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Reports written by Dr. Jovan Lalosevic (Dermatologist, Serbia) and Dr. Nicolas Kluger (Dermatologist, Finland)
By
Dr. Jovan Lalosevic
Related topics
Chairs: Prof. Kilian Eyerich and Dr. Hok Bing Thio.
Speakers: Prof. Kilian Eyerich, Dr. Hok Bing Thio, Prof. Hervé Bachelez, Dr. Satveer Mahil.
Report written by Dr Jovan Lalosevic, M.D., Ph.D.
Speaker: Prof. Kilian Eyerich (Freiburg)
In this updates session, the first lecture was given by Prof. Eyerich, who started with the definition of disease modification. In order to influence the course of the disease, we need to know the objective measurements that quantify clinically meaningful outcomes. In the case of psoriasis, the PASI score is not a valid way of measuring inflammatory activity.
Even if we could measure disease activity, we would then need a cut-off value to further define whether there has actually been success in modifying the course of the disease.
Referring to the expert opinion regarding the different definitions of disease control, remission and modification, he further stated that all experts can agree that the cure of a disease (psoriasis) is a maximum effort to modify a disease.
As factors such as race, gender and age do not influence the course of the disease, the only factor that does and that we can influence is the duration of the disease.
In the following lecture, Prof. Eyerich explained that introducing biologic therapy in the early stages of psoriasis can prevent the expression of systemic comorbidities, as it is well known that psoriatic arthritis and cardiovascular complications are part of the systemic spectrum that this disease manifests. By preventing comorbidities, we can actually modify the course of the disease.
It is postulated that this effect is produced by affecting the memory of resident cells in the tissue. In the skin, these cells are reduced over time when patients are treated with biologic treatments. The effect on these tissue memory resident cells is also present with other topical and systemic treatments, but biologics, as the most effective therapy, are thought to be most susceptible to this type of mechanism of disease modification.
The other postulation is that the epigenetic mechanism, in the form of DNA methylation in lesional skin, is normalised in new-onset psoriasis compared to chronic plaque forms.
In conclusion, more specific patient profiling is required in order to find the most successful treatment option, or rather to have the maximum effect on modifying the course of the disease.
Speaker: Dr. Hok Bing Thio (Rotterdam)
In the next presentation, Dr. Hok Bing Thio looked at population differences in psoriatic patients. In his presentation, he stated that there are no differences in prevalence between men and women, but that there are differences in age of onset, with a higher prevalence in adults compared to children.
Although the general population prevalence is around 2%, Dr. Bing Thio addressed the fact that there is a higher prevalence in more economically developed countries (high income countries), with examples of higher percentages of psoriasis patients in Australia, Europe and North America. Lower prevalence was found in East Asia, with the lowest prevalence in Taiwan.
In contrast to a lower prevalence rate, the clinical forms of psoriasis in these countries are more severe, with higher PASI scores and BSA affected. Also, the clinical forms in dark-skinned and Asian patients are different, with the colour being more violent than the erythematous, which is the clinical hallmark of fair-skinned patients.
This difference in appearance and severity of the disease can be explained by the variance in the expression of human leukocyte antigen alleles in certain ethnic groups. For example, in cases of HLA Cw6, expression is most common in the general population. However, in cases of HLA Cw1, which is more common in the Asian population, there is a higher incidence of pustular and erythrodermic psoriasis. With these differences in gene expression, there is a variable response to systemic treatment that should also be considered. In addition to gene expression, the triggers of psoriasis can be influenced by the geographical location (environment) of a particular ethnic group, but also by their lifestyle (type of diet, lifestyle, stress).
Differences in diet make the microbiome variable, so some food preferences can induce dysbiosis and cause mild but chronic inflammation in psoriasis.
Dr. Bing Thio further postulated that there are differences in immunometabolism, more specifically mitochondrial activity, between different populations, which is an important factor in the exacerbation of psoriasis. He then focused on medication that can modulate mitochondrial activity, such as metformin and semaglutide, and gave case examples of psoriasis improving in a patient on ozempic.
In the final slides of his talk, he highlighted the importance of air pollution and its effect on psoriasis by also modifying mitochondrial activity.
In summary, we can conclude that genes, epigenetics, microbiome and mitochondria (plus pollution) are the key factors influencing psoriasis, but with differences in expression between races.
Speaker: Prof. Hervé Bachelez (Paris)
In the introduction, Dr. Bachelez hypothesised that there may be a link between pustular and plaque psoriasis. A clear link was established by the fact that almost half of patients with generalised pustular psoriasis had previously had chronic plaque psoriasis. The same association was found for patients with palmoplantar psoriasis, psoriasis vulgaris and psoriatic arthritis.
More specifically, the first gene expression association was made with CARD14 gain-of-function mutations, which were "hot spots" in more than 60% of patients with psoriasis vulgaris, pityriasis rubra pilaris and generalised pustular psoriasis. In cases with CARD 14 mutations, spontaneous psoriasis-like skin eruptions occur due to an increased keratinocyte response to IL17A. Patients with these types of mutations may also benefit from biologic treatments with secukinumab and ustekinumab.
IL36 loss-of-function mutations are mainly found in generalised pustular psoriasis, but not in plaque psoriasis. Therefore, patients with generalised pustular psoriasis who have IL36 mutations do not have a history of chronic plaque psoriasis.
Although Dr. Bachelez's first hypothesis was that pustular psoriasis is either driven by an IL17A pathway or an IL36-only pathway, he went on to say that this was completely wrong. There are twenty different immunological pathways that are the same in both pustular and plaque psoriasis, but the degree of upregulation differs significantly between the two. In his presentation, he points to the interferon-I-driven response, which is expressed in a high percentage, more so in palmoplantar pustulosis, but also in psoriasis vulgaris. With this dominant response, patients are more resistant to any type of biologic therapy and small molecule therapy, with the exception of JAK1/TYC2 inhibitors.
This approach can be confirmed by the studies carried out on patients receiving spesolimab, where less than 50% of patients had complete clearance of pustules, concluding that pustular psoriasis is not a disease driven solely by IL36.
Finally, he concluded that we need more knowledge of gene expression and the causes of inflammation, raising the question of whether there should be a change in taxonomy (different endotype of pustular lesions), paving the way for more precision medicine approaches.
