The evolving field of Dermato-oncology and the role of dermatologists: Position Paper of the EADO, EADV and Task Forces, EDF, IDS, EBDV-UEMS and EORTC Cutaneous Lymphoma Task Force

BACKGROUND

The incidence of skin cancers has been increasing steadily over the last decades. Although there have been significant breakthroughs in the management of skin cancers with the introduction of novel diagnostic tools and innovative therapies, skin cancer mortality, morbidity and costs heavily burden the society.

OBJECTIVE

Members of the European Association of Dermato-Oncology, European Academy of Dermatology and Venereology, International Dermoscopy Society, European Dermatology Forum, European Board of Dermatovenereology of the European Union of Medical Specialists and EORTC Cutaneous Lymphoma Task Force have joined this effort to emphasize the fundamental role that the specialist in Dermatology-Venereology has in the diagnosis and management of different types of skin cancer. We review the role of dermatologists in the prevention, diagnosis, treatment and follow-up of patients with melanoma, non-melanoma skin cancers and cutaneous lymphomas, and discuss approaches to optimize their involvement in effectively addressing the current needs and priorities of dermato-oncology.

DISCUSSION

Dermatologists play a crucial role in virtually all aspects of skin cancer management including the implementation of primary and secondary prevention, the formation of standardized pathways of care for patients, the establishment of specialized skin cancer treatment centres, the coordination of an efficient multidisciplinary team and the setting up of specific follow-up plans for patients.

CONCLUSION

Skin cancers represent an important health issue for modern societies. The role of dermatologists is central to improving patient care and outcomes. In view of the emerging diagnostic methods and treatments for early and advanced skin cancer, and considering the increasingly diverse skills, knowledge and expertise needed for managing this heterogeneous group of diseases, dermato-oncology should be considered as a specific subspecialty of Dermatology-Venereology.

Acute maculopapular eruption in Covid-19 patient: A case report

We report the case of a positive COVID-19 patient who presented to our hospital for a maculopapular skin rash which appeared 7 days after the onset of COVID-19 symptoms. He was 34 years old and nothing relevant was recorded at his previous anamnesis. The patient was hospitalized for 3 days and received systemic therapy with steroid, antihistamines, tocilizumab, and hydroxicloroquine. On the third day of the hospitalization the cutaneous rash had almost completely disappeared.

Evidence-based (S3) guideline for the treatment of androgenetic alopecia in women and in men - short version

Androgenetic alopecia is the most common hair loss disorder, affecting both men and women. Initial signs of androgenetic alopecia usually develop during teenage years leading to progressive hair loss with a pattern distribution. Moreover, its frequency increases with age and affects up to 80% Caucasian men and 42% of women. Patients afflicted with androgenetic alopecia may undergo significant impairment of quality of life. The European Dermatology Forum (EDF) initiated a project to develop evidence-based guidelines for the treatment of androgenetic alopecia. Based on a systematic literature research the efficacy of the currently available therapeutic options was assessed and therapeutic recommendations were passed in a consensus conference. The purpose of the guideline is to provide dermatologists with an evidence-based tool for choosing an efficacious and safe therapy for patients with androgenetic alopecia.

CONSENSUS REPORT: Recognizing non-melanoma skin cancer, including actinic keratosis, as an occupational disease - A Call to Action

