News and Highlights from Dermatology
Largest European dermatology congress to present new trends in diagnosis and treatment of skin diseases
Oct 8, 2010 – Gothenburg. For the first time ever hosted in Sweden, Europe’s largest dermatology congress opens its doors on October 6, 2010. Almost 6,000 dermatologists, researchers and scientists from all around the globe come to join the 19th Congress of the European Academy of Dermatology and Venereology (EADV) in the Swedish Exhibition and Congress Centre Gothenburg, and to discuss the latest trends in the diagnosis and treatment of skin diseases, giving justice to the congress motto „Making waves in dermatology“. Dedicated to presenting the most recent developments in clinical as well as experimental dermatology and venereology, the programme includes lectures, symposia, workshops, and courses for both office and hospital based dermatologists and venereologists until 10 October 2010.
„Dermatology and Venereology has a more than 100 year old tradition in Sweden“, says Congress President Professor Olle Larkö. „Swedish clinical research is of an especially high class. Dermatology and Venereology are among the specialties in Sweden that are growing in competitiveness.“
Novel diagnostic tools for skin cancer, the alarming increase in HIV prevalence and the challenges of early HIV diagnosis as well as new findings for a better cosmetic use of Botulinum Toxin are among the key issues of the EADV Congress. Moreover, the meeting will provide insights into recent advances in dermatosurgery, new therapies of immune-mediated skin disorders, as well as an update on dermatoscopy and aesthetic dermatology.
Alarming increase in skin cancer incidence
Despite substantial efforts in prevention, the incidence rates of skin cancer continue to increase all over the world. Especially, the melanoma increase is alarming, but also squamous cell carcinoma is increasing. The latter is of special concern among patients having undergone heart, lung or kidney transplantation. The risk increase may be 100-fold.
Focus of research lies in better diagnosis with new image analysis and improvement of treatment options. Recently, photodynamic therapy has evolved as a promising alternative, especially in the organ transplant population. It is important that patients are allowed to see a dermatologist primarily, as recent data demonstrate better diagnosis and lower cost for society if patients may seek a dermatologist without passing a general practitioner first.
Botulinumtoxin: Lessons from the past and promises for the future
The cosmetic use of Botulinum Toxin-A (BoNT-A) continues to increase since its approval some years ago, and is now the most commonly performed cosmetic procedure worldwide. According to recent data, BoNT-A was used approximately 3.2 million times in 2006, while in 2009 the number went up to approximately 4.8 million in the USA - more than twice as frequently as administration of hyaluronic acid based fillers. In Europe, BoNT-A treatments were almost tripled in the last 4 years. More than 80 per cent of patients using Botulinum Toxin-A are satisfied with the results. Improving the degree of satisfaction and treatment outcomes depends on adequate dosing, proper consultation, adequate injection techniques and setting realistic expectations.
Other than the commonly treated glabellar lines BoNT-A has been gradually used in the treatment of horizontal forehead rhytids, periorbital lines (crows feet) and the central lower eyelid to widen the eye. Now, apart from the upper face, BoNT-A injections are used for many other applications such as nasal wrinkles on the dorsum of the nose (bunny lines), fine wrinkles around the lips, chin dimpling and platisma bands. BoNT-A is not only a cosmetic privilege for females: in 2009 more than 300,000 males have been treated in the US with BoNT-A for cosmetic reasons.
Future goals are to perfect the technique and expand the use of BoNT-A to other indications, and to combine BoNT-A with fillers and other cosmetic procedures towards perfectionism.
Stem cells: therapeutic use in dermatological diseases
Exciting developments in stem cell research may have major implications in the comprehension and therapeutic approach of many dermatological diseases, including wound healing, cancer, cell and gene therapy. The recent use of allogenic transplantation of bone marrow or mesenchymal stem cells as well as the use of ex vivo autologous stem cell gene therapy to treat disabling dermatological diseases opens new avenues.
In regenerative medicine, stem cells are viewed as a tool to improve tissue renewal, repair and regeneration. One can envision manipulating stem cell fate either by designing new drugs that will impact stem cell migration, proliferation and lineage specification in vivo, or by designing culture conditions favouring ex vivo stem cell expansion, in combination with efficient transplantation and engraftment.
Future development includes manipulating stem cell fate by reprogramming using defined factors usually a combination of transcription factors and/or cell signaling inhibitors (Silva et al., PLoS Biol 2008).
Reprogramming of adult cells to ground state pluripotency (induced Pluripotent Stem Cells - iPS) has been achieved by means of defined factors (Takahashi and Yamanaka, Cell 2006). Similarly, reprogramming of adult pancreatic exocrine cells to b-cells (Zhou et al., Nature 2008) or of fibroblasts to functional neurons (Vierbuchen et al., Nature 2010) has been reported.
Manipulation of the stem cell niche, i.e. the environment in which a stem cell lives, is an alternate route to gain knowledge in stem cell fate. However, one should keep in mind that, in a clinical situation, the niche is likely to be diseased, if not completely absent, e.g. in extensive third degree burns.
