Developments and challenges in dermatology: an update from the Interactive Derma Academy (IDeA) 2019

The 2019 Interactive Derma Academy (IDeA) meeting was held in Lisbon, Portugal, 10-12 May, bringing together leading dermatology experts from across Europe, the Middle East and Asia. Over three days, the latest developments and challenges in relation to the pathophysiology, diagnosis, evaluation and management of dermatological conditions were presented, with a particular focus on acne, atopic dermatitis (AD) and actinic keratosis (AK). Interesting clinical case studies relating to these key topics were discussed with attendees to establish current evidence-based best practices. Presentations reviewed current treatments, potential therapeutic approaches and key considerations in the management of acne, AK and AD, and discussed the importance of the microbiome in these conditions, as well as the provision of patient education/support. It was highlighted that active treatment is not always required for AK, depending on patient preferences and clinical circumstances. In addition to presentations, two interactive workshops on the diagnosis and treatment of sexually transmitted infections/diseases (STIs/STDs) presenting to the dermatology clinic, and current and future dermocosmetics were conducted. The potential for misdiagnosis of STIs/STDs was discussed, with dermoscopy and/or reflectance confocal microscopy suggested as useful diagnostic techniques. In addition, botulinum toxin was introduced as a potential dermocosmetic, and the possibility of microbiome alteration in the treatment of dermatological conditions emphasized. Furthermore, several challenges in dermatology, including the use of lasers, the complexity of atopic dermatitis, wound care, use of biosimilars and application of non-invasive techniques in skin cancer diagnosis were reviewed. In this supplement, we provide an overview of the presentations and discussions from the fourth successful IDeA meeting, summarizing the key insights shared by dermatologists from across the globe.

[Andrology in oncological diseases]

In dermato-oncological treatment there are many gonadotoxic interventions. Alkylating and hormonally active substances as well as gonadal irradiation, in particular, are known to have a fertilization-limiting effect in men. Since 2017 certified skin cancer centers in Germany therefore have the task to implement counselling on preservation of fertility. This is supported by the S2k guidelines on preservation of fertility in oncological treatment. Because recommendation of the various interventions from the dermato-oncological guidelines are dependent on the stage, the authors advocate at least the question "Is the desire to have children of interest to you?" when patients reach the appropriate stage. Fertility protection of men via cryopreservation of ejaculates or testicular tissue is then a simple and safe option. The procedure is standardized and usually available. In addition, the possibility of cryopreservation of testicular tissue from prepubertal male children and infants is now available via the new Androprotect project. If signs of hypogonadism occur during therapy, a treatment can be considered by weighing up the effects of testosterone but in this case it is important to take the anabolic and immunomodulating effects into account.

[Semen analysis in involuntary childlessness. What information does it provide?]

Involuntary childlessness is a common problem. In about 50% of cases, inadequate semen quality plays a relevant role. A semen analysis provides information regarding exocrine function of the male reproductive organs of the testes, epidydimis, seminal vesicles, prostate gland, and vas deferens. These parameters can only be interpreted in conjunction with medical history and physical examination. Then they can be useful to identify relevant disorders or the causes of these disturbances. The fundamental principles for the interpretation of a semen analysis are easily learned and traditionally belong to the field of dermatology. This article explains the variables which are examined in a routine semen analysis as well as the reference values. Furthermore, common causes for deviations from the normal values are discussed to allow decision-making for further diagnostic workup. The interpretation of these values must always take into account the situation of the couple.

Macrophage metalloelastase-12 is detectable in human seminal plasma and represents a predictor for inflammatory processes in the male genital tract

Macrophage metalloelastase-12 (MMP-12), a protein of the matrix metalloproteinase family, is involved in the breakdown of extracellular matrix in normal physiological processes as well as in disease processes. MMP-12 is almost exclusively produced by macrophages and is associated with inflammatory disorders. Giving the fact that inflammation negatively influences ejaculate parameters, we investigated a possible presence and correlation of MMP-12 in seminal plasma with parameters of the ejaculate, especially in leucocytospermic ejaculates. Forty-two patients who presented for semen analysis were assigned into four groups depending on the result of semen analysis according to the WHO guidelines 2010: normozoospermia (n = 11), OAT (n = 10), azoospermia (n = 10) and leucocytospermia (>1 mio. peroxidase-positive cells per ml) (n = 11). MMP-12 was detected by ELISA and was measurable in nearly all seminal plasma samples. Generally, MMP-12 concentrations were significantly higher in leucocytospermic samples than in nonleucocytospermic ones (P = 0.001). The MMP-12 levels between the latter nonleucocytospermic groups did not differ. Moreover, MMP-12 levels correlated with the presence of peroxidase-positive leucocytes. No correlation with CD 14 positive monocytes/macrophages was detected. In this study, we demonstrate that MMP-12 is present in seminal plasma and is correlated with inflammatory conditions in human semen and therefore may serve as predictor of ongoing inflammatory processes.

