed, particularly in cities.
For the therapeutic strategy, Dr Vitale proposes a preventative approach based on topical and oral photoprotection and protection from environmental contaminants. In terms of treatments, although there are no new depigmentation treatments to mention, the antioxidants included in the new photoprotectors result in major improvements. Sunscreens with iron oxide are the best for blocking visible light, along with make-up. Use of oral photoprotectors like Polypodium leucotomos derivatives is another preventative and antioxidant tool with proven effectiveness.
Phototherapy: excimers in dermatology
Use of excimers in dermatology
According to the oral communication of Javier Ubogui (Argentina)
In the symposium on phototherapy, Dr Javier Ubogui discussed his experience on the use of excimer light in dermatology. In reality, an excimer is a powerful light with a 308-nm wavelength (UVB).
Phototherapy using lasers can only treat small areas and is more costly compared to the use of excimer emission lamps, and there are no other documented differences.
Excimers are used for areas that are difficult to access with traditional phototherapy, as a complementary treatment, or when there are contraindications for traditional phototherapy. They are most commonly used for psoriasis and vitiligo, although their use is being extended to eczema, alopecia areata, granuloma annulare, morphea, etc. Dr Ubogui recommends using special templates or moulds to limit the application of light to the area requiring treatment. Advantages of excimer use compared to traditional phototherapy are that it is more versatile, with faster responses, short session times and the ability to preserve the healthy skin. No long-term adverse effects have been described.
One of its advantages in psoriasis treatment is that it can be used to optimise complementary medical treatments, such as traditional systemic treatment (methotrexate or cyclosporine), and even with biological treatments as well. It can also be applied in areas with hair using a mineral gel, or for nail pathology which typically represents another complicated area. With vitiligo, the doctor proposes using excimers with protection of the edges of the healthy skin with sunscreen, to avoid pigmentation of the healthy area. In addition, excimers offer advantages in the treatment of small vitiligo patches when there is no response to topical treatment. They are also being studied as a complement to punch microimplants in the skin.
Complications in Cosmetic Dermatology
CO2 and Nd:YAG lasers and their complications
According to the oral communication of Daniel Galimberti (Argentina)
In the symposium on complications in cosmetic dermatology, the speakers reviewed the complications caused by different techniques. Dr Galimberti discussed the potential complications after the use of ablative fractional lasers for acne scars, such as post-inflammatory hyperpigmentation. These types of hyperpigmentation tend to subside, but they can last for several weeks or even months and require topical depigmenting agents, including hydroquinone. A recent article predicts the risk of post- inflammatory hyperpigmentation based on the pigmentation seen in palm lines, such that high phototypes that do not have this pigmentation have a lower risk than was initially thought. Fortunately, bacterial infections are rare after this type of lasers, but herpes simplex recurrences can be frequent. He recommends investigating the medical history to provide prophylactic treatment. As for the use of topical antibiotics, Dr Galimberti mentioned the potential risk of allergic sensitisation from applying these drugs to damaged skin. For this reason, he does not recommend them unless there is a particular risk. As for long-pulse Nd:YAG lasers, the doctor reminded us of the complexity of this treatment and of the need to adapt the pulse length to the size of the vascular lesion being treated.
The risk with using high energies is that they may generate skin necrosis, ulcerations and permanent scars. If treatment generates significant inflammation with scabs, immediate use of strong topical corticosteroids is recommended.
Hyaluronic acid: complications
According to the oral communication of Carlos Echevarria (Peru)
Complications with the use of fillers like hyaluronic acid were masterfully explained by Dr Carlos Echevarría. He reminded us that these complications may be acute (erythema, oedema, haematomas, etc.), subacute and late (infections, granulomas, etc.). Fortunately, most early complications are self-resolving. If oedema occurs, it is always a good idea to rule out the risk of sensitisation to the product. This type of complication is most common in patients with rosacea. Nodules can also frequently appear, either because too much material is applied or due to hypersensitivity or even infection. Non-inflammatory nodules due to excess product can be treated with hyaluronidase. For non-infectious inflammatory nodules, intralesional corticosteroids can be used. Regarding the use of hyaluronidase, the doctor recommended application by levels from lower to more superficial, applying immediate pressure with the fingers to detect product dilution. Late nodules can also result from late type IV hypersensitivity reactions; they are usually resistant and it is not uncommon for them to require surgical excision. The most dreaded complication is vascular occlusion, especially due to the possibility of blindness resulting from retinal vascular occlusion. This risk is always greater if we inject 0.1 ml with a needle (or with 27 G cannulas). The nasal and glabellar region has the highest risk of blindness, due to the possibility of hitting supratrochlear arteries. The complication with this technique lies in the large anatomical variability we are faced with. Even so, it is important to direct the needle from top to bottom, especially when working in these areas. Rapid application of hyaluronidase (ca. 300-500 units) to the zone where the ischaemia occurred is essential to returning the skin to normal, as well as massage and hot compresses on the area. It is also useful to use a hyperbaric chamber during recovery. We must be attentive to the primary sign of ischaemia: blanching in the area, livedo, and bluish colouring in advanced cases.
With regard to recent publications that link the messenger RNA COVID-19 vaccine to late reactions to prior fillers, it has been calculated that the actual risk is tiny and therefore not significant, and in a series of recently published cases it has been shown that they respond unproblematically to anti- inflammatory drugs.