Several reports have suggested that stem cells have some degree of plasticity, meaning that they can broaden potency (the range of commitment options available to a cell) in response to physiological demands or insults (Smith Nature 2006; Bonfanti et al., Nature 2010). Stem cell plasticity has generated a lot of hope and controversy. Even so, the capacity to take advantage of stem cell “plasticity or transdifferentiation"? may have great therapeutic interest, (Slack, Nat Rev Mol Cell Biol 2007).
Jonathan Slack, Director of the Stem Cell Institute, University of Minnesota: “Transformations from one tissue type to another make up a well established set of phenomena that can be explained by the principles of developmental biology. Although these phenomena might be rare in nature, we can now imagine the possibility of deliberately reprogramming cells from one tissue type to another by manipulating the expression of transcription factors. This approach could generate new therapies for many human diseases"?.
HIV is here to stay
HIV is not as “obvious"? now as it was 20 years ago when high profile celebrities were dying with lots of media coverage. Yet the numbers of new cases of HIV continue to increase at alarming rates throughout Europe. Now most patients can be managed with anti HIV drugs if diagnosed early enough. But therein lies the problem! Early diagnosis is not happening.
Almost half of new HIV positive diagnoses are in patients who have had the infection for years but have never been tested. Even when patients become unwell doctors are still not considering HIV in the differential diagnosis. We see many cases of patients who have been attending doctors with various conditions that should have raised the possibility of HIV but the opportunity of HIV testing was missed. When the patient finally becomes seriously unwell the diagnosis is usually made but by then there is significant immune system damage that can never be recovered fully. Also, the patient may now have unknowingly passed the virus on to loved ones.
As dermatovenereologists we are ideally placed to make early diagnosis, as many patients present to sexual health clinics for routine check-ups and as dermatologists we often see early signs of HIV as it always causes skin problems, i.e. shingles, seborrhoeic dermatitis, worsening eczema or psoriasis, multiple or giant molluscum contagiosum.
The EADV wishes to highlight the ongoing HIV problem and bring to the attention of the public and doctors that early diagnosis is essential. This can only be achieved by greater awareness of manifestations of HIV and normalising HIV testing so it becomes routine in any sick patient – irrespective of their sexual orientation.
Multiresistant bacteria: an increasing problem not only in dermatology
Multiresistant bacteria are an increasing problem not only in dermatology but in all area of both human and veterinary medicine. The bacteria responsible for the majority of skin infections are Staphylococcus aureus, Streptococcus haemolyticus, Pseudomonas aeruginosa and Propionibacterium acnes. Impetigo, folliculitis, furunculosis, atopic dermatitis, erysipelas, Staphylococcal Scalded Skin Syndrome (SSSS) and acne vulgaris are among the most important skin infections and other skin diseases where microorganisms play an important role.
Antibiotics can destroy bacteria in many different ways: they affect the synthesis of the cell wall; they change protein synthesis; folic acid synthesis; DNA and RNA-synthesis, and they destroy the cell membrane.
Bacteria can become resistant to antibiotics: Penicillinase production by S. aureus, Meticillin Resistant S. aureus (MRSA), Fucidin Resistant S. aureus (FRSA), Vankomycin Resistant Enterococci (VRE) and Extended Spectrum Beta Lactamases (ESBL).
In dermatology an increase in P. acnes resistant to tetracycline is a growing problem. MRSA is also a growing problem and today it is not only a bacterium that you will find in hospitals but also in the community (CA-MRSA). In Sweden we have an increase from 315 patients per 100,000 inhabitants in the year 2000 to 1307 patients per 100,000 in 2008. Compared to many other countries, e.g. the USA, this number is still low.
The first report about FRSA came from Norway in 1995, and soon after they were reported also in Sweden. This was from a clone of S. aureus that produced bullous impetigo. However, soon after FRSA was also reported in patients with other forms of impetigo and atopic dermatitis. In a study Sahlgranska Hospital, finished in 2008, 32 per cent of S. aureus in regular impetigo were FRSA compared to 75 per cent in bullous impetigo and 6.1 per cent in atopic dermatitis.
It is important to learn how to handle patients with MRSA correctly. Fucidic acid should not be used topically and tetracycline should only be given in 3 months courses for the treatment of acne.
The metabolic syndrome in psoriasis patients
The perception of psoriasis has changed dramatically over the past decade. From being regarded as a disease confined to the skin with occasional joint complaints, psoriasis is now perceived as a systemic immune-mediated disorder.
Current research has shown that psoriasis is associated with a considerable co-morbidity affecting several organ systems, and that patients with severe psoriasis have a highly increased risk for cardiovascular events and mortality. The underlying pathogenesis linking psoriasis and cardiovascular disease is the focus of intense investigations. Psoriasis is linked to the metabolic syndrome with obesity, insulin resistance and hyperlipidemia, to which are added environmental and life style risk factors such as smoking. Whether the psoriatic inflammation actually drives the cardiovascular risk or if these are parallel processes is as yet not clear. The potential impact of effective anti-inflammatory treatment may provide clues in this regard.
European Academy of Dermatology and Venereology (EADV)
The European Academy of Dermatology and Venereology is Europe’s leading professional organization for dermatology and venereology. Founded in 1987, EADV is a non-profit association whose mission is to advance excellence in clinical care, research, education and training in the field of dermatology and venereology. www.eadv.org
More detailed information on the congress are available on the Internet: www.EADVGothenburg2010.org.