Treatment of cutaneous lupus erythematosus

In patients with cutaneous lupus erythematosus (CLE) and mild skin involvement, local therapy consisting of topically applied pharmacological agents, e.g., topical/intralesional steroids, may be sufficient. Recent reports have also shown efficacy of topical calcineurin inhibitors in patients with CLE, particularly on the face. Special attention receives consistent sun protection through photoresistant clothing and application of light-shielding substances with highly potent chemical or physical UVA- and UVB-protective filters. These substances should be applied in sufficient amount (ca. 2 mg/cm(2)) at least 20-30 minutes before sun exposure in order to avoid induction and exacerbation of cutaneous lesions. The mainstay of treatment for disfiguring and widespread skin manifestations in patients with CLE, irrespective of the subtype of the disease, is antimalarial agents. Our understanding of the use of combinations of antimalarials and proper dosing according to the ideal bodyweight limits problems with toxicity. Further therapies, such as methotrexate, or retinoids, dapsone, mycophenolate mofetil, and thalidomide in selected cases, can be helpful for patients with resistant disease; however, side effects need to be taken into consideration. Recent advances in biotechnology resulted in the development of novel systemic agents, but randomized controlled trials are necessary for the approval of new therapeutic strategies in CLE.

[Acne. Current pathophysiologic considerations]

Seborrhea, follicular hyperkeratosis, propionibacteria, and inflammatory reactions are the most important factors leading to acne. The combination of increased sebum producation and follicular hyperkeratosis facilitates an increased growth of Propionibacterium acnes. Its metabolic products lead to follicular inflammation and, in extreme cases, even to perifollicular abscesses. Sebum production is influenced by androgens, so that abnormalities in androgen levels can produce seborrhea and acne. Follicular hyperkeratosis may be triggered by a relative deficiency in linoleic acid, peroxides from sebum components, and especially by inflammatory mediators such as interleukin-1. Bacterial metabolic products such as lipases, proteases, or chemotactic factors lead to the perifollicular inflammation. This inflammation is not only a response to other pathogenetic factors, but also a cause of acne. An initial mild perifollicular inflammation can induce comedogenesis via a variety of mediators. The influence of dietary factors on the initiation and course of acne has recently received increased recognition. A connection has been postulated between acne and a high nutrients with glycemic index, as well as with milk products.

[Generalized purpura as dermatologic manifestation of thrombcytopenia]

A 72-year old patient was initially misdiagnosed with allergic vasculitis. He rapidly developed petechiae and mucosal bleeding. There were no other abnormal physical findings and the patient was otherwise in good physical condition. There was no history of trauma or infectious disease. The patient's complete blood count showed a marked thrombocytopenia of 2000/nl. A bone marrow biopsy confirmed the initial diagnosis of idiopathic thrombocytopenic purpura (ITP). The number of thrombocytes increased and the skin lesions resolved shortly after the patient was put on oral prednisone. This case emphasizes the importance of dermatologic symptoms in diagnosing severe systemic disease.

Mycophenolate mofetil is effective in the treatment of atopic dermatitis

OBJECTIVE

To evaluate whether mycophenolate mofetil, a new immunosuppressive agent, is effective for treating moderate-severe atopic dermatitis (AD).

DESIGN

In an open-label pilot study, mycophenolate mofetil, 1 g, was given orally twice daily for 4 weeks. At week 5, the dosage was reduced to 500 mg twice daily until study end (week 8). Patients were followed up for 20 weeks.

SETTING

University hospital dermatology department.

PATIENTS

Ten consecutive patients with moderate-severe AD nonresponsive to standard therapy.

MAIN OUTCOME MEASURE

Severity of AD as measured using the subjective SCORAD [SCORing Atopic Dermatitis] index.