Speaker: Dr. Satveer Mahil (London)
The final presentation of the session was given by Dr. Satveer Mahil, who explained how we can personalise treatment for each patient, with data-driven information leading to prevention, targeted treatment and improved long-term prognosis.
The concept of an individualised approach is to explore the potential of biomarkers in each patient that can give us a predictive role in assessing the risk of serious disease, thus giving the opportunity for early introduction of targeted treatment and therefore ideal therapy.
The later part of the presentation focused on the durability of modern therapy, more specific biologics, based on real-world data. The effects of biological treatment should be based on certain biomarkers, but none have been identified as sufficient to be used in daily clinical practice. One of the factors that could predict treatment response was serum drug levels. In the case of adalimumab, drug levels at 4 weeks can predict response at 6 months. With these findings, we can predict a required adalimumab concentration at 4 weeks of treatment necessary to achieve a PASI 75 response (therapeutic range 3.2-7 ug/L), making a reach into clinical guidelines and real-world practice.
In addition to biomarkers, polygenic risk scores may also influence disease severity, the latter being influenced by early age of onset, obesity, smoking and alcohol consumption.
The presentation included data showing that early intervention with guselkumab improves outcomes when comparing short (<2 years) to long (>2 years) duration of psoriasis. The results also show that early intervention can lead to dose reductions while maintaining the results achieved to date. All of this points to the upcoming study to be conducted in the UK with the aim of reducing the long-term drug burden on patients. The trial has the potential to individualise dosing for each patient.
Speakers: Assoc. Prof. Marieke Seyger, Prof. Amy Paller, Dr. Joan GarcĂas Ladaria, Dr. Peter Hoeger.
Report written by Dr Jovan Lalosevic, M.D., Ph.D.
Speaker: Assoc. Prof. Marieke Seyger (Nijmegen)
The lecture included a short introduction to the possible differential diagnosis of paediatric psoriasis and Prof. Seyger gave us some hints about possible skin signs that can give us a clue to make a better diagnosis of psoriasis. She included the 7 predictive sign criteria (Burden-The et al. DIPSOC study, Br J Dermatol 2022), consisting of:
The next presentation was on updates in the topical treatment of paediatric psoriasis, which reviewed the previously used topical steroids, calcineurin inhibitors and calciportiol, but also introduced new treatment options in the form of 0.3% roflumilast cream (PDE-4 inhibitor) and 1% tapinarof (AhR modulator), which showed promising results (Lie et al, Pediatric Drugs 2024). Prof Seyger also emphasised that ditranol/antralin can have a significant effect on paediatric psoriasis, but that adherence is the main problem with this treatment option (Aoki et al, Dermatol Clinics 2024).
The opinions of patients, parents and physicians may differ. The non-physicians want a quick and safe treatment with complete resolution of the skin lesion, whether the medical staff is less strict about the criteria regarding the effectiveness of the prescribed treatment.
The available systemic drugs for paediatric psoriasis include retinoids, cyclosporine A and methotrexate (Bruins et al, Acta Derm Venereol, 2022), which can give up to 50% of treated patients a PASI 75 response. Apremilkast is a new drug available for the treatment of paediatric psoriasis, with similar results to conventional systemic therapy (Fiorello et al, J Am Acad Dermatol, 2024).
All of the available biologic drugs that are available for paediatric psoriasis are used from 6 years of age, with the exception of etanercept, which can be used from 4 years of age.
The biologics give us a much more effective response, with the majority of patients achieving PASI 75,90 and even around a third achieving PASI100 (Bodemer et al. JEADV 2020). They are also more effective and safer than methotrexate (Sun H et al, Pediatric Dermatol, 2022).
The drugs currently in phase III trials for paediatric psoriasis are cetrolizumab, guzelkumab, risankizumab, tildrakizumab, bimekizumab and an oral deucravacitinib (www.clinicaltrials.gov).
Finally, the professor shared her data on the factors present in paediatric patients who have a greater risk of a severe psoriasis and therefore have a potential need for systemic treatment (in her opinion start first with methotrexate and then with biologics) that are male sex, nail involvement and obesity.
Speaker: Prof. Amy Paller, MD, MS (Chicago)
We know that topical steroids are the cornerstone of topical treatment in atopic dermatitis. The thing that is a variable in the management of patients with mild to moderate AD is the maintenance treatment, either going to a less potent topical steroid, applying a proactive 2-3x per week treatment with either topical steroids or topical calcineurin inhibitors. More recently, topical PD4 inhibitors give us an option for safe and effective treatment of more sensitive areas with 2% crisabolol as the first developed and subsequently 0.15% roflumilast as the FDA approved topical treatment for AD. Newer topical treatments include 1.5% ruxolitinib (JAK inhibitor), which has shown efficacy in moderate AD (Boguniewicz et al, Ann Allergy Asthma Immunol 2018).
Topical non-steroidal anti-inflammatory drugs are becoming more available, and topical calcineurin inhibitors are now approaching their 20th anniversary, with the previously thought risk of lymphoma development now known to be infinitesimally small.
Prof. Paller went on to discuss the efficacy of 0.15% roflumilast in patients older than 6 years, pointing out that even though it is a cream it does not cause irritation as was the case with crisaborole (Eichenfield et al, presented at ACAAI 2023).
Tapinarof 1% cream (aryl hydrocarbon receptor agonist) has shown efficacy in two phase 3 trials (ADORING 1 and 2), with mild side effects, mostly in the spectrum of folliculitis.
For patients who require systemic treatment, the first-line therapy is dupilumab in countries where it is available (Butata, Paller, Ann Allergy Asthma Immunol 2022). In countries where it is not available, patients should be treated with methotrexate, cyclosporine A, azathioprine, mycophenolate mofetil, with the addition of narrow-band UVB therapy if it can be combined.
New and anticipated biologic treatments include IL13 inhibitors (tralokinumab, lebricizumab), similar to dupilumab but potentially with a lower incidence of conjunctivitis; IL31R inhibitors (nemolizumab), focusing on the itch segment of the disease (has to be combined with topical steroids); OX40L inhibitor (amlitelimab), affecting antigen-presenting cells.