1. Non-melanoma skin cancer (NMSC) is by far the most common cancer diagnosed in westernized countries, and one of the few almost preventable cancers if detected and treated early as up to 90% of NMSC may be attributed to excessive exposure to ultraviolet radiation. 2. The incidence of NMSC is increasing: 2-3 million people are diagnosed worldwide annually, with an average yearly increase of 3-8% among white populations in Australia, Europe, the US and Canada over the last 30 years. 3. The link between solar ultraviolet (UV) radiation and certain forms of NMSC is clearly recognized. It is estimated that outdoor workers are exposed to an UV radiation dose 2-3 times higher than indoor workers, and there is a growing body of research linking UV radiation exposure in outdoor workers to NMSC: I. Occupationally UV-exposed workers are at least at a 43% higher risk of basal cell carcinoma (BCC) and almost doubled risk of squamous cell carcinoma (SCC) compared to the average population, with risk increasing with decreasing latitude. II. The risk for BCC, SCC and actinic keratosis (AK) among workers who have worked outdoors for more than 5 years is 3-fold higher than the risk among those with no years of working outdoors. 4. Primary prevention, early detection, treatment and regular follow-up of skin cancer (NMSC and melanoma) are shown to be beneficial from a health economic perspective. 5. Action is needed at international, European and national level to legislate for recognizing AK and NMSC as an occupational disease, which has the potential to improve access to compensation and drive preventative activities. 6. This report is a Call to Action for: I. The engagement of key stakeholders, including supranational institutions, national governments, trade organizations, employers, workers and patient organizations to drive change in prevention and protection of at-risk groups. II. Employers should be obliged to prevent outdoor worker's UV exposure from exceeding limit values, and to implement occupational skin cancer screening programmes among the at-risk workforce. III. Educational programmes for the outdoor workforce are needed to improve health literacy and drive behavioural change. IV. Nationally, steps to improve notifications and surveillance of skin cancers through both occupational services and public health programmes are required. V. Future research activities should focus on the precise definition of at-risk groups among outdoor workers through increased data gathering, including UV-dosimetry, and evaluation.

Skin cancer risk in outdoor workers: a European multicenter case-control study

BACKGROUND

Exposure to ultraviolet radiation (UVR) is the most important external risk factor for skin cancer. Outdoor workers, who are exposed to high ambient UVR levels are at increased risk.

OBJECTIVE

To compare outdoor with indoor workers in terms of: (i) skin cancer risk factors, and (ii) risk of developing skin cancer.

METHODS

Using descriptive methods and a large multicenter European case-control study, we compared risk factor patterns between outdoor (N = 1416) and indoor workers (N = 1863). Risk of developing basal cell carcinoma (BCC), squamous cell carcinoma (SCC), melanoma and actinic keratosis (AK) were analysed by type of work using multivariate logistic regression models, for three categories of work: indoor; farming/construction; other outdoor work.

RESULTS

Although skin phototype was equally distributed by type of work, significantly less outdoor than indoor workers used sunscreen in their own country (44.3% vs. 60.2%), but had more outdoor hobbies (66.2% vs. 58.2%). Outdoor workers had lower educational levels, and felt less confident in understanding medical information and filling medical forms (all P < 0.001). Outdoor workers had more signs of photodamage (78.1% vs. 65.5%) and among the skin cancer patients, 37.7% of outdoor workers vs. 28.6% of indoor workers had ≥2 skin cancers diagnosed during their lifetime. Multivariate logistic regression models showed significantly increased risk of outdoor vs. indoor work for AK (ORother outdoor = 1.55, ORfarming/construction = 2.58), SCC (ORother outdoor = 1.32, ORfarming/construction = 2.77) and BCC (ORother outdoor = 1.53, ORfarming/construction = 1.83). No significant associations were found for melanoma. The risk of all types of skin cancer and AK was significantly increased for workers with ≥5 years of outdoor work.

CONCLUSIONS

Outdoor workers had more risk behaviour with similar constitutional skin cancer risk factors: more UV exposure (both occupational and leisure) and less sunscreen use and lower health literacy. This results in higher exposure, more photodamage and an increased risk of developing AK, BCC and SCC.

Inhibition of MCP-1 and MIP-2 Chemokines in Murine Trichinellosis: Effect of the Anti-Inflammatory Compound L-Mimosine

Mimosine, is a plant amino-acid which has been reported to block DNA replication in mammalian cells and to arrest cells reversibly towards the end of the G1 phase or at the beginning of the S phase. In this study, 42 mice were infected with T. spiralis, a nematode parasite, and treated with the anti-inflammatory compound L-mimosine, to determine if any alteration in the chronic inflammatory state occurred, by investigating the host's immunological response. MCP-1, a C-C chemokine and MIP-2, a C-X-C chemokine were tested and measured in the sera of infected animals, after 1, 10, 20, 30, 40, 50 and 60 days postinfection, by ELISA method. The diaphragm/muscle and the masseters of the infected mice, were tested for inflammatory response. We found that MCP-1 was partially inhibited by L-mimosine, while MIP-2 was totally inhibited. Moreover, in sections of the diaphragm and masseters, the infiltration of inflammatory cells such as macrophages, lymphocytes and eosinophils were more intense in untreated animals compared to those treated with L-mimosine. These findings show, that L-mimosine may have an inhibitory effect on MCP-1 and MIP-2 serum levels in Trichinellosis and may influence the recruitment of inflammatory cells and the intensity of the inflammatory reaction in this parasitic disease.

