Акценти от 1-ви ден
Laser and light therapy, Collagenopathy, Therapeutic innovations for advanced melanoma
Dr. Joséfina MARCO-BONNET
Laser and light therapy
Nd:Yag Q-Switched 1064 nm laser treatment of onychomycoses
Dr. Héctor Ricardo Galván Garcia (Dermatologist, Mexico)
Dr. Ricardo Galván Garcia reported on his experience with Nd:YAG Q-switch 1064 nm laser (NYQS 1064nm) in the treatment of onychomycosis.
Several lasers have been tried in this indication (long pulse YAG, KTP) with little efficiency and significant pain experienced during sessions.
The NYQS 1064nm laser was chosen because onychomycosis can have different colours. The NYQS 1064nm laser is used at 3Hz, 600mJ/cm2 with a 3-mm spot. Only one session is necessary with three passes on the entire surface of the the affected nail (200 to 400 pulses on large nails and 20 to 40 on small ones). The endpoint is achieved when one hears a series of popping sounds that decrease with each pass. The session is painless. The nail clears up immediately after the session.
He presented a series of 700 treated patients (188 adults and 12 children) over a period of 7 years, which equals 3,400 treated nails (3,100 toenails and 300 hand nails). No cultures were performed because various studies have
shown that the KOH test shows a specificity of 60-80% vs 30-60% for cultures. All patients were KOH positive. He obtained 90% healing at 4 months, 100% at 9, 12 and 18 months. At 24 months relapse occurs in 14%. In 10% of cases, a second session was performed after 4 months.
In conclusion, this is a quick and easy method that does not cause side effects. The laser energy makes it possible to change the fungus polarity, thus inactivating it (in vitro studies conducted on M. canis and T. mentagrophytes).
News on laser treatment of melasma
Dr. Carlos bravo rojas’s experiment (Dermatologist, Costa Rica)
In a physiopathology review, Dr. Carlos Bravo Rojas mentions that melasma has a high level of inflammation and neovascularisation as well as an imbalance between the synthesis and elimination of melanin. He explains that, therefore, there targets are to be considered in treatment of melasma: melanosome, epidermal keratinocytes and the vascular network.
This is not a first line treatment. It should be offered to patients who are resistant to topical treatments and to patients looking for a quick improvement. It must always be combined with topical treatments, which makes it possible to reduce the risk of post-inflammatory hyperpigmentation (PIHP) and the risk of relapse.
Non-ablative QS lasers combined with Nd:YAG non-ablative fractional lasers and picosecond lasers will have the best risk-benefit ratio. They allow pigment removal with less risk of PIHP. Picosecond laser is probably the best one, but it is the most expensive one. Fractional lasers create micro-wells that help topical treatments penetrate the skin more deeply. PRP, tranexamic acid, hydroquinone, kojic acid and corticosteroids can be used.
IPL can also be used, mainly on predominantly epidermal melasma and on clear (1 to 3) phototypes.
In a series of 287 patients, Dr. Bravo Rojas has one case of PIHP, 25% of relapses; most are associated with sun exposure at the beach, the discontinuation of topical or oral maintenance treatment and the use of hormonal or photosensitising treatments. 88% of his patients report being satisfied at the end of treatment.
The treatment always starts with skin preparation, for at least 4 weeks before the laser session:
- Topical treatment with hydroquinone or azelaic acid + retinoic acid + kojic acid + hydrocortisone 3 times a week.
- High photoprotection.
- Arbutin and niacinamide cream used in alternation.
- Stop hormonal treatments, if possible.
- TSH test, since dysthyroidism is often associated with melasma.
- Photography with visible light and with Wood’s light.
- Polypodium leucotomos and melatonin per os, if possible.
- Depending on the case, he combines QS Nd:YAG 1064 nm laser until the appearance of light erythema, short pulse Nd:YAG laser (FRAC) and QS 1064 nm sublative or ablative fractional laser.
- If there is a high epidermal component, he uses IPL.
- Immediately after the laser session, he applies 4% tranexamic acid or PRP, topically or by infiltration.
- 6 to 10 sessions, 1 or 2 weeks apart.
- Maintenance sessions every 1 to 3 months with non-ablative QS laser and short-pulsed Nd:YAG laser.
Post laser treatment protocol:
- Maintain the hydroquinone treatment for 6 months. After this, depending on the evolution, either stop the treatment or lower the percentage of hydroquinone.
- Use photoprotection including protection against visible and infrared light.
- Conduct clinical and photo point monitoring every 3 months.
Continue melatonin and polypodium treatment based on the risks.
Dr. Silvina Daniela MALDONADO
Laser and light therapy
Combining technologies to treat scars
Dr. Andrés Luque-Ayala (Dermatologist, Colombia)
In the Laser and Light Therapy Workshop, Dr. Andrés Luque spoke about combining technologies to treat scars, and placed a special emphasis on changing the idea of waiting for scars to develop before attempting to improve them, given that lasers help with collagen remodelling during the early stage of scar formation and that the same results cannot be obtained if this intervention occurs later in the fibrosis stage. He also discussed combining light therapies with other tools such as silicones, topical and intralesional corticosteroids, using lasers as soon as the sutures are removed. He also suggests combining a 1550 nm fractional laser with a CO2 laser. His final recommendation is not to extend sessions any longer than 6 months.