Further to her presentation, Prof. Paller stated that she usually switches from one systemic drug to another within 2 months of treatment, and when considering when and if to extend the treatment interval or lower the dose, she pointed out that the patient needs to be "doing well" for at least a year. There was also a comment about the pain of injections given, mostly due to the volume of the drug, where education about appropriate administration is key to reducing unwanted pain.
Avoiding injections opens the door for systemic JAK inhibitors, upadacitinib, baricitinib, abrocitinib. They are as effective as the biologics, have a rapid and strong effect on pruritus and are good at managing flares. Their main issue is the safety profile, with frequent laboratory requirements, neutropenia and hypercoagulability scenarios. In general, they have a broader immunosuppression compared to the biologics, so they are not the first choice for systemic treatment.
Speaker: Dr. Joan GarcĂas Ladaria (Mallorca)
The definition of hidradenitis suppurativa (HS) is the presence of "typical lesions" (papules, nodules, draining sinuses) affecting specific regions (flexural sites) with 2 or more flares in a 6-month period. There are two peaks of incidence, in children around puberty (10-12 years) and in adults around the age of 25, with a second peak around the age of 40.
The main problem is that hidradenitis suppurativa is an under-diagnosed disease in many countries of the world, and most paediatric patients are not diagnosed until adulthood. The approximate delay in diagnosis in paediatric patients is about 2 years, and a delay of more than 1 year is associated with a more severe/disseminated disease (Liu-Wong et al, JAMA Dermatol 2021). Follicular occlusion and follicular damage are central to the pathogenesis of the disease.
The most common comorbidity in paediatric HS is Down's syndrome (2.7-5% of cases), with a female predominance and a strong association with insulin resistance, obesity, smoking and hormonal imbalances (precocious puberty and PCOs).
Unlike other chronic inflammatory diseases, early age of onset does not correlate with more severe disease (Krueger et al, Br J Dermatol 2024).
There are no universally accepted treatment protocols for paediatric HS, so clinicians use treatment protocols developed for adults. The aim of treatment is to relieve symptoms and prevent disease progression. However, we recommend general measures such as reducing friction, avoiding close shaving and reducing body weight if necessary. Treatment is based on a combination of medical and surgical interventions.
One scale used to assess the severity and management of the disease is the Hurley scale (mainly a surgical scale), other scales (IHS4) take into account different clinical aspects of the lesion (follicular or inflammatory) (Zouboulis et al. Dtsch Dermatol Ges, 2024, Martorelli et al. J Eur Acad Dermatol 2020).
Treatment of paediatric HS should be based on the phenotype of the lesions, whether they are follicular or inflammatory (Melgosa-Ramos et al Actas Dermosifiliogr. 2024). Patients with a mixed phenotype are better candidates for biologic treatment to achieve disease remission.
Special considerations in the treatment of paediatric HS should include the use of tetracyclines (after the age of 8), finasteride in girls before menarche, isotretinoin in cases of concomitant acne, and secukinumab can be tried as an off-label use in children older than 6 years.
Finally, Dr Garcia Ladaria concluded that paediatric HS mirrors adult HS and requires a holistic approach, treating inflammation, identifying comorbidities and avoiding exacerbating factors.
Speaker: Dr. Peter Hoeger (Hamburg)
Newborn babies have the same number of sebaceous glands as adults, but they are distributed over a smaller area. They are also more visible in the first month of life due to maternal androgen stimulation, colloquially known as mini-puberty.
The spectrum of acneiform disorders in prepubertal children consists of
Prepubertal children may have rosacea-like conditions, the most common of which is perioral dermatitis, which in the majority of cases is caused by topical steroids or the use of fluoride toothpastes.
Another rosacea-like condition is idiopathic aseptic facial granuloma, which is often associated with other rosacea-like conditions. The condition has a high rate of spontaneous resolution. It can be treated with anti-inflammatory oral antibiotics. Full-blown rosacea with ophthalmic manifestations is rare and should be treated as in adult patients.
Moderation: Prof. Diamant Thaçi.
Speakers : Prof. Sonja Ständer, Dr. Sarina Elmariah and Dr. Andrew Pink.
Report written by Dr Jovan Lalosevic, M.D., Ph.D.
The main goal of any therapy is to relieve the patient from pain and to reduce itch, whether it is prurigo nodularis or atopic dermatitis.
Among the tools that can help us in this task are the unidimensional itch intensity scales, the numerical rating scale being one of the most accurate (Stander et al, J Dtsch Dermatol Ges, 2022).
What is considered a meaningful reduction in NRS itch:
One of the main expectations of every patient is the fast reduction of itch, and more than 50% of all patients with prurigo nodularis expect it to be in the first month of treatment introduction.
When we look at the expert’s consensus on the management of prurigo nodularis, we can see that it includes:
as well as systemic neuromodulating drugs such as gabapentin, antidepressants and systemic immunomodulating drugs such as methotrexate, azathioprine, cyclosporine A and, in recent years, systemic JAK inhibitors, dupilumab and a new promising drug, an IL-31 signalling inhibitor.
Until now, most patients with prurigo nodularis have not been satisfied with the prescribed treatment. New therapies that are proving effective in reducing itching and nodules are dupilumab (IL4/IL13) and nemolizumab (IL31a) (FDA approved).
Atopic dermatitis (AD) is a chronic and multifactorial disease in which pruritus is a key element, but in most of the moderate to severe forms it is often accompanied by pain. In these cases, the narrative is always directed towards systemic immunomodulatory treatment.
The new treatment armamentarium includes either biologics or systemic JAK inhibitors. Dupilumab is one of the first widely used and effective biologics in AD, with recent studies showing efficacy of tralokinumab, lebrikizumab and nemolizumab in combination with topical steroids and/or topical calcineurin inhibitors. At the other end of the spectrum, the development of JAK inhibitors is giving us even greater effects on pruritus, with abrocitinib, upadicitinib and baricitinib showing efficacy in the 4-point reduction of itch on the NRS.
In the only head-to-head study comparing upadacitinib with dupilumab (Blauvelt et al, JAMA Dermatol, 2021) in adults with moderate to severe atopic dermatitis, upadacitinib showed superior and faster skin clearance and itch relief with tolerable safety.
Chairs: Dr. Vincenzo Bettoli, Dr. Lajos Kemeny.