[Management of non melanoma skin cancer by the general practitioner]

The incidence of skin cancer cases has increased significantly during the last decades. Non melanoma skin cancer (NMSC) is the most common cancer in Caucasian populations. This term refers to 2 major types of skin cancer : basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Mortality from BCC and SCC is low but there may be substantial morbidity from disfigurement as these lesions tend to be located on the skin of the head and neck. Actinic keratosis is a premalignant condition that may evolve into SCC. Fortunately, skin cancer is amenable to early detection and potential cure. General practitioners may play a very important role in the timely diagnosis and management of these tumors. They are on the front line to detect NMSC : opportune examination coupled with good observation skills allow a high detection rate of suspicious lesions. It is essential to identify the high-risk patient as well as the clinical signs of suspicious lesions. This article outlines the clinical features of common NMSC and highlights which lesions should be best referred to a dermatologist.

Demographic, behavioural and physician-related determinants of early melanoma detection in a low-incidence population

BACKGROUND

Knowledge of the factors that influence early detection of melanoma is important in developing strategies to reduce associated mortality.

OBJECTIVES

To identify sociodemographic, behavioural and medical care-related factors associated with melanoma thickness in a low-incidence population but with a high case fatality.

PATIENTS AND METHODS

In a multicentre, retrospective, survey-based study of 202 patients with a recent diagnosis of invasive melanoma (< 1 year), we collected data on demographic and behavioural factors, attitudes towards prevention, access to medical care, frequency of skin self-examination (SSE) and physician skin examination (PSE) in relation to melanoma thickness.

RESULTS

Thinner tumours (≤ 1 mm, 80 melanomas) were associated with female sex (P ≤ 0.049), nonnodular (superficial spreading melanoma, lentigo maligna melanoma, acral lentiginous melanoma) histological subtypes (P < 0.001), absence of ulceration (P ≤ 0.001), and location other than lower extremity or trunk location (P ≤ 0.004). Patients married at the time of diagnosis or who performed SSE during the year prior to diagnosis were more likely to have thinner tumours than those who did not [odds ratio (OR) 3.45, 95% confidence interval (CI) 1.48-8.04 and OR 2.43, 95% CI 1.10-5.34, respectively]. Full-body skin examination by a physician was not significantly associated with thinner melanoma (OR 1.99, 95% CI 0.66-6.07).

CONCLUSIONS

SSE was shown to be an important factor in the detection of thin melanoma, in contrast to partial or full-body PSE, which did not show any statistically significant effect on tumour thickness.

Potential impact of interventions resulting in reduced exposure to ultraviolet (UV) radiation (UVA and UVB) on skin cancer incidence in four European countries, 2010-2050

BACKGROUND

Behavioural interventions to reduce exposure to ultraviolet radiation (UVR) can reduce risk of skin cancer.

OBJECTIVES

To integrate the data and to evaluate the impact of interventions to limit exposure to UVR on skin cancer incidence in four selected countries.

METHODS

Using PREVENT, a dynamic simulation model, we modelled the potential for skin cancer prevention in four European countries under various scenarios to avoid damage by UVR.

RESULTS

In general, the most effective interventions were those aimed at protecting people during outdoor work and outdoor hobbies against the harmful effects of UVR, and combinations of several interventions. These could in theory lead to reductions of up to 45% in skin cancer cases projected for the year 2050.

CONCLUSIONS

The scope for prevention depends on the prevalence of the risk factors in the different countries, as well as the associated risk factors and time lags modelled.

The Euromelanoma skin cancer prevention campaign in Europe: characteristics and results of 2009 and 2010

BACKGROUND

Euromelanoma is a skin cancer education and prevention campaign that started in 1999 in Belgium as 'Melanoma day'. Since 2000, it is active in a large and growing number of European countries under the name Euromelanoma.

