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11 June 2015

WCD 2015 Vancouver - Tumours and nail psoriasis, male androgenetic alopecia, plantar warts, dermatoscopy and BCC, DL-PDT

Vancouver ranked as the 7th most livable city in the world! This news is on the front page here, and we can only agree, even though the congress participants had very little free time, given the variety of events and the schedule on this day of 11 June. Like every day, here is a summary of Thursday's highlights, with the report from our dermatologists' sessions. For information, the city of Tokyo came in 1st place, reminding us of last year's Bioderma World Rendez-Vous!

World congress of dermatology - Vancouver 2015


Diagnostic approach for a black band on a nail. Bianca-Maria Piraccini (Bologne). By Dr Florence Corgibet 

- Is the pigmentation caused by melanin in the nail or not? - If so, it is a case of longitudinal melanonychia (LM). How many nails are affected?
- If just one, is it combined with other nail damage that could explain the appearance?
- If not, it is a case of unexplained LM. Is it a child or an adult?
- If it is a child, simple monitoring is required (fewer than 10 worldwide cases of nail melanoma in children published)
- If it is an adult, apply the ABCDEF rule + dermoscopy
A for age - peak between 50 and 70 years- + Asian, African American, American origins
B for band: dark (brown-black), breadth (2 to 3 mm) and an irregular border
C for rapid change (proximal width of the band greater than distal width)
D for affected digit (first the thumb, then the big toe, then the index finger and especially the dominant hand)
E for extension (Hutchinson's sign)
F for family history 

Other tumours that can occur with a black band on a nail 12% of subungual epidermoid carcinomas occur as a periungual wart with a highly evocative longitudinal black band that requires a biopsy (B Richert – Brussels) Onychomatricoma (A Rubin – USA) can appear as an LM (23.3% of cases) when the tumour is in the nail bed but with thickening of the nail bed (Br J Dermatol 2015, May 12, epub ahead of print) Onychopapilloma including LM starts only after the nail matrix with clearly visible distal thickening with dermoscopy; the same is true for onychocytic matricoma, which is often mistaken for a foreign body (Rubin et al, JAMA 2014 ; 150).  

Local treatments for nail psoriasis. Dimitris Rigopoulos (Athens) By Dr Florence Corgibet

Statistically significant efficacy of tacrolimus with one application per day for 12 weeks in an open-label study in 21 patients versus the opposite hand used as the control (De Simone et al. JEADV 2013 ; 27 : 1003-6) Efficacy of IPL (Tawfik et al, Dermatol Surg 2014) in 20 patients treated every two weeks for 6 months especially with damage to the nail bed (71.2% versus 32.2% for matrix damage). Comparative study of IPL versus Excimer (long, time-consuming and ineffective) for this indication in favour of IPL (Al Mutain, Dermatol Ther 2014 ;4 :197-205). Formulations of local Methotrexate are under study (phase 2) to assess tolerance and therapeutic efficacy. May be an attractive alternative. 

Treatments for male androgenetic alopecia by Elise Olsen, USA By Dr Rémi Maghia 

Finasteride causes serum DHT to decrease by 70% whereas dutasteride causes it to decrease by over 90% (Olsen, 2006). And yet Olsen proved that the lowering of DHT in the scalp is correlated with an increase in hair count, for finasteride and dutasteride (Olsen, 2006). In terms of hair count, dutasteride 0.5mg performs better than finasteride 5mg and a placebo (Olsen 2006) and performs better than finasteride 1mg and a placebo (Harcha, 2014). Potential sides effects on spermatogenesis: seldom reported with finasteride 1mg; -25% at 52 weeks with dutasteride. Other comparisons, in order of increasing therapeutic efficacy: 2% minoxidil, finasteride 1mg, combination of finasteride 1mg + topical 2% minoxidil, finasteride 1mg + 2% minoxidil + Ketoconazole shampoo 2% 3x/week. In clinical trials, zinc pyrithione and ketoconazole 2% shampoos have shown to be helpful, by reducing hair loss, even in the absence of seborrhoea thanks to their anti-inflammatory action. Ketoconazole lotion is also thought to have an anti-androgen property: a 2007 Japanese study showed "remarkable" regrowth (daily ketoconazole lotion, 12 months). The Laser comb (LaserComb*): positive results versus a "fake device" in terms of hair count, Jimenez 2014 and Olsen 2002 studies. The LED and Laser helmet, 16 weeks of daily 25-min. sessions, efficacy versus "fake device". 