Speakers: Dr. Nicolas Kluger, Dr. Layos Kemeny, Dr. Vincenzo Bettoli, Dr. Margarita Larralde.
Report written by Dr Jovan Lalosevic, M.D., Ph.D.
Speaker: Dr. Nicolas Kluger (Helsinki)
Transgender people undergoing masculinising hormone therapy experience a wide range of dermatological effects during the initiation and maintenance of testosterone therapy. The role of hormone therapy is to reverse or reduce the physical sexual characteristics of the sex assigned at birth and to enhance and build up the characteristics of the expressed sex, and these therapies apply to both transgender and gender non-conforming patients. Acne is one of the most common side effects for many transmasculine patients receiving testosterone. Acne can worsen body image and mental health and has a significant impact on the quality of life of transgender patients.
Discussing the condition with patients should be neutral, using terms that may not trigger gender dysmorphia (chest, genitals).
Treatment should be the same as for cisgender patients, taking into account the risk of pregnancy in female transgender patients.
Speaker: Dr. Layos Kemeny (Szeged)
Is there an unmet need for new therapies? was the first question asked by Prof. Kemeny asked in his presentation. Even though we have very effective forms of treatment, patients are asking for treatment that is fast-acting and has a long-term effect without relapse or scarring.
New therapies could include targets such as inflammatory cytokines.
Cutibacterium acnes strains can induce different th17 responses in the skin (Agak et al, JID 2018). All this leads to the question of which cytokines can actually be targeted, such as IL1beta, IL17A and TNF alpha.
Clinical trials have not shown efficacy in blocking inflammatory cytokines with antibodies in the case of IL1beta and IL17. However, the efficacy of anti-TNF, IL-13/23 and IL-23 has been demonstrated in case reports of acne and acne-associated syndromes.
The question that arises is whether these cases are really acne, but perhaps a facial type of hidradenitis suppurativa (conglobate type).
The other way we can influence the pathogenesis of acne is by modulating C. acnes towards the non-acne causing strains, either by neutralising antibodies against CAMP or by overpowering it with other bacteria (Karoglan et al, Act Derm venreol 2019, Labeer et al, Cell Resp Medicine 2022). The latest effort has been demonstrated with topical phage therapy in a mouse model (Rimon et al, Nat Commun 2023).
Ultimately, no biologics are approved for the treatment of acne. For treatment-resistant acne, think of HS. For severe therapy-resistant acne, with or without acne syndromes, you could try blocking TNF-alpha, IL-17 or IL-23. Modulating the skin microbiome may be a new way to improve acne.
Speaker: Dr. Vincenzo Bettoli (Ferrara)
The definition of a low dose may vary. A common definition is that a low dose is one that is lower than the standard dose (in the case of isotretinoin, this is 0.5-1 mg/kg). A low dose can also be thought of as being lower than the highest dose that a particular patient can tolerate (the dose that a patient can tolerate without side effects).
Low-dose isotretinoin can be given continuously or intermittently (alternate days, alternate weeks). Treatment can either start with a low dose followed by a gradual increase to a maximum tolerated dose, or it can start with a high dose and then be reduced to a low dose due to poor tolerance of side effects.
Each individual patient has a different metabolism and bioavailability for drugs, therefore patients will develop side effects (cheilitis being the most common) according to their personal dose dependency.
Patients on treatment can develop flares, which are often related to a dose that is too high for them. Studies show that starting with a low dose and increasing to the highest tolerated dose significantly reduces the frequency of severe flares (Bettoli et al. Dermatology, 2009). The dose should be increased each week, up to a daily increase of 10 mg. This dosing regimen has demonstrated efficacy while minimising treatment side effects.
Notwithstanding the lower incidence of side effects, low-dose isotretinoin is better tolerated, equally effective in the long term, and procedures such as peels or lasers are easier to perform while on it.
Low-dose oral isotretinoin has its drawbacks, with women needing to use contraception for longer and taking longer to clear their acne.
Relapses are more common with low-dose isotretinoin, but some patients experience them more frequently, and these are
Finally, Dr Bettoli gave us his treatment preference:
Speaker: Dr. Margarita Larralde (Buenos Aires)
Light treatment for acne can be divided into treatment of active lesions (IPL and PDT) and treatment of acne sequelae (CO2, Q-switched, IPL). The mechanisms of action of light-based therapies may include
Intense pulsed light improves inflammatory acne and reduces the size and number of glands by direct phototoxic damage, reducing their density and sebum production. It may also exert an anti-inflammatory effect by down-regulating tumour necrosis factor and up-regulating transforming growth factor beta1 signalling. IPL also corrects vascular dilation, resulting in a reduction in erythema in inflammatory acne.
A new light device that has been used for mild to severe inflammatory lesions is a diode laser wavelength of 1726nm that performs selective photothermolysis of the sebaceous glands. It is combined with prior, parallel (during energy delivery) and post-cooling of the superficial epidermal dermal structures to ensure safety and minimal patient discomfort.
Another device that can be used in the treatment combines vacuum and broadband light technology. Vacuum deep cleanses the pore by extracting the blocked sebaceous material. Broadband light targets porphyrins, destroying the C. acne bacteria, reducing sebum production and reducing the erythema and pigmentary changes associated with acne.
The fractional Q-switched 1064 nm laser is often used to treat acne scars.
Conclusion:
Speaker: MD Karina Polak (Katowice, Poland) Kozik A et al. Skin lesions in runners – systematic review. e-poster 1883
In this Olympic year, it was expected to read about some sports during this EADV congress.
I was very pleased to find that the polish team from Katowice performed an exhaustive review of the skin associated issues that can affect runners. An enormous range of dermatological changes can affect runners.
They mainly include:
Prevention strategies include properly educating runners, using moisture-wicking fabrics, applying anti-chafing products, maintaining good hygiene, wearing sunscreen, and staying mindful of environmental conditions to mitigate these risks.