Rare dermatoses treated with lasers
Dr. Kléber Ollague Murillo (Dermatologist, Ecuador)
Next, Dr. Kléber Murillo discussed Rare dermatoses treated with lasers. With vitiligo, despite the risk of the Koebner phenomenon, good results are obtained with Fractional Erbium YAG with sessions lasting 6 months to 1 year, with melanocyte migration and release of cytokines being observed. Other uses: androgenetic alopecia (Fractional Erbium YAG), alopecia areta, perifolliculitis abscedens (CO2 produces physical breakdown of scar tissue, drainage of necrotic material, collagen regeneration and stimulation of the hair follicle). Also used with solar lentigo (Q-Switched), hypertrophic and keloid scars (Fractional plus Triamcinolone), melasma (only in refractory cases, and is transitory), ocronosis (Fractional Q-Switched), postinflammatory hyperpigmentation (Fractional), pseudoacantosis / acantosis nigricans (Fractional CO2 combined with glycolic acid), REFRACTORY tattoos (Q Switched plus Fractional), morphea (Erbium YAG), lichen amyloidosis (erbium YAG) and onychomycosis (2940 nm Fractional YAG plus intraprocedural amorolfine).
Dermatomyositis (DM) with neoplasia
Prof. Jeffrey Callen (Dermatologist, United States of America)
In the Collagenopathy Workshop, Prof. Jeffrey Callen spoke about dermatomyositis (DM) with neoplasia. In general population studies, it was found that 20 to 25% of patients with dermatomyositis have or will develop cancer, and this is also possible with amyopathic DMs. Those with polymyositis (PM) tend to have a lower rate, approximately equal to that seen in the general population. As is well-known, the most significant risk period is between the first and third years, and while the risk declines after that, it does not disappear. The most frequently-occurring cancers are gynaecological cancers, particularly ovarian cancer, and nasopharyngeal cancer in Southeast Asia. According to a Scandinavian study, the most frequent cancers are ovarian, lung and colorectal cancer, followed by pancreatic cancer, breast cancer and non-Hodgkin’s lymphoma. There may also be a relationship between the immunosuppressive drugs used for DM with malignancy, increasing the risk of lymphoproliferative disorders. With regard to how to evaluate a patient to rule out cancer, Prof. Callen notes that although people started saying 10 years ago that PET/CT is sufficient, those conclusions are based on small numbers of patients, and he says that he is not ready to change how he evaluates his patients with conventional tests (X-ray, chest and abdominal CT, faecal occult blood test, pelvic ultrasound and other tests as appropriate for age, symptoms, ethnicity, etc.). He suggests once per year for 3 years and specific advice to the patient about any suspicious symptoms. The antibodies which indicate an increased risk of cancer, especially NXP2 and TIF 1 gamma, are a very interesting topic, but an overlap has been observed between patients with cancer without autoantibodies and others with autoantibodies who do not develop cancer; therefore, he emphasises that the absence of autoantibodies is no reason not to study the patient.
Therapeutic innovations for advanced melanoma
Lymph node management with advanced melanoma
Dr. Abel Gonzàlez (Dermatologist, Argentina)
In the workshop on Therapeutic innovations for advanced melanoma, Dr. Abel González spoke about Lymph node management with advanced melanoma. In cases of a positive sentinel lymph node (SLN+), he recommends only observation and consideration of lymphadenectomy in special cases: in the head and neck, when there are monitoring difficulties, and with melanomas with a poor prognosis (high Breslow and ulcerated, high SLN tumour burden). Ultimately, the decision is up to the patient, to whom we must thoroughly explain the results of recent clinical trials. An SLN biopsy remains indicated as a source of prognostic information, for clinical trials and for SIII treatment. For low-risk patients (micrometastasis and low tumour burden), it can be diagnostic and therapeutic, with ultrasound monitoring in experienced hands being a sensible option afterwards. For high-risk patients, we need to talk about cost/benefit ratios, co-morbidity rates, life expectancy, compliance with monitoring and availability of imaging tests, and also consider the prognostic value of complete removal and impact on adjuvant treatments or entry into clinical trials.
In conclusion, SLN currently remains the standard for melanomas with Breslow greater than 0.8mm (N=M=). An SLN is observed except in the cases described (monitoring every 3 months for 3 years, then every 4 months for the next 2 years) and in SIII-B immunotherapy and then developing treatment.
Ganglionar management in advanced melanoma
Dr. Matìas Maskin (Dermatologist, Argentina)
New treatments for melanoma. Mechanisms of action and long-term effectiveness.
Dr. Pablo Uribe (Dermatologist, Chile)
Discussion of clinical cases
Dr. Matìas Turienzo (Dermatologist, Argentina)
With regard to new treatments, Dr. Pablo Uribe, Dr. Matìas Turienzo and Dr. Matìas Maskin discussed the benefits of combining pharmacological inhibitors like Vemurafenib, Dabrafenib (BRAF inhibitors), Tramatinib and Cobimetinib (MEK inhibitors), and immunotherapy with Ipilimumab (anti-CTLA4), Nivolumab and Pembrolizumab (anti-PD1). The former require BRAF mutations, are taken orally, with rapid anti-tumour response, but generate resistance. The latter do not require BRAF mutations, and the response is slower (except in combinations) and more prolonged. The combination appears to increase survival, and is used in an adjuvant context. The first line would be for wild-type BRAF, Nivolumab or Pembrolizumab. For BRAF mutations, Dabrafenib/Trametinib, Nivolumab or Pembrolizumab.
In conclusion: determine absence or presence of BRAF mutation; risk/benefit analysis; availability/cost/coverage, logistics and concomitant diseases. It remains to be determined whether adjuvant therapy should be early or late, if more prolonged use is more effective, real effect on survival, and especially whether patients can be re-exposed to the same drugs in case of metastatic disease.
Finally, talimogene laherparepvec (T-VEC) is an oncolytic virus, modified from HSV-1, which replicates selectively in tumour cells, promoting regional and systemic immunity against tumours. It is applied intralesionally. New drugs being studied may offer prospects for the treatment of advanced melanoma.