Акценти от 3-ти ден
Diet and acne, Acne/Rosacea, Psoriasis, Pediatric dermatology, Vulvar pathology, Oncology, Atopic dermatitis from children to adults
Dr. Joséfina MARCO-BONNET
Diet and acne
Dr. Daniela Villavicencio (Dermatologist, Ecuador)
Dr. Juan Carlos Diez De Medina (Dermatologist, Bolivia)
Diet is not the main cause of acne but it can affect it, therefore, dietary advice should be part of our therapeutic strategy.
Several studies have shown that acne patients have an increased mTOR complex. It impairs metabolism by inducing obesity, insulin resistance and diabetes.
Several foods contribute to acne breakouts:
- An imbalance between omega 3 (anti-inflammatory) and omega 6 (pro-inflammatory) intake increases the production of sebum, which aggravates acne. It would take a ratio of 16 omega 3 (fish) to 1 omega 6 (oils) to have anti-inflammatory activity. This means that we must ask our patients to consume more omega 3 and reduce omega 6.
- Foods with a high glycemic index (carbohydrates, milk, dairy products, chocolate) induce an increase in IGF1, which leads to an increased production of adrenal and gonadal androgens, induced proliferation of keratinocytes and sebocytes and increased expression of mTORC1. The mTORC1 complex regulates IGF-1, increases androgen levels, sebum production and favours lipogenesis.
- Milk solids or whey increases insulin levels, IGF-1, insulin and IGF-1 receptor expression in epidermal keratinocytes. The current WHEY formulas (consumed by athletes) correspond to the consumption of 6 to 12 litres of milk per day. This leads to acne outbreaks that are monomorphic in appearance, as in case of drug-induced acne.
- B-complex vitamins aggravate acne by altering the skin microbiota and increasing porphyrins, which promotes inflammation. We must therefore ask our patients about their consumption of food supplements or vitamins and inform them that certain foods are fortified with vitamin B (cereals, cereal bars, etc.).
Secrets of warriors
Prof. Ana Kaminsky (Dermatologist, Argentina)
Every dermatologist in this session shared one of his or her secrets.
Professor Ana Kaminsky presented a case of severe acne that required treatment with corticosteroids and isotretinoin for several months. Her approach to this type of patients consists in establishing a relationship of trust, so that the patient adheres to the treatment, and always applying topical maintenance treatment.
Dr. Luna Azulay (Dermatologist, Brazil)
Dr. Luna Azulay spoke about generalised pustular psoriasis. When she wants to quickly whiten patient’s skin, she uses short-term ciclosporin, followed by acitretin in combination therapy for a few weeks, after which she stops ciclosporin treatment.
Prof. Margarita Larralde (Dermatologist, Argentina)
Professor Margarita Larralde talked about two aspects of infantile hemangioma. Hemangiomas of the nose, ears and mouth must be treated very early to avoid necrosis that causes scarring. In case of an angiomatous lesion of the pelvis associated with pelvic malformation, one must remember that this lesion is a hemangioma, which can be therefore treated with propanolol, and that this is a PELVIS syndrome.
Dr. Claudia Giuli Santi (Dermatologist, Brazil)
Dr. Claudia Giuli Santi insists that when a patient with pemphigus vulgaris of the vulva undergoes a cytological examination of mucous membranes (vaginal swab), it is necessary to inform the pathologist who will perform the analysis, as acantholytic cells look like dysplastic cells and cervical cancer could be wrongly diagnosed.
Dr. Montserrat Molgó (Dermatologist, Chile)
Dr. Montserrat Molgó spoke about lymphoma. If one suspects the presence of a lymphoma, it is necessary to perform several biopsies, discuss the matter with one’s pathologist and get multidisciplinary care.
« Non-freezing technique »
Dr. Liliana Calandria (Dermatologist, Uruguay)
The best for last: the « non-freezing technique » is a treatment for persistent postherpetic neuralgia invented by Dr. Liliana Calandra. The treatment consists in cooling the painful area without freezing it with liquid nitrogen (20 cm away from the skin) until a slight erythema appears. A protocol consists of one session per week for 6 weeks. In a study of 107 patients, Dr. Calandra obtained 69% of excellent response, 24% of good response and 7% of poor response. This treatment with few side effects is a true innovation in the management of a difficult-to-treat pathology.
The environment and its effect on the skin: A challenge for the 21st century.
Atopic dermatitis from children to adults
Dr. Adriana Valencia Herrera (Dermatologist, Brazil)
A new clinical classification ranks atopic dermatitis (AD) by the age of onset and thus get a sense of its evolution.
1. Very early AD (3 months to 2 years old).
It accounts for 60 to 80% of AD cases and the vast majority of them improve before 2 years of age. 40% of those who are still affected by AD have a highly elevated risk of atopic march (asthma, rhinitis, food allergy).
2. Early AD (2-6 years old).
These AD cases have a high risk of being chronic.
3. Childhood AD (6-14 years old) represents 10% of cases.
4. Adolescent AD (14-18 years old) represents less than 10% of cases.
5. Adult-onset AD (20-60 years old).
20% of patients are first affected by AD in adulthood; they are mostly women with normal IgE levels. The awareness about these cases of AD is limited.
6. Late-onset AD (> 60 years old).
Two subgroups of AD are distinguished: those with family history of AD at a young age and those who are first affected by AD after 60 years old. The first subgroup most often has severe AD with very high IgE levels.
This concludes RADLA 2019. We hope you enjoyed reading this report.