RESULTS

Clinical efficacy was measured every 2 weeks using the subjective SCORAD index. Treatment with mycophenolate notably reduced the severity of AD within 4 weeks in all patients (P<.05), and after 8 weeks the mean +/- SD SCORAD index dropped from the pretreatment value of 49.2 +/- 13.8 to 21.9 +/- 26.5 (P<.01). One patient had to discontinue mycophenolate therapy after 4 weeks because of the development of herpes retinitis. Except for this event, mycophenolate was tolerated well in all patients. Six of 7 patients who had responded to mycophenolate monotherapy had no relapse of disease during 20-week follow-up. In the 7 patients who finished the study, the SCORAD index was reduced by 74%, from 44.0 +/- 7.8 before treatment to 11.4 +/- 5.9 at 20-week follow-up.

CONCLUSIONS

Mycophenolate is a highly effective drug for treating moderate-severe AD, with no serious adverse effects occurring in any patients. Thus, mycophenolate might develop into a promising alternative in the therapy of moderate-severe AD.

PUVA-cream photochemotherapy for the treatment of localized scleroderma

BACKGROUND

The efforts to treat localized scleroderma, including therapies with potentially hazardous side effects, are often unsatisfactory. Recently, PUVA-bath photochemotherapy has been proven highly effective in the treatment of localized scleroderma. Another form of topical PUVA therapy, 8-methoxypsoralen (8-MOP) containing cream or gel preparations, has been proven to be as effective as PUVA-bath therapy for palmoplantar dermatoses.

OBJECTIVE

We sought to assess the efficacy of PUVA-cream photochemotherapy in patients with localized scleroderma.

METHODS

Four patients with localized scleroderma were included in the study. Diagnosis was confirmed by 20 MHz ultrasound assessment as well as pretreatment skin biopsy specimens from lesional skin. PUVA-cream therapy was performed 4 times a week; all patients received 30 treatments.

RESULTS

PUVA-cream photochemotherapy induced significant clinical improvement or clearance of localized scleroderma in all patients. Clearance was documented by clinical features as well as by 20 MHz ultrasound and histopathologic analysis.

CONCLUSION

PUVA-cream phototherapy can be highly effective in patients with localized scleroderma even if previous therapy was unsuccessful.

Treatment of chronic plaque-stage psoriasis and psoriatic arthritis with mycophenolate mofetil

Mycophenolate mofetil (MMF), a widely used immunosuppressant in organ transplantation, is a recent addition to the therapeutic armamentarium of autoimmune and inflammatory skin disorders in dermatology. We describe 5 patients with moderate to severe chronic plaque psoriasis and 6 patients with psoriatic arthritis that was refractory to conventional systemic and/or topical antipsoriatic treatment who were treated with MMF monotherapy (2 g/d) in a 10-week study. Although MMF was tolerated well in all patients, only patients with moderate psoriasis and psoriatic arthritis improved with therapy, whereas patients with severe psoriasis did not respond to MMF. Although MMF seems to be effective and safe for blistering autoimmune diseases and pyoderma gangrenosum, our data do not allow optimistic statements on the use of MMF in severe plaque-stage psoriasis. However, MMF may develop into an interesting therapeutic alternative for patients with psoriatic arthritis.

Ablative techniques in Psoriasis vulgaris resistant to conventional therapies

BACKGROUND

Treatment of patients with psoriasis vulgaris exhibiting only solitary plaque-stage lesions might become difficult since topical treatments often fail and systemic therapies seem inappropriate.

OBJECTIVE

We evaluated the feasibility of ablative techniques in this clinical setting comparing dermatome shaving to the application of an Er:YAG laser.

METHODS

Six patients were treated by means of dermatome shaving; in four of these patients additional lesions were ablated utilizing an Er:YAG laser (2 J, 10 Hz, 5 mm spot size).

RESULTS

Four of six patients experienced complete clearance of the lesions treated, three of the four patients receiving additional Er:YAG treatment also showed a complete clinical response.

CONCLUSION

Our observations document that removal of epidermis and the papillary dermis is effective in treating recalcitrant psoriatic plaques. The Er:YAG laser represents a state-of-the-art device for performing this task. The beneficial effect on skin might be due to clearance of the putative autoantigen along with a considerable part of the potential effector cell population.