- With tinea capitis, dermoscopy and videodermoscopy are easy and rapid methods for making a diagnosis before the mycological sample result. The highly characteristics signs are comma hairs and corkscrew hairs. Also useful for monitoring treatment efficacy. -To facilitate the diagnosis of androgenetic alopecia (Bianca-Maria Piraccini-Bologne), whether female or male, it is necessary to compare, using dermoscopy, the homogeneity of hair diameter in the occipital area, rarely affected by AGA, with the heterogeneity of hair diameter (anisotrichia) in the anterior area which is difficult to identify without this comparison. When should trichoscopy be performed? At the time of diagnosis and during follow-up (every 6 to 12 months). Miniaturisation explains the diversity of diameters, but it should be noted that the prolongation of the so-called kinogenic phase induces the empty follicle phenomenon, because there is a lag phase without the rapid arrival of a new anagen phase in the follicle. In dermascopy, this lag phase is expressed as yellow dots, observed more often in males than in females in AGA. 

A technique for the simple treatment of plantar warts D.Ratod (Mumbai) By Dr Jean-François Sei 

The number of plantar wart treatments is a good indicator of the difficulties in dealing with this condition. A poster designed by Dipali Ratod and coll., from Mumbai, India, proposes a simple "needling" technique. 25 patients with at least 3 plantar warts which had evolved for more than 5 years and were resistant to the usual treatments were included in this study. Under local anaesthetic, the warts were repeatedly pricked with an 18G needle until this caused minor localised bleeding: 18 patients recovered after 3 weeks, with no notable adverse effects and no recurrence after 3 months; partial responses were observed in 5 patients and 2 were lost to follow-up. Another study conducted by Longhurst (J. Clin. Med. 2013,2,13-21) shows a recovery within 8 weeks in 69% of cases with 46 patients. This rapid, simple and inexpensive method is worth implementing in certain difficult cases and should be the subject of a controlled study. 

Dermatocopy and BCC– S. Ishizaki (Tokyo) By Dr Jean-François Sei 

A Japanese poster, designed by Sumiko Ishizaki and coll. from the University of Tokyo, compares the average diameter of the BCCs diagnosed in the Pre-dermoscopy Era (PE) (1998-2005) with that observed in the Dermoscopy Era (DE) (2006-2013): the difference is statistically significant with an average diameter of 13.3mm in PE versus 10.5mm in DE (p = 0.03) and a diameter of less than 15mm for 2/3 of the BCCs operated upon in PE versus 3/4 of the BCCs/DE. Of course, the dermatoscope is probably not the only factor responsible for this evolution but its early diagnosis efficacy certainly contributes to the treatment of smaller lesions. 

Efficacy of Day-light mediated PDT– C. Zachary (Irvine - California) By Dr Jean-François Sei 

Pr Chris Zachary pointed out during today's plenary session that "Daylight mediated PDT (DL-PDT)" is suitable for the treatment of mild to moderate AK. A chemical sunscreen must first be applied onto the areas exposed to the sun and ALA applied after skin cleansing and light curettage (or fractional laser treatment) of the lesions 60 minutes before exposure to light: the patient is then exposed to natural light for 2 1/2 hrs. The weather can be cloudy but not rainy. Imperative: the patient must not go out in the sun for the following 48 hours to avoid the risk of phototoxicity. This technique is far less painful than traditional PDT, requires no specific equipment and is just as effective as traditional PDT. He also presented the spectacular results achieved by picosecond laser in tattoo removal: this laser injects high levels of energy into the tissues, enabling the localised destruction of pigment granules with very limited reaction from the surrounding tissues.