Dr. Silvina Daniela MALDONADO
Acne and Rosacea/Connective tissue diseases/Epidemiology/Laser
Resistance of Cutibacterium acnes to tetracyclines in patients with moderate to severe acne vulgaris
Dr. Hector Jose Castellanos Lorduy (Dermatologist, Colombia)
Oral Presentations included a presentation of a Colombian group’s work on Resistance of Cutibacterium acnes to tetracyclines in patients with moderate to severe acne vulgaris. These bacteria are strict anaerobes which constitute 20-70 of the microflora; in acne, they incite and amplify the inflammatory response and produce biofilms, follicular hyperkeratosis, lipogenesis and micro-comedogenesis. Antibiotic treatments (ABTs) for acne suppress the growth of these bacteria and reduce the inflammatory response. Bacterial resistance was identified as early as 1997 with a resulting decrease in effectiveness, larger number of exacerbations and resistance in other organisms. An Australian study showed that 50% of strains were resistant and 3.6 not resistant with a history of prior use of ABTs. A Mexican study showed higher rates of resistance: azithromycin 92.5%, trimethoprim/sulfamethoxazole (TMS) 77.7%, erythromycin 59.2%, doxycycline 33% vs no use: azithromycin 72.7%, TMS 59% and erythromycin 31.8%.
Тhe Colombian group performed a study on 147 patients with moderate to severe acne, excluding people who required isotretinoin, those who had used topical or systemic ABTs in the past 3 months, and pregnant women. Samples were taken by extrusion of follicular contents which were then placed in enriched thioglycolate broth and inoculated onto Schaedler Agar and incubated at 37 degrees in anaerobiosis for 4 to 6 days. The resistance profile obtained in this way was: 5.43% for doxycycline, 0.78% for minocycline and 5.43% for tetracycline. The resistance of C. acnes to ABTs is due to mutations in ribosomal RNA, mutations in the rpoB gene, changes in permeability (efflux pumps) and biofilm. The study showed 100% cross-resistance, as in Dummont-Wallon’s work (France), and consistent with the low resistance found by Mendoza et al. 6 years ago. They did not find an association between the age variable and resistance, in contrast with Luk et al. and Schafer et al. Nor did they find an association with previous exposure to ABTs. In conclusion, the present work reports low resistance to tetracyclines despite their extensive use. Nevertheless, it is important to promote their proper use in acne treatments. Molecular biology may explain the low resistance over time in the strains obtained in Colombia.
Dermatoscopic findings and the population density of Demodex spp in facial erythema
Dr. Alfredo Chávez (Dermatologist, Ecuador)
Next, Dr. Alfredo Chávez discussed the relation between dermatoscopic findings and the population density of Demodex spp in facial erythema. Demodex spp is considered as part of the flora of the skin microbiome. Under certain conditions, it can cause severe infection or demodecidosis, and this is associated with facial erythematous dermatoses. The pathogenesis consists of: blocking of follicles and sebaceous ducts; stimulation of the humoural and cellular immune response by the parasite and its waste products; inflammatory reaction with resulting perifollicular erythema and granulomatous reaction to a foreign body caused by the chitin of the skeleton; and as a vector for development of bacterial infection. Diagnostic methods include mite testing, skin biopsy, and confocal microscopy. The use of dermatoscopy is proposed as a non-invasive real-time method through a prospective, observational and cross-sectional 4-month study on 40 patients, including facial erythematous dermatoses (acne, rosacea, seborrhoeic dermatitis, contact dermatitis and perioral dermatitis) with clinical signs of Demodex spp, without previous treatments and seen for the first time. Excluded were patients with prior intake of ivermectin or other antiparasitics in the month prior to the study, and of course those who refused to participate. The population density determined by surface biopsy was considered positive above 5/cm2.
The results showed that perifollicular vessels, follicular openings and Demodex spp tails are observed in dermatoscopy of Demodex spp. The dermatoscopic connection with rosacea and acne in particular allowed researchers to establish that the blood vessels and follicular openings are key findings for the identifying the parasite in these pathologies. Regarding the population density of Demodex spp in the 40 patients studied, 24 had a significant density exceeding 10/cm2, with rosacea and acne being the pathologies that are related with these figures. It was also
shown that the greater the erythema, the higher the population density. In conclusion, dermatoscopy had greater sensitivity relative to skin surface biopsy for the determination of dermatoscopic findings of Demodex spp, suggesting its diagnostic utility for facial erythematous dermatoses.
The environment and its effect on the skin: A challenge for the 21st century.
Environmental pollution and skin
Prof. Ana Kaminsky (Dermatologist, Argentina)
In the Symposium entitled The environment and its effect on the skin: A challenge for the 21st century. Environmental pollution and skin, Prof. Ana Kaminsky specifically focused on occupational acne through exposure to chemical, physical and environmental agents of three different types: cosmetic (follicles plugged by comedogenic substances or follicular irritation by acnegenic substances), mechanical (generally in places in contact with clothing impregnated with mineral oils or polycyclic aromatic hydrocarbons, some of which have been identified as carcinogens, mutagens and teratogens), or industrial (halogenated aromatic hydrocarbons, chloracne). In oil-based acne or elaioconIosis, continuous exposure induces reactive hyperkeratosis and subsequent follicle obstruction. Chloracne occurs in most cases through occupational exposure and exposure to contaminated industrial waste or contaminated food products, which are absorbed percutaneously, by inhalation or ingestion, and is ALWAYS A SIGN OF SYSTEMIC EXPOSURE, as it is a manifestation that indicates dioxin poisoning. The dioxin may gradually decrease after exposure or persist indefinitely due to its chemical stability and its tendency to accumulate in fatty tissue. It does not manifest as quickly in the skin as in other organs, but it persists longer there, and chloracne is therefore a chronic and systemic disease. The goal would be to transition in the very near future to renewable energies, convert buildings into power plants, and use “smart grid” technologies for electric power distribution and transportation based on electric vehicles using renewable energy as fuel.