12 June 2015
WCD 2015 Vancouver - Dermoscopy and inflammatory pathologies, alopecia in women, dermoscopy in scabies, dermoscopy and diagnosis, pigmented facial lesions
While the sun had been shining since the Congress began, a wind storm swept over a large part of British Columbia during the night from Thursday to Friday. Winds reached up to 90 km/h with substantial damage in Vancouver, uprooted trees and a large number of households with no power. At the Convention centre, the programme continued as planned and Friday was another day of valuable education. Here is a report from our on-site dermatologists…
Events at the World Congress of Dermatology By Dr Florence Corgibet
A reminder of where previous congresses were held:
“And now, ladies and gentlemen, the winner is …”:
The 24th World Congress of Dermatology will be held in Milan in 2019
Congratulations to Prof Brigitte Dréno who has been re-elected as Regional Director for Europe on the Board of the ILDS and nominated at the first board meeting of the ILDS for the position of Treasurer
3 French dermatologists are making a presentation at the World Congress: Sandra Ly, Jean-Michel Amici and Jean-François Sei. Bravo!!!!
"Inflammoscopy" or the application of dermascopy for inflammatory pathologies. Penny Poh Lu Lim (Australia) By Dr Florence Corgibet
3 criteria make it possible to distinguish the various inflammatory pathologies: the type of vessels and their layout, the colour of the scales and their layout, the background colour, and of course the patient history and clinical exams.
- Psoriasis: vessels in evenly distributed points, white central scales, light-red background
- Atopic dermatitis: vessels in points grouped together as plaques, yellow scales in plaques, dark-red background
- Lichen planus: vessels in points or linear at the edge, white lines (Wickham's striae) +/ widespread scales, purplish-red background
- Pityriasis rosea Gibert: several vessels in points at the edge, white scales distributed in a ring around the edge, yellowish-brown background
- Pityriasis rubra pilaire: linear and pointed vessels, round or oval yellow areas
Treating alopecia in women with low-dose minoxidil by mouth – Rodney Sinclair (Sydney) By Dr Rémi Maghia
His presentation was based on the fact that a certain number of women who have obtained very positive results with topical minoxidil for their androgenetic alopecia (AGA) were extremely disappointed to have to stop treatment due to contact eczema from the lotion. Therefore, he set out to come up with another way to retain the original efficacy. Oral MIN is an antihypertensive. For this indication, therapeutic doses start at 5 mg/day and can be increased up to 40 mg/day, with a maximum of 100 mg/day. Its side effects include cardiovascular issues, weight gain, sodium retention, temporary oedema, hypertrichosis (24% to 100%). The idea is to combine it with low-dose spironolactone: it is a sodium-sparing agent with anti-androgenic properties, sometimes used in the treatment of androgenetic alopecia in women.
100 women with AGA were treated for 1 year with capsules containing low doses of MIN and spironolactone. Clinical and biological checks every 3 months. Results: reduction in severity scores (average reduction of 0.85 after 6 months, and 1.3 after 12 months). Well-tolerated drop in BP. No hyperkalaemia or abnormal blood tests. 2 patients experienced urticaria. Treatment once per day by mouth with low doses of minoxidil and spironolactone appears safe and effective in treating AGA in women. A llb phase compared to placebo is being launched. Note that R. Sinclair has not published the doses... it's a secret... secret agent Sinclair...
New developments in dermoscopy for scabies (J. Yoshimizumi, Tokyo) By Dr Rémi Maghia
- Where should we look for signs of scabies with a dermatoscope? The palms, wrists, skin folds, between the fingers, absolutely. But above all, the mites are not in the papules, they are in the furrows.
- With no gel, to be done dry ("dry dermascopy"), the polarised-light dermoscope is the most suitable. Any liquid makes the furrow invisible as it erases the desquamation of the horny layer.
- The sign of a furrow! When a duck paddles on water, it leaves behind a v-shaped wake. In scabies, this V is found in the tail of the furrow. This ends up creating a Y, with the lower point indicating the progress made by the mite.
- Did you know? The furrow is 0.4 mm in diameter (= the diameter of the mite).
- A pitfall: a small bloody scab can imitate the mite, but is located outside the confines of the furrow.
- Don't rely on the usual dermoscopic signs in cases of hyperkeratotic scabies. They are concealed by the thickness of the scabs!!! A parasitological exam or biopsy is the answer.
The dermatologist who specialises in dermoscopy – Giuseppe Argenziano (Naples) By Dr Jean-François Sei
Giuseppe Argenziano explains the cognitive process of the Dermatologist who specialises in dermoscopy: according to him, the mental process unfolds in 3 stages: "Blink, Think, Compare".
"Blink" is the diagnosis in the blink of an eye: this instant recognition is based on experience gained over time. The grounds for the diagnosis are analysed later to support a diagnosis already made: this is the "Top to Bottom" reasoning, from the peak (the diagnosis) to the base (the grounds for the diagnosis). This is the recognition method used most frequently in everyday life, e.g. for diagnosing psoriasis or recognising an elephant...
"Think" is the second stage, required when there is no immediate diagnosis. This time, the semiology of lesions must be examined in detail to reach a diagnosis: this is "Bottom to Top", where the semiology (Bottom) leads to the diagnosis (Top).
"Compare" is the third step in the cognitive process: faced with a suspicious image which leaves some doubt as to whether it is benign or malignant, and in particular in the case of a "suspicious" naevus, a comparison with the patient’s other naevi provides additional information: if the patient only has one naevus of this type, this one is the ugly duckling, described clinically primarily but also relevant in dermascopy: here an excisional biopsy is a must. On the other hand, if the "suspicious" appearance is also found on plenty of other naevi in the patient, the lesion is most certainly benign and this reassuring comparison will have prevented an unnecessary excision.
He also gives some tips for distinguishing a recurrent naevus after excision (Acekerman's pseudomelanoma with its diagnostic difficulties) from a recurrent melanoma (RM): the recurrent naevus affects younger patients (on average 35 years of age versus 63 for recurrent melanoma) and recurrence happens sooner (8 months versus 25 months). The most common architecture in dermascopy features radius lines in RN and circles in RM (often Dubreuilh's melanoma). But the most relevant argument is the location of the pigmentation in the recurrence: for RN, the pigmentation remains in the scar, while it spreads outside the scar for RM.
Pigmented facial lesions – Iris Zalaudek (Austria) By Dr Jean-François Sei
Iris Zalaudek presented 2 new pieces of information related to pigmented facial lesions:
- Dubreuilh's melanoma (JAAD 2015) is found in different locations according to sex: in women, it is most often an isolated pigmented macule on the cheek while in men the most common locations are the tip of the nose, the preauricular and retroauricular areas and the scalp.
- A differential diagnosis between Dubreuilh's melanoma and pigmented actinic keratosis is challenging: in dermascopy, the follicular orifices look white in actinic keratosis due to the hyperkeratotic corneal plugs whereas they have a grey edge in Dubreuilh's melanoma because of the proliferation of malignant melanocytes: these grey circles are highly indicative of melanoma.
In all cases, Iris recommends avoiding the use of lasers or liquid nitrogen to treat any pigmented lesions for which there is even the slightest doubt as these methods could modify the natural history of the lesion and make a potential melanoma more aggressive: guided biopsy, preferably by the shave method (simple, quick, leaving barely any scar) makes it possible to clarify the diagnosis.