Figure 1. Skin associated issues in runners
Speaker: Dr. Bruno Halioua (Paris, France)
Skayem C et al. Use of magnetizers and traditional healers by people with skin diseases: A worldwide study ALL Project. e-poster 3447
Musa BS et al. The use of non-conventional medicines among adult dermatology patients attending a tertiary facility in Northern Tanzania. e-poster 2740
Fikri C et al. Acute Localized Exanthematous Pustulosis induced by topical herbal medicine. e-poster 0243
El Fekih I et al. DRESS syndrome in a Chinese induced by Chinese herbal medicine. e-poster 0290
It is known that some patients may decide to turn to “alternative” or “complementary medicine” to treat their chronic conditions.
Healers and magnetizers are among those alternative healers that allegedly influence a person’s energy fields to enhance their health. A worldwide survey, including 20 countries and a representative sample of the general population of each country, enrolled 50,552 individuals, among which 35% (n=17,627) had one skin disease or more. Among these respondents, for the purpose of this study, the researchers analysed a population of 12,485 individuals. The main skin conditions were acne (35.6%), atopic dermatitis (AD, 20.1%), psoriasis (7.9%), rosacea (3.9%), vitiligo (1.4%) and hidradenitis suppurativa (HS, 0.8%). The researchers found that 3.1% of the respondents reported consulting magnetizers or traditional healers to treat their conditions. The use of magnetizers/healers was more frequent among the young and urban residents. The highest prevalence was in India (8%), UAE (5.2%), South Africa (4.9%); China (4%), Kenya (3.6%), South Korea (3.5%) and… France (3.4%). The prevalence in Europe was 2%. Patients with vitiligo and HS disease were most likely to go to magnetizers/healers. Thankfully, in most cases the use of a healer did not interfere with the medical management (66.3%).
It is notable that patients with vitiligo and HS are those who most turn toward those alternative healers. The explanation relies most likely in the lack of fully efficient therapies thus far in notoriously resistant diseases. With therapeutic progress, the patients might not go to those healers.
A second poster addressed similar issues in Northern Tanzania. A monocentric study showed that 35.5% of the respondents (out of 414) had consulted an alternative medicine provider for acne (64.7%), psoriasis (63.6%), AD (52.3%), pigmentary disorders (47.8%) and blistering disorders (43%). Alternative medicine included African traditional medicine and home remedies.
However, alternative medications such as phytotherapy/herbal treatments can be responsible for cutaneous side effects from various severity. This was illustrated by, on one side, a case of self-limited acute localized exanthematous pustulosis due to application of Capparis spinosa to treat sciatalgia on one leg and hip and, on the other hand, a case of DRESS syndrome that prompted hospitalization of the patient and supportive care with systemic corticosteroids after application and oral intake of Chinese herbal medicine preparation that contained 23 different ingredients!
Jain S et al. Characterizing disparities in dermatology publishing: a bibliometric analysis of authorship trends. e-poster 1888
Authors from low and low-middle income (LMIC) are underrepresented in medical literature. However, they belong to countries that share the highest burden of dermatological diseases. Authors value publishing in high impact journals to build scientific rapport and to showcase scholastic productivity, for academic promotion.
American authors undertook a bibliometric analysis to assess the top 6 dermatology journals based on cited impact factor (IF) and search for publications from 2018 to 2023. They extracted publications with authors from low-, low- and middle and upper middle/high income.
Over the last 6 years, only 12% of publications in the highest IF dermatology journals included ≥1 author from LMIC. Less than 10% of publications had an LMIC author in a first or senior position. The most represented countries were China, Brazil, Turkey and Mexico. Authors from LMIC were less likely to be listed as first or senior author.
There is an over-domination of China, India and Brazil.
Explanations for such discrepancies and underrepresentation of LMIC authors in high impact journals include:
Speaker: Dr. Nicolas Kluger (Helsinki, Finland)
Tattoos are getting increasingly popular. With almost 20% of adults having at least one tattoo, one of the issues that has arisen is the risk associated with moles. Tattooing on a melanocytic lesion can trigger traumatic clinical and histological modifications that will lead to excision and analysis to rule a malignancy. Large tattoos may cloud the proper surveillance of patients with atypical mole syndrome or numerous moles. Dermoscopy may be challenging due to the superposition of melanocytes and tattoo pigments.
Hopefully, the development of melanoma remains rare and is still considered to date as a fortuitous event. In almost 80% of the cases, melanoma developed de novo within the tattoos. Fortunately, not all pigmented lesions within tattoos are melanomas. Cases of seborrheic keratoses, warts and spitz nevus have been described. The main common-sense rule is to avoid getting a tattoo on any pigmented lesions. Besides, as a rule, tattoos should not be done over a preexisting lesion without diagnostic. Of course, surgical scar of melanoma should never be tattooed to allow clinical surveillance. In case of doubt, tattoo session should be postponed, or the customer should choose another area to get the tattoo and referral to the GP or the dermatologist is then warranted. Tattooists’ training is also important. Tattooists should be aware that skin lesions should not been tattooed without any medical evaluation. They should leave spaces if they are tattooing in the vicinity of tattoos and leave about 0.5 to 1 cm around each naevus. Thequestion of the role of tattooists in melanoma screening remains open but has also ethical limitations that need to be addressed.
Figure 2. Suggestion of (a) a decisional algorithm and (b) key points for the tattooist in case of lesion on area planned for a tattoo
Loubaris Z et al. Traction alopecia secondary to an oxygen mask in a child: a case report. e-poster 2164
Sharma A, et al. Traction alopecia in the paediatric Sikh population. e-poster 2020
Phiske M et al. Congenital triangular alopecia with eyebrow and lower eyelid alopecia: a hitherto unreported rare association. e-poster 2056
Mansour Billah L et al. Sisaipho: a rare presentation of Alopecia Areata. e-poster 2177
Pappa G et al. Alopecia areata in a pattern distribution: redefining sisaipho under a new pathogenetic perspective. e-poster 2104
Several posters reported surprising clinical presentations of hair disorders.
Loubaris et al. from Rabat, Morocco, reported the case of a 2-year-old girl that had developed areas of alopecia on the occipital and temporal areas. She also disclosed brownish spots on the cheeks and nose matching the mask. Medical history revealed that she has been wearing a high concentration oxygen mask for a week because of broncho-alveolitis. The authors concluded on the role of the oxygen mask in the occurrence of alopecia and diagnosed traction alopecia (TA). No biopsy has been performed and the evolution of the hair condition is unknown.