[Results of in vitro fertilization therapy methods in Germany in 1996--the German In Vitro Fertilization Registry]

We believe that on the IVF subject, which is nowadays applied exept a standard method in the world. In the next years we could expect further improvement in our success++. It is also to anticipate that next changes in the development of assistance-reproduction will be: 1. Freezing of ovums, 2. To get in vitro-meture of the immature cells, 3. Transplantation of ovarium tissue, 4. Transfer of the blastocyst, 5. Transfer of cytoplasma or the cell nucleus. We recommend that the IVF/ICSI--therapy and birth of children has to be registrated in one central register.

Photoallergic skin reaction to ribavirin

A 65-yr-old woman with chronic hepatitis C was treated with three million units interferon-alpha t.i.w. and 1000 mg ribavirin daily. At wk 16 of combination therapy the patient developed an itchy eczematous erythema, partly of urticarial character, which was almost confined to ultraviolet (UV)-exposed sites. Histopathological examination of the skin lesions was consistent with a photoallergic reaction. The minimal erythematous dose for UVA and UVB was assessed on healthy skin. After 24 h, a distinct erythema at the UVB irradiated site was found, whereas no reaction was seen with UVA provocation up to a dose of 10 J/cm2. Correspondingly, determination of the absorption spectrum of ribavirin revealed maximum absorption within UVB at 282.5 nm. Ribavirin was stopped, and the cutaneous lesions and pruritus completely disappeared without subsequent hyperpigmentation. This case indicates that ribavirin is a potential photosensitizer for UVB, which may become increasingly relevant in patients with chronic hepatitis C undergoing combination therapy for 6-12 months with interferon-alpha and ribavirin.

Multiparameter analysis of clastogenic factors, pro-oxidant cytokines, and inflammatory markers in HIV-1-infected patients with asymptomatic disease, opportunistic infections, and malignancies

HIV-1-infected patients are in chronic oxidative stress and clastogenic factors (CFs) are present in their plasma. CFs from patients with HIV are formed via superoxide anion radical and stimulate further superoxide production. The pathophysiolgic significance and the exact composition of the circulating clastogenic material in patients with HIV is unknown. Cytokines, such as tumor necrosis factor-alpha (TNF-alpha), are increased in the plasma of patients with HIV and TNF-alpha shows clastogenic activity in vitro. The aim of this clinical study was to compare levels of CF in HIV-1-positive patients with asymptomatic disease, opportunistic infections, and malignancies with those in HIV-1-negative control groups and to correlate CF activity with CD4+ T cell numbers, the cytokines (TNF-alpha, interleukin-2 [IL-2], IL-6), and the inflammatory markers (C-reactive protein [CRP], neopterin, granulocyte elastase). CFs were significantly increased in all HIV-1-positive patients and in HIV-1-negative patients with malignant tumors. HIV-1-positive patients with Kaposi's sarcoma showed the highest CF activity in their plasma (p < 0.08). CFs appear very early in HIV infection, and they correlate negatively with CD4+ T cells, which are an indicator of disease activity. The presence of CF in the plasma of HIV-infected patients is not a general response to a viral infection because these factors are not increased in HIV-1-negative patients with viral infection (zoster). CFs are not specific for the HIV-1 infection; they also occur in HIV-1-negative patients with malignant tumors. There was a tendency towards a positive correlation (p < 0.14) between CF and TNF-alpha but there was no positive correlation of CF with IL-2, IL-6, CRP, elastase, and neopterin levels. This indicates that TNF-alpha may be among the components of CF in HIV-1-infected patients. In addition, other unidentified components may contribute to the clastogenic activity of the plasma or the composition of CF may vary from patient to patient. Further clinical studies with larger sample populations are necessary to analyze the composition of CF in HIV-1-positive patients.

Oxidative imbalance in HIV infected patients

We present an outline of the complex interplay of oxidants and antioxidants in infectious diseases in general, and in particular with reference to the HIV infection, and subsequent opportunistic infections. Viral and opportunistic infections may directly or indirectly cause an imbalance in prooxidant/antioxidant mechanisms and result in generation of increased steady state concentrations of reactive oxidants. In HIV patients a prooxidant state could lead to a self-perpetuation of infection via stimulated expression of genes carrying the virus genome, and subsequently to immunosuppression, and promotion of initiated cells to neoplastic growth.