OBJECTIVE

To evaluate results of Euromelanoma in 2009 and 2010 in 20 countries, describing characteristics of screenees, rates of clinically suspicious lesions for skin cancer and detection rates of melanomas.

METHODS

Euromelanoma questionnaires were used by 20 countries providing their data in a standardized database (Belgium, Croatia, Cyprus, Czech Republic, FYRO Macedonia, Germany, Greece, Hungary, Italy, Lithuania, Luxembourg, Malta, Moldavia, Portugal, Serbia, Slovenia, Spain, Sweden, Switzerland and Ukraine).

RESULTS

In total, 59,858 subjects were screened in 20 countries. Most screenees were female (64%), median ages were 43 (female) and 46 (male) and 33% had phototype I or II. The suspicion rates ranged from 1.1% to 19.4% for melanoma (average 2.8%), from 0.0% to 10.7% for basal cell carcinoma (average 3.1%) and from 0.0% to 1.8% for squamous cell carcinoma (average 0.4%). The overall positive predictive value of countries where (estimation of) positive predictive value could be determined was 13.0%, melanoma detection rates varied from 0.1% to 1.9%. Dermoscopy was used in 78% of examinations with clinically suspected melanoma; full body skin examination was performed in 72% of the screenees.

CONCLUSION

Although the population screened during Euromelanoma was relatively young, high rates of clinically suspected melanoma were found. The efficacy of Euromelanoma could be improved by targeting high-risk populations and by better use of dermoscopy and full body skin examination.

Viral oncogenesis and its role in nonmelanoma skin cancer

In recent years, the contribution of viruses to cutaneous oncogenesis has steadily gained recognition. The archetype is human herpesvirus 8, which is well established as the causative agent in Kaposi sarcoma. Other viruses believed to play a role in nonmelanoma skin cancer include human papillomavirus and the recently described Merkel cell polyomavirus. We review the mechanisms by which these three viruses interact with the host cell, ultraviolet radiation and immunosuppression to result in carcinogenesis.

Efforts to counteract locally the effects of systemic immunosupression: a review on the use of imiquimod, a topical immunostimulator in organ transplant recipients

The potent systemic immunosuppression therapy necessary to sustain a life-saving solid organ transplant is associated with an increased incidence of various infections including human papillomavirus infection and skin cancers in organ transplant recipients. Imiquimod, a topical agent that functions through local induction of a specific anti-viral or anti-tumor immune response, appears to be a promising therapeutic option that could potentially counteract in situ the effects of systemic immunosupression in this vulnerable group. Up-to-date studies using this local immune-response modifier in transplanted patients have yielded reassuring and encouraging results regarding its safety and efficacy in this population. However, in order to establish the use of imiquimod as a standard treatment option for organ transplant recipients, additional research and clinical trials are required.

Photodermatoses with onset in the elderly

Photodermatoses are a group of skin disorders induced by ultraviolet radiation (UVR) and, in some cases, visible light. To establish a diagnosis it is important to carefully take a history, physical examination and perform phototesting as well as other testing when appropriate (patch and photopatch tests, antinuclear antibodies, porphyrin profile). This article focuses on the photodermatoses that affect the elderly, which with the ageing of population, particularly in the industrialized societies, are becoming an increasingly important group for the healthcare systems. The most common photodermatoses with onset in the elderly are chronic actinic dermatitis and drug induced photosensitivity.

Skin biopsies in DC vaccines for stage III-IV melanoma patients: role of neutrophils?

Dendritic cell (DC) vaccines are used for the induction of anti-tumor T cell reaction in melanoma patients. DC are generated in vitro, pulsed with antigen and matured prior to injection. They are supposed to migrate to lymph nodes and to present the processed antigen to naive T cells allowing activation of tumor-specific lymphocytes. It has been suggested that intradermal injection allows a superior migration to the lymph node. Eight HLA-A2 positive patients with stage III or IV melanomas expressing NA 17 antigen were collected. They were included in a pilot trial of vaccination in which they received IL3/INFb DC presenting the NA17 A2 antigen. In each patient, a skin biopsy was performed at the injection site, 24 h after inoculation. The striking features of the biopsies were the presence of a perivascular CD3+/CD8+ T cell infiltrate with a slight population of CD4+ cells and the presence of a massive neutrophilic infiltrate associated with the injected DC still present, realizing a suppurative granuloma. The persistence of DC 24 h after the injection suggests that migration in the lymph node is not necessary for the induction of the immune response. The skin itself could be the location of a reaction starting with a massive recruitment of neutrophils.