Sikhism is a monotheistic religion founded in the 15th century in Punjab, India. In Sikhism, uncut hair is considered a symbol of devotion and respect for God's creation. Sikhs keep their hair long, tend to tie them in a tight knot over the vertex and they cover their hair with a turban. Such constant hair style leads to TA in adult Sikhs. In a poster from the UK, the authors reported two paediatric cases of TA in Sikh boys aged 14 years-old with a notable recession of the fronto-temporal hairline and a fringe sign. Parents were advised to avoid putting the hairs in a tight knot for long periods of time, to let them loose as often as possibly open or in a loose bun or ponytail. Local minoxidil 2 or 5% can be tried to stimulate regrowth.
Sisaipho alopecia (“ophiasis” written backward, or ophiasis inversus) is rare clinical variant of alopecia areata (AA), that has been first described in 1996. It presents as a scalp hair loss sparing the temporal and occipital areas, with a possible centrifugal extension. It can be easily mistaken for androgenetic alopecia. So much so that some authors, like Pappa et al. have suggested to rename this clinical presentation “alopecia areata in a male or female pattern distribution” to allow a better recognition of this rare situation.
Involvement of eyebrows and eyelashes is infrequent. Conversely trachyonychia and comorbidities would be more frequent in those patients.
Lastly, Phiske et al. from Mumbai, India reported the case of an 8-year-old girl who presented with bilateral congenital triangular alopecia associated to lower eyelid eyelashes loss and patchy hair loss of both eyebrows.
Jachiet M et al. Dupilumab in Adult Patients with Moderate-to-severe Prurigo Nodularis: 6-months Real-world Follow-up Results from the French Early Access Program. e-poster 3056
Harrison K et al. Dupilumab Is Efficacious in Patients With Prurigo Nodularis Regardless of History of Atopic Comorbidities: Pooled Results From Two Phase 3 Trials (LIBERTY-PN PRIME and PRIME2). e-poster 3076
Prurigo nodularis (PN) is a skin condition characterized by intensely itchy nodules or bumps. It is often caused by chronic scratching due to severe itching, and has a notable impact on quality of life. Dupilumab, an IL-4/IL-13 antagonist, has been approved in the treatment of moderate (> 20 nodules) to severe (> 100 nodules) PN. In France, an early-access authorization allowed prescription of dupilumab in autumn 2022. A poster reported the results of 155 patients that received 600 mg dupilumab subcutaneously (initial injection) and then 300 mg every two weeks. Demographic, disease characteristics, efficacy and safety were evaluated.
Mean age of the cohort was 62.8, including 60% of women. 72% of the patients had comorbidities of any type but only 17% of the patients had atopic comorbidities (asthma, atopic dermatitis, conjunctivitis). Dupilumab has been discontinued only in 11%.
Overall, almost 40% and 73.5% of the patients reached an IGA PN-S score* of 0 to 1 at 3 months and 6 months respectively. Regarding itch intensity, the WI-NRS score (Worst Itch Numeric Rating Scale)** was initially at 7.1 and decreased to 3.5 and 2.8 at 3 months and 6 months respectively and a relative change from the baseline of -46.8% and -50.2% respectively. The quality of life has improved, as shown by the DLQI of 6.5 points and 8.4 points at 3 and 6 months respectively.
The most frequently reported adverse events were headaches and pruritus in 6.8% each.
The improvement in clinical outcomes and the safety profile of dupilumab were consistent with previous studies.
Of note, a pooled analysis of two phase 3 studies that assessed the efficacy of dupilumab (LIBERTY-PN PRIME and PRIME 2) showed that a history of atopic dermatitis had no influence on the outcomes.
*IGA PN-S ranges from 0 (clear, no nodules) to 1 (almost clear, ≤5 nodules), 2 (mild, 6-19 nodules), 3 (moderate, 20-99 nodules), and 4 (severe, ≥100 nodules).
**Worst Itch Numeric Rating Scale (WI-NRS) is a single-item, patient-reported questionnaire designed to measure an individual's “worst itch” (ie, intensity of itch) in the past 24 hours on an 11-point rating scale (with 0 representing “no itch” and 10 “worst itching imaginable”).
Barbarot S et al. Maternal supplementation with prebiotics during pregnancy regulates colonization of the microbiota of high-risk children, but does not prevent atopic dermatitis at one year of age. The PREGRALL multicenter randomized control trial
ETFAD - European Task Force of Atopic Dermatitis
The PREGRALL study is a French prospective randomised trial that evaluated the efficacy of a prebiotic in the primary prevention of the development of atopic dermatitis (AD) in 1-year-old infants.
A prebiotic is an undigested sugar that stimulates the growth or activity of beneficial intestinal bacteria. Prebiotics have direct effects on epithelial and immune cells, but also indirect effects via an increase in Bifidobacteria and Lactobacillus bacteria. Animal studies have shown that administration of prebiotics to pregnant mothers protects offspring from food allergies.
The hypothesis of the PREGRALL study was that taking prebiotics during pregnancy would modulate the foetal immune system and reduce the risk of developing AD in the child. However, it is known that taking prebiotics after birth has no effect on the prevention of AD.
This randomized study included 376 pregnant women at risk of AD in 2 groups: a placebo group (PBO) and a group taking the prebiotic from 20 weeks’ gestation until delivery (188 patients per group). The primary outcome was the prevalence of AD at 1 year of age.
There were no differences between the two groups in either the prevalence at 1 year of age (around 20% in both groups) or the severity of AD. Nor was there any difference according to whether the baby was born vaginally or by Caesarean section, according to breastfeeding mode or according to allergies. However, there was indeed a modification of the maternal microbiota, which was transmitted to the child at the start of life.
It appears that the prebiotic used in this study has no effect on the prevention of AD in the short term. The aim of the study is now to see the prevalence of asthma at 5 years of age.
Prof. Brigitte Dréno from Nantes (France) reported her experience with spironolactone for acne. Spironolactone (SPL) is among the current trendy drugs that can be given for acne patients.
SPL is a synthetic 17-lactone steroid that acts as an aldosterone receptor antagonist, a potassium sparing diuretic and an anti-androgen that targets the sebocyte, inhibits testosterone, dihydrotestosterone, and also 5-alpha reductase, and increase SHBG (sex hormone-binding globulin).
