09 June 2015
WCD 2015 Vancouver - APK in paediatrics, periocular cancer, rosacea and genital herpes
The World Congress of Dermatology is in full swing in Vancouver's Convention Centre, where dermatologists from all over the world are delighted to meet and exchange. The sun is out, but on the edge of the Pacific Ocean, what's important is inside! A lot of visitors to Bioderma's magnificent stand as well as people attending conferences, where a succession of speakers share their latest treatment research and feedback. We go to our special reporters for their daily selection.
The meaning of aquagenic palmoplantar keratoderma (APK) in paediatrics – Dr Lisa Weibel from Zurich (Switzerland) by Dr Florence Corgibet
The speaker presents the case of a 17 year old girl who was diagnosed with cystic fibrosis (CF) at age 2 and suffers from APK which appears after being in the water for 3 minutes, with a sensation of discomfort, tingling, burning and swollen fingers. She also presents with bulging nails. APK is found in 41% to 84% of CF cases. Finger "wrinkles" affect healthy subjects after being in the water for 11 minutes, but only after 3 minutes for CF patients and 7 minutes for healthy carriers. The neonatal screening for CF can overlook atypical or attenuated forms or healthy carriers. When a case of APK is discovered, and after ruling out other causes (marasmus, palmoplantar hyperhidrosis, atopic dermatitis and certain medicinal products: angiotensin-converting enzyme inhibitors, nonsteroidal anti-inflammatory drugs and COX-2 inhibitors), the "soft signs" of CF must be identified: chronic fatigue, chronic sinusitis, nasal polyps, abdominal pain, bulging nails, respiratory problems, infertility, etc., evidence of which should result in genetic screening. However, in the absence of an obvious cause and symptoms consistent with CS, nothing should be done under the age of 18 but, after this age, we recommend discussing genetic investigation with the patient. Botulinum toxin, urea creams, topical aluminium hydroxide or local corticoids can be used to treat APK. APK also helps test the efficacy of the Ivacaftor used in CF.
Ophthalmology in dermatology, the management of periocular cancer – Dr David Zloty from Vancouver (Canada) by Dr Florence Corgibet
A few figures to start with: basal cell carcinoma represents 80% to 95% of these tumours, while squamous-cell carcinoma accounts for 5% to 10%, sebaceous carcinoma 1% to 5% and melanoma 1%. It can be very difficult to diagnose and any lesion resistant to the symptomatic treatment (such as chalazion) or suspicious in any way should be immediately biopsied. The tell-tale signs include the loss of eyelashes, the presence of spreading erythema or telangiectasias, induration or thickening, bleeding, erosion or ulceration, indentations, particularly if symptoms persist for a long time. A yellowish tumour is evocative of a sebaceous carcinoma and should lead to testing for Muir-Torre syndrome. These tumours can be treated surgically with sufficient lateral margins, often via Mohs surgery in infiltrating tumours which are often far more invasive and widespread than suspected after the clinical examination. A study showed that an 8.4mn margin on average was necessary for Lentigo Maligna Melanoma(LMM) (4 to 19.5mn). Imiquimod must be reserved for a few carefully selected cases of LMM, cryosurgery by highly trained practitioners, radiotherapy for conditions contraindicating surgery. Additional explorations can be justified according to the diagnosis and extent (imaging, sentinel lymph node, etc.). The multi-disciplinary approach (oculoplastic surgeons, oncologists, etc.) is often invaluable for these tumours which, when poorly treated, particularly after inappropriate radiotherapy, can have dramatic consequences (exenteration, etc.).
Therapeutic management of rosacea, overview – Dr Diane Thiboutot, from Hershey, Pennsylvania (USA) by Dr Rémi Maghia
A Cochrane review of April 2015 lists the following as high quality evidence treatments: azelaic acid (topical), ivermectin (topical), brimonidine (topical), doxycycline, isotretinoin. Moderate quality evidence: metronidazole (topical), tetracycline (oral). Low quality evidence for: low doses of minocycline, laser and pulsed light therapy, cyclosporin ophthalmic emulsion for ocular rosacea.
Specific features of certain treatments. Oxymetazoline is an alpha1-adrenergic receptor agonist which induces vasoconstriction, currently under clinical trial. Post-marketing reports concerning brimonidine indicate a rebound effect of the erythema or contact allergy in 10% to 20% of patients. Carvedilol is a nonselective beta/alpha1 blocker. A small study reveals that its oral administration helped significantly improve the facial erythema within 3 weeks. Ivermectin cream was approved by the FDA as a treatment for rosacea in light of two 12-week randomised studies versus placebo. Two 48-week extensions of these studies showed additional improvement, with more than 70% improvement in the lesions. A European study shows the superior efficacy of an ivermectin 1% cream vs a metronidazole 0.75% cream.
Cochrane analyses of genital herpes treatments – Pr Olivier Chosidow from Créteil's Henri Mondor Hospital (France) by Dr Rémi Maghia
For the treatment of the common primary infection: orally, for 7 to 10 days, acyclovir (ACV) 200mg 5X/day, or ACV 400mg 3X/d, or valaciclovir (VCV) 1g 2X/day, or famciclovir (FCV) 250mg 3X/day. No difference found between the 3 medicinal products during a major randomised controlled trial. Topical forms are not recommended.
For preventing recurrences: ACV 400mg 2X/day, or VCV 500mg 1X/day, or VCV 1g x/day, or FCV 250mg/d, with periodic reassessment of the treatment (1 x/year). ACV, VCV and FCV perform better than the placebo in patients suffering from more than 4 annual recurrences. No superiority of one medicinal product over the other. To treat the recurrence of genital herpes: orally, 5 days of the following doses: ACV 200mg 5X/d, or ACV 400mg 3X/day, or ACV 800mg 2X/day, or VCV 1g/d in a single dose, or FCV 125mg 2X/d.
Shorter patterns: 2d of ACV 800mg 2X/d, or 3d of VCV 500mg 2X/d, or 2d of FCV 250mg 2X/d, or 1d of FCV 1g x 2.