Aussies lobby and learn at #AAD19


The American Academy of Dermatology (AAD) Annual Meeting was held in Washington DC this year and for the estimated 20 Australians who attended there was more on the program than educational sessions.

Associate Professor Stephen Shumack, from Central Sydney Dermatology, was one of the attendees and shared his perspective on some of the highlights with the limbic.

He said Sydney is one of six cities bidding for the International League of Dermatology Societies (ILDS) World Congress of Dermatology for 2023.

The decision – between Beijing, Dubai, Guadalajara in Mexico, Rio de Janeiro, Singapore and Sydney – will be made at the Milan World Congress in June, so there was important networking to be done at AAD.

“It’s a big field so there was a lot going on from the bidding point of view and the Australians that went helped greatly as part of that bid process,” Associate Professor Shumack said.

Read more about the bid to bring World Congress 2023 down under.

Skin cancer

In one of the plenary sessions, Dr Paul Nghiem, from the University of Washington, received the Eugene J Van Scott Award for Innovative Therapy of the Skin and presented the Phillip Frost Leadership Lecture.

Associate Professor Shumack said the topic – Merkel cell carcinoma (MCC) – was of particular interest in Australia where about 80% of cases are related to sun exposure and reduced immunity. In the US, more cases of Merkel cell carcinoma are related to the Merkel cell polyomavirus.

“In Australia over the last decade or so, we have been more attuned to treating MCC with radiotherapy very quickly after the diagnosis. Whereas in other places in the world, including the US, what they have done is treat with quite extensive and widespread surgery and then 6-8 weeks later with radiotherapy.”

However Dr Nghiem has now basically backed the Australian approach.

“What he was saying is that big surgery is out and the main reason is because it delays radiotherapy and radiotherapy is probably the most important part of the treatment for MCC to prevent recurrence and spread to other areas.”

“So do minor surgery with primary closures and then irradiate as quickly as possible,” he said.

Associate Professor Shumack said the meeting was also told that the jury was still out on when to follow-up MCC.

However patients with the virus and a low level of antibodies to the virus were at a higher risk of recurrence and should be followed up more frequently than patients with high antibody levels.

Hair loss

Associate Professor Shumack said the meeting heard the jury was also still out on the use of platelet-rich plasma for hair loss.

As well, there was some debate about whether the controversial Post-Finasteride Syndrome (PFS) actually exists in men treated with the drug for male pattern baldness.

“There is some suggestion that this may cause impotence or sexual dysfunction, further down the track in a group of males.”

However the study that demonstrated this was possibly a skewed cohort of subjects taken mainly from men already engaged with PFS advocacy and support.

“So there is still no hard evidence at all that PFS actually exists.”

Associate Professor Shumack said there was obviously a lot of work being done on both topical and oral JAK inhibitors for alopecia areata.

“They work in about two thirds of patients but it seems they only work when you are taking them and there is still not a lot of evidence about applying them topically.”

“Watch this space. JAK inhibitors are currently still very expensive but may be a good treatment further down the track if the price comes down.”

He added that JAK inhibitors were also being used for vitiligo and there were some studies in atopic eczema as well.

Antibiotic resistance

Delegates were reminded that there were probably millions of patients having illnesses related to antibiotic resistance in the US each year.

“It’s becoming more of a problem and because dermatologists use a fair number of prescriptions for antibiotics, particularly tetracyclines for our acne patients, we need to be aware.”

“This is one of the reasons we combine antibiotic treatment with topical agents such as benzoyl peroxide which has antibacterial activity, and that we should limit the amount of time we use antibiotics to six months maximum. If they don’t work [in that time], use another treatment.”

“It was basically confirming what we have come to know over the last few years.”

He added that new antibiotics in the pipeline may over the next few years allow for more specific treatments with topical agents rather than oral agents such as doxycycline and minocycline.

Biologics

Associate Professor Shumack said biologic agents were deemed to be safe in the context of treating psoriasis.

“There is perhaps a slight increase in malignancies in psoriasis patients with the TNF blocking agents but it is really quite slight and there is no increased risk with the newer IL-17 and IL-23 targeted agents.”

“There might even be some theoretical reason that blocking IL-17 and IL-23 might be protective against the development of malignancy.”

“In fact comparing to methotrexate and cyclosporine which were the old systemic agents that we used to use in patients with severe psoriasis, both of those are associated with a significant risk of developing other malignancies e.g. non-melanoma skin cancers, melanoma, lung cancers, lymphomas and other solid organ cancers like bowel cancer.”

He said dupilumab, which is approved but not yet subsidised in Australia for atopic eczema, was just the beginning of the biologic agents for this indication over the next 5 to 10 years.

“Quite a number of agents are being investigated including those targeting the IL-31, IL-33 and OX4OL pathway, and also some other intracellular targets such as the JAKs and PD4 blocking agents and a new group called the histamine 4 receptor antagonists which are supposed to be very good for itch.”

“So there is a huge amount of work going on at the moment in Phase 1, 2 and 3 studies for more systemic treatment for atopic eczema.”

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