SPL is used at low dose in acne, between 50 and 150 mg daily, in the middle of a fat-containing meal. Patients with inflammatory lesions and previous treatment with isotretinoin respond better to treatment, while those with a contraception with intrinsic androgenic activity of progestin did not respond to the treatment.
Prof. Dréno provided reassuring data regarding safety and tolerance. Side effects of SPL are dose related. SPL is not associated with a risk of hyperkaliemia when prescribed to patients aged 15-45 yo. It is not associated with increased risk of thromboembolic events, breast or uterine tumours, or hypotension.
The best indications for acne patients are those with:
Patients with central hyperandrogenism like with hirsutism and alopecia are not a good indication for SPL.
A recent randomized double-blind trial comparing doxycycline with PBO5% 3 months followed by PBO alone and SPL 150 mg/daily + PBO 6 months showed that SPL
was 1.37 times more effective at 4 months, and significantly more at 6 months than doxycycline. However, doxycycline proved to be more rapidly efficient.
Adverse events were low, including dysmenorrhea.
Overall, there is a body of evidence supporting SPL in acne of women. It is an alternative to isotretinoin. It can also improve pre-pubertal acne, although less than for adults.
It is also important not to stop the treatment abruptly, but to decrease the dose by 25 mg after 6 months.
Speaker: Dr. Aaron Mangold (Scottsdale, United States)
Deucravacitinib in the treatment of lichen planopilaris - interim analysis.
Mahmoudi et al. Efficacy and safety of the oral Janus kinase inhibitor tofacitinib in the treatment of adults with lichen planopilaris: A randomized placebo-controlled trial. e-poster 2064
Lofti et al. Platelet-rich plasma as a new and successful treatment for lichen planopilaris: A controlled blinded randomized clinical trial. e-poster 2066
Lichen planopilaris (LPP) is a lymphocyte-mediated cicatricial alopecia that is difficult to manage and without any effective treatments. The etiology and scarring are poorly understood.
First line treatments include local and intralesional corticosteroids, followed by hydroxychloroquine, or systemic treatments like cyclosporine, mycophenolate mofetil or methotrexate.
In cutaneous lichen planus, type I and type II interferon pathways are thought to be accessible to JAK inhibitors. Besides, Th17 cells may play a role in the process.
Dr Aaron Mangold presented the interim results of a small open-label single-arm study that sought to evaluate the safety and efficacy of Deucravacitinib, a TYK2 inhibitor, in adults over 18 yo with a biopsy-proven active LPP. The dosage was 6 mg twice a day. PGA score, lichen planopilaris activity index (LPPAI) and other secondary measures, such as DLQI, and evaluation of itch or Skindex were analyzed. The endpoint of the study is planned at 24 weeks, but only intermediate results at 12 and 16 weeks were presented.
Ten patients have been included with a mean age of 61.4 years, 70% of women, all white. The median duration for the disease was 6.4 years.
Compared to baseline, there was a clear improvement of the LPPAI, with a drop from 3.8 to 1.6 (60% improvement) and 1.2 (70% improvement) at week 12 and 16 respectively. PGA score had also improved at week 12 and week 16. Deucravacitinib was well tolerated with no drug-related serious treatment-emergent adverse event, no discontinuation. 70% of the patients had acne. Deucravacitinib improved the disease activity and PGA in a small cohort of patients at week 12 and 16. Improvement is seen at 3-4 months. Additional comparative studies are needed to better assess safety and efficacy.
A randomized multicenter double-blind placebo-controlled trial from Teheran, Iran, included 37 patients (26 women; mean age 45 yo) attempted to assess the safety and efficacy of a JAK inhibitor, tofacitinib. However, the study took place during 2020-2022 and COVID-19 has clearly impacted the study, in the placebo group mainly.
Another study from Iran compared highly potent corticosteroid (clobetasol) with platelet-rich plasma (PRP) in combination with clobetasol in 24 participants. Interestingly the PRP group had better outcomes regarding LPPAI and patients’ satisfaction. Both treatments were well tolerated. The mechanisms of action of PRP in LPP are unknown. Work hypotheses include a stimulation of hair follicle stem cells and a reduction of inflammation. However, the results in the literature regarding PRP in LPP have showed mixed results. PRP may be of interest, but more robust data are needed to define its place in the arsenal against LPP.
Speaker: Dr. Martina L Porter (Boston, United States)
Ruxolitinib cream for mild-to-moderate hidradenitis suppurativa: 32-week data from a randomized phase 2 study.
Hidradenitis suppurativa (HS) is a debilitating inflammatory skin disease characterized by painful nodules, drainage and scarring in skin folds. Injectable adalimumab and secukinumab are currently the two biologics approved for the treatment of HS. Dysregulation of Janus kinase (JAK)-dependent signalling pathways is implicated in HS, therefore opening the possibility to explore the efficacy of JAK inhibitors.
Porter et al. reported results of a phase 2 study evaluating ruxolitinib cream 1.5%, a JAK1 and JAK2 inhibitor, twice daily in mild-to-moderate HS.
69 adults with Hurley stage I/II HS (mean age 29 yo, mainly women, without draining tunnels, and a total of abscess and inflammatory nodules of 3 to 10 (AN count, mean 5.4) were equally randomized in 1:1 to 1.5% ruxolitinib cream or vehicle (placebo) for a 16-week continuous twice a day treatment, after which all patients applied ruxolitinib cream twice as needed (AN count ≥1 and/or Pain NRS score ≥1) during a 16-week open label extension (OLE). Efficacy was assessed by:
Figure 3. Study protocol
The results are summarized as follows:
the change in baseline of the AN was of almost -3.95 at week 32. The proportion of patients achieving AN50, AN75, AN90 and AN100 was of 79%, 54%, 21% and 21% and 81%, 67%, 19%, and 19% at week 16 and 32 respectively. Over 80% of the patients achieved a HiSCR 50 at week 32. Ruxolitinib was well tolerated.
Application of 1.5% ruxolitinib cream through Week 32 of the OLE study period resulted in sustained or improved clinical signs of HS and was generally well tolerated. Ruxolitinib cream may be a novel approach to address an unmet medical need in the treatment of milder HS.