Melanoma risk in association with serum leptin levels and lifestyle parameters: a case-control study

BACKGROUND

Solar radiation has been identified as a principal factor for the causation of melanoma, whereas changing lifestyle patterns associated with obesity and diabetes might also contribute to the increasing incidence of the malignancy. No study has investigated the role of leptin, a hormone whose levels increase in obesity and which has also been related to cancer.

PATIENTS AND METHODS

Fifty-five patients with incident melanomas and 165 age- and gender-matched healthy controls were interviewed on the basis of a questionnaire that covers phenotypic features, sociodemographic and medical history variables, lifestyle habits and frequency of consumption of major food groups. Anthropometrical measures were also recorded and blood samples were obtained for determination of serum leptin levels. Adjusted odds ratios (ORs) for melanoma risk were derived through multiple logistic regression analyses.

RESULTS

An excess melanoma risk was observed for sun sensitive individuals and those with high circulating levels of leptin (OR: 1.56, 95% confidence interval 1.07-2.28, P = 0.02), after controlling for obesity indices, diabetes mellitus and education. Increased physical exercise, lower alcohol consumption and plant food consumption seem to play a protective role against melanoma development.

CONCLUSIONS

Melanoma risk was found to be positively associated with serum leptin levels and inversely with healthy lifestyle factors. The findings need to be confirmed in prospective studies.

Circulating adiponectin levels in relation to melanoma: A case–control study

AIM

Melanoma, a malignancy with steadily increasing prevalence, has been associated not only with sun exposure but also with phenotypic characteristics including obesity. Adiponectin, an adipocyte secreted endogenous insulin sensitizer, has been found to play a protective role in several obesity related cancers but has not yet been studied in relation to melanoma. We investigated the association of circulating adiponectin levels with melanoma in Greece, a country with rather low incidence of the disease and high annual sunshine levels.

METHODS

In the context of a case-control study, we studied over a 22-month period 55 patients with incident, histologically confirmed melanoma cases and 165 healthy controls matched for gender and age.

RESULTS

After controlling for the possible confounding effect of education, body mass index and waist-to-hip ratio in multiple logistic regression analyses, sun sensitive skin type was significantly and positively associated with melanoma risk (OR: 2.48, 95% Confidence Interval: 1.22-5.10, p: 0.01). On the contrary, there was a sizeable, though non-significant, inverse association of serum adiponectin levels with the disease (OR: 0.75, 95% Confidence Interval: 0.52-1.10, p: 0.14).

CONCLUSION

A protective role of adiponectin in the development of melanoma cannot be excluded given the presented empirical evidence (25% reduction per one SD of adiponectin) and the direct anti-neoplastic features of the hormone. The results are intriguing enough to point to the need for further investigation.

Epidemiology of nonmelanoma skin cancer (NMSC) in Europe: accurate and comparable data are needed for effective public health monitoring and interventions

Nonmelanoma skin cancer (NMSC) is the most common malignancy occurring in white populations. It is currently becoming an important challenge in terms of public health management as the increasing incidence rates will probably have a tremendous impact on healthcare costs. Possible factors driving this rise in NMSC numbers are increases in both acute and prolonged UV exposure together with increasing numbers of older people in the population. A better understanding of NMSC epidemiology in Europe is essential if an evidence-based European-wide public health policy is to be developed. It is obvious this can only be achieved by recording and analysing comparative epidemiological data. Finally, by improving the skin examination training for physicians, developing guidelines and exchanging best practices, a high level of healthcare could be provided for NMSC.