Speaker: Dr Ayelet Rishpon (Tel Aviv, Israel)
Skin problems in the transgender population
Speaker: Dr Nicolas Kluger (Helsinki, Finland)
Management of acne in transgender individuals
The number of people with gender identity issues seeking professional help increased dramatically in recent decade. In the US 1,3 M adults identify as transgender (Tg, 0,5%) and in the EU, there is about 1,5 M of Tg (Amnesty International, 2015). Transfeminine people (TgF) are people assigned male sex at birth and with a gender identity along the feminine spectrum (includes transgender women and may include non-binary people). Transmasculine people (TgM) are people assigned female sex at birth and with a gender identity along the masculine spectrum (includes transgender men and may include non-binary people as well).
Tg patients may be reluctant to seek medical care as they fear judgmental approaches and stigmatization. Besides, health care providers may not feel comfortable in managing Tg patients because of lack of training and knowledge. In dermatology, Tg patients may avoid skin examination (for moles for instance). Therefore, there is a need for creating an inclusive environment by posting non-discrimination statements, providing gender-neutral restrooms, using gender-neutral language etc.
Acne represents 80% of TgM with skin problems. In 70% of the case, acne is associated with testosterone intake, its overall prevalence is around 26%, with a delay of 12 months after testosterone initiation. Risk factors for acne include younger age at hormonotherapy, BMI, testosterone levels, smoking.
TgM develop hormonal acne in similar locations to other forms of androgen-dependent acne, on the lower third of the face, chest, upper arms, and back. Acne fulminans is rare and may occur with testosterone increase. Binder’s acne is a specific acne of the trunk due to the use of compressive garment to flatten the chest in TgM.
Management of acne in TgM is very close to cis-gender patients according to severity. The specificities include:
Figure 4. Therapeutic scale for treating acne in transgender individuals
The second dermatological complication is pattern hair loss (avoid using “male” or “female” pattern hair loss). Pattern hair loss is more common in TgM due to testosterone, with delay of onset after testosterone. It can be desired or not. Oral or topical minoxidil can be given for both Tg, 2.5 mg in TgM, 1,25 in TgF. Finasteride and dutasteride can be used as they don’t lower the level of serum testosterone. Some recommend waiting 2-5 years to allow for the development of secondary sexual characteristics. Consider gynecomastia, decreased libido and depression in TgM, but this is debatable. Spironolactone works well in TgF. It is contraindicated in TgM. Other treatments may include PRP, hair transplantation and hairline advancement for TgF.
Lastly, facial and body hair in TgF can be treated by laser hair removal and electrolysis. In TgM topical minoxidil may be used to improve facial hair growth.
Additional roles of dermatologist in gender transition include:
Speaker: Dr. Thibault Mahevas (Paris, France)
VEXAS syndrome (Vacuoles, Enzyme E1, X-linked, Autoinflammatory, Somatic mutation) is a severe autoinflammatory disease recently discovered in 2020. VEXAS syndrome is secondary to the acquisition of a somatic mutation in the ubiquitin-activating enzyme 1 (UBA1) gene in the myeloid lineage. There are 3 main loss of function mutations of UBA1 (c.121A> G; c.122T>C; c121A>C) that will lead to the accumulation of proteins triggering cellular stress and activation of immune pathways. Since its first description in 2020, about 300 cases have been described.
VEXAS occurs in men in 95% of the cases (as the disease is X-linked), with a mean age of 68 years, and combines systemic inflammation, haematological manifestations and inflammation of target organs, of which skin involvement appears to be the most frequent (85%) and often the first.
Haematological involvement included: cytopenia, macrocytosis (95%), myelodysplasia (25-55%) and monoclonal gammopathy.
Inflammation: Fever (65%), weight loss (55%) and elevated CRP (97%)
Other manifestations include relapsing chondritis, eye inflammation, lung inflammation, arthritis and increased risk of thromboembolism.
Figure 5. Manifestations of VEXAS
Interestingly, 20 years prior to its individualization, Camille Frances and Jean-Charles Piette from La Pitié-Salpetrière in Paris had reviewed the dermatological manifestations of 200 patients with relapsing chondritis and found that cutaneous manifestations during relapsing chondritis in male was associated significantly with a risk of myelodysplasia. It is highly possible that that subset of patients presented a VEXAS syndrome.
The cutaneous manifestations of VEXAS syndrome are heterogeneous, but frequent (83-89%) and can also be the first manifestation of the syndrome. The diagnosis of VEXAS should be considered in the presence of skin eruption consisting of multiple (> 10) pink or red inflammatory maculopapules and nodules, more rarely pustules, located on the trunk and limbs, sometimes on the face, particularly if associated with arciform lesions observed in a third of cases, in patients aged over 50 with signs of systemic or organ inflammation, or haematological abnormalities. Other symptoms include livedo, pathergy phenomenon, pseudo-cellulitis, and peri orbital oedema. Clinical phenotype and histological infiltrate vary according to genotype and aminoacidic variants.
Histological analysis of VEXAS cutaneous lesions reveals a typical neutrophilic dermatosis infiltrate, but from the histiocytoid Sweet syndrome type rich in immature myeloid cells, often associated with leukocytoclasia with or without vasculitis.
The concept of Myelodysplasia cutis illustrates that non-blastic cells at varying stage of differentiation can infiltrate the skin while a patient had myelodysplastic syndrome cells in the blood. Those patients have a tendency to corticoresistance and a higher risk of acute myeloid leukaemia.
Very recent studies showed skin of VEXAS and myelodysplasia cutis are both marked by the activation of inflammatory pathways related to cytokine signalling, interferon signalling especially.
The current management of VEXAS syndrome include as first line treatment oral corticosteroids, knowing that there is a corticodependence. In the absence of myelodysplasia, JAK inhibitors (ruxolitinib), tocilizumab and azacitidine are 2nd and 3rd line of treatment. In case of myelodysplasia, bone marrow allograft needs to be considered or Azacitidine.
VEXAS is an haemato-autoinflammatory syndrome related to clonal haematopoiesis and the concept of myelodysplasia cutis. The future of the management may rely in targeting the interferon pathway.
Bioderma Congress Reports EADV 2023
BIODERMA Congress Reports EADV Spring 2023
BIODERMA Congress Reports EADV 2022