Skin Prick Tests in Patients with Chronic Urticaria

Acute or chronic urticaria is not a common manifestation of systemic disease. However it affects 15% of the population at least once during their lives. The most common causes of urticaria are allergic. In all, we studied 130 patients (mean age 54.8) with chronic urticaria, 88 women and 42 men, in an effort to identify common causes of urticaria, using environmental and food allergens. 90 of our patients (69.2%) did not present with skin sensitivity. The remaining 40 individuals presented with skin sensitivity: 20 (15.3%) to food allergens, 14 (10.7%) to environmental allergens and 6 patients (4.6%) to both allergens (environmental and food). We note that in chronic urticaria it is unusual to find underlying causes.

The Safety of Immunotherapy in Patients with Allergic Asthma and Allergic Rhinitis

We studied systemic reactions associated with immunotherapy in a group of 50 patients with mean age 31.4 years. The group consisted of 36 women and 14 men who followed a three-year immunotherapy treatment with pollen and mite allergen extracts (HAL-Holland Corporation). A total number of 2550 injections were administered. Eight patients developed systemic reactions; 6 had allergic rhinitis and 2 allergic asthma. None developed severe anaphylaxis. Seven of the systemic reactions occurred immediately after injection while one was a late reaction manifested as generalized urticaria, local edema and rubor at the site of the injection. From the 7 patients who showed an immediate reaction, 5 developed generalized urticaria with local edema and rubor at the site of the injection, while 2 presented with bronchial spasm. We did not observe any reaction when the quantity of the extract injection was reduced by 50%. Our study points out that, in the vast majority of cases, immunotherapy is free of severe systemic reactions. Those that occur are associated with the injection of high-density extracts and none of them is severe.

Bronchial Hyperresponsiveness in Patients with Inflammatory Bowel Disease

Pulmonary complications have been described in patients with inflammatory bowel disease. The aim of this study was to evaluate bronchial hyppersponsiveness (BHR) in patients with Crohn's disease (CD) and ulcerative colitis (UC). Fifteen patients (8 men, 7 women, mean age: 42.20 ± 12.20 years) participated in the study. None of the patients had a prior history of respiratory disease or suffered from other systematic disease. Skin prick tests for common allergens (such as pollens, mites, foods and moulds) were administered to all patients of the study. The control group included 15 healthy volunteers (10 men, 5 women, mean age: 40.33 ± 5.06 years). The skin tests showed that 3 of 15 patients with inflammatory bowel disease were sensitive to common allergens (two patients to mix grasses and one to D. Pteronysinnus). In the control group, one subject was sensitive to D. Pteronysinnus. BHR was estimated after methacholine challenge. The frequency of BHR among the patients with inflammatory bowel disease was 7 of 15 (46.60%), compared with only one in the control group who was positive at the maximum dosage of methacholine (16 mg/dl). Our results indicate that there is an increased frequency of BHR in patients with inflammatory bowel disease.

Pyridoxine deficiency: new approaches in immunosuppression and chemotherapy

Pyridoxine deficiency leads to impairment of immune responses. It appears that the basic derangement is the decreased rate of production of one-carbon units necessary for the synthesis of nucleic acids. The key factor is a pyridoxine enzyme, serine hydroxymethyltransferase. This enzyme is very low in resting lymphocytes but increases significantly under the influence of antigenic or mitogenic stimuli, thus supplying the increased demand for nucleic acid synthesis during an immune response. Serine hydroxymethyltransferase activity is depressed by deoxypyridoxine, a potent antagonist of pyridoxal phosphate, and also by known immunosuppressive or antiproliferative agents. The combination of these agents is additive. Our results lead us to suggest the following medical applications: (a) combination of deoxypyridoxine with immunosuppressive or chemotherapeutic drugs may be effective in cases of immunosuppressive therapy or organ transplantation, (b) the development of special agents directed against the serine hydroxymethyltransferase apoprotein may prove to be a valuable medical tool, since this enzyme presents an excellent target for chemotherapy, (c) lymphocytes of individual patients could be used to design tailor-made specific immunosuppressive or chemotherapeutic treatment, and (d) the serine hydroxymethyltransferase activity of lymphocyte culture presents an excellent indicator for the evaluation of potency of immunosuppressive, chemotherapeutic or genotoxic compounds in a simple and rapid test.