One in two people across Europe live with skin disease on a daily basis 

Almost half of people in Europe have declared at least one dermatological condition in the past 12 months, according to a new survey presented at the European Dermatology and Venereology (EADV) Congress 2021.

The Burden of Skin Disease in Europe survey is the largest ever undertaken of its kind in Europe. Data has now been collected from 44,689 adults from 27 European countries, including all countries from the European Union as well as the UK, Norway and Switzerland.

Preliminary findings show that among 21,401 members of the general population, 47.9% of people 18 years of age or older self-reported at least one skin condition.

On average, those people affected declared a median of two skin diseases. Projecting these figures to the total NEUKS (Norway, European Union, UK and Switzerland) population of 408 million inhabitants aged 18 years shows that more than 195 million adults in Europe self-reported at least one skin condition.

The most common skin conditions among those surveyed is fungal skin infection, affecting almost one in 10 people (9.07%).

Other common conditions, each affecting more than one in 20 people, were atopic dermatitis (eczema) (5.34%), alopecia (5.22%), and acne (5.49%). 

Other skin symptoms/unpleasant skin sensations including tightness and itch as a specific consultation request were reported by 20% of people 18 years of age or older.

The EADV, which undertook this study, said little was known about the prevalence of skin diseases in the general population across Europe. In addition, there is a lack of solid, objective and homogeneous data at the European level on the quality-of-life impact of skin diseases, including stigmatisation, or on the perception of and access to dermatologists.

The Burden of Skin Disease in Europe also aimed to understand the reasons for consulting a dermatologist. Other themes in the survey were: the impact of skin conditions on patients; the public perception of skin conditions; skin disease care pathways; prescribed treatment; and confidence in dermatologists.

Marie-Aleth Richard, Professor at the University Hospital of La Timone, Marseille and the EADV Board Member leading the survey, said: “The fact that one in two people across Europe live with skin disease on a daily basis makes the skin the most affected organ in the body and as an organisation we are therefore committed to making skin disease a public health priority."


New portable device could transform basal cell carcinoma treatment

A new prototype photodynamic therapy (PDT) device that can be used at home has the potential to transform how basal cell carcinoma (BCC) is treated globally, according to the results of a breakthrough pilot study presented at the EADV Congress. 

It found that PDT significantly reduces pain levels during treatment of BCC, while achieving efficacy comparable with a hospital stay.

The efficacy of PDT, a treatment that involves light-sensitive medicine and a light source to destroy abnormal cancer cells, for low-risk BCC has been proven through multiple studies. However, a need to reduce the pain experienced during treatment and the long hospital stay prompted the development of a new device, even before the Covid-19 pandemic.

Standard PDT treatment consists of two sessions performed within a hospital environment that usually requires a 1.5-2 hour wait with a one-week interval.

Ana Gabriela Salvio, lead author of the study, said: “The importance of a portable PDT device is crucial in its country of origin, Brazil, where many patients need to travel more than 300km to receive specialised dermatological treatment. However, the global pandemic accelerated the need to develop this at-home treatment element, which has the potential to impact the treatment of BCC internationally.”

A group of 15 BCC patients took part in the pilot study at Amaral Carvalho Hospital together with Sao Carlos Institute of Physics, in Sao Paulo State, Brazil. The first PDT session was performed at the hospital where a 20% methyl aminolevulinate cream was applied to the BCC lesion, which was then illuminated for 20 minutes with a commercial red light LED device.

Immediately after the first illumination, a light layer of cream was applied and the new portable irradiation device - the size of a coin - was fixed to the skin using medical adhesive tape. The patient was then sent home and advised to turn on the illumination after 1.5 hours and turn it off after two hours.

Pain was assessed every three minutes during the hospital PDT treatment session and self-reported every 20 minutes during home treatment on a numerical scale from 0 to 10. The median score values were compared between hospital and home treatments.

According to histological analysis, the clearance at 30 days after PDT was 86.67%, which is similar to standard PDT treatment, and the pain score was significantly lower for the PDT treatment performed at home [self-reported by the patients as a 1 for the first three measures and a 0 for the four that followed], as compared to 3-4 for the hospital treatment, suggesting that a more comfortable treatment with less pain is possible.

Ana Gabriela Salvio added: “Patients reporting much lower levels of pain from the at-home treatment is really encouraging, especially because it doesn’t come at the cost of efficacy.”

Following the success of the pilot study, a clinical trial with more than 200 participants has been approved. The new portable irradiation device is also in the process of being patented.


Researchers uncover link between genital warts and the immune system

New research reveals a link between genital warts and the human leukocyte antigen (HLA) system - the part of the immune system which helps regulate immune responses.

The findings presented at the EADV Congress suggest that genetic variants in the HLA system influence the risk of genital warts.

Condyloma acuminata, commonly known as genital warts, are a manifestation of human papillomavirus (HPV), presenting as soft fleshy growths that develop around the genitals or anus.

HPV is the most widespread and common sexually transmitted disease worldwide, with more than 80% of sexually active women and men expected to acquire at least one HPV infection by the age of 45 years – though most of these are normally short-lived infections without any clinical impact.

The HLA system is part of the genetic region which holds genes essential for normal functioning of immune response, helping to distinguish between ‘foreign items’ called antigens (which cause the body to make an immune response) and the body’s own cells.

All humans have genetic diversity in their HLA which means that responses to certain diseases are varied. When studying the association, researchers identified 12 protective gene variations (odds ratios (OR) 0.4-0.8) and seven risk alleles (OR 1.1-1.3) in their patient cohort. Individuals with risk alleles were less successful at recognising the HPV virus and therefore more likely to present with genital warts – conversely, participants with protective alleles had better immune responses and were more effective at recognising HPV, limiting the likelihood of presenting with condylomas.

“Condylomas is one of the most prevalent of all sexually transmitted diseases, but its association with the HLA system is poorly understood,” explains Dr Pernille Lindsø Andersen, PhD Fellow, Department of Clinical Immunology and Department of Dermatology at Zealand University Hospital in Denmark. “Our research identifies key immunologic features that prove there is a link between the immune system and condylomas.”

A cohort of 65,791 blood donors were examined, with 4,199 participants considered as condyloma acuminata cases and the remaining 61,592 participants used as a control group. Cases were defined as those registered with a minimum of one redeemed prescription of medication for condyloma acuminata or had a diagnosis of condyloma acuminata.

Genetic information (HLA types) and its association with being a case or control was assessed in all participants. Additional research is needed to determine whether protective alleles (HLA types) can recognise specific proteins made by HPV.


Treatment of chronic spontaneous urticaria in adults

New research presented at the EADV 30th Congress unveiled key insights on the characteristic differences in chronic spontaneous urticaria (commonly presented as hives) in children versus adults.

The findings reveal chronic spontaneous urticaria is less severe in children than in adults, with lower rates of angioedema and thyroid autoimmunity, supporting the idea that different management strategies may be required.

There is high prevalence of both acute and chronic urticaria in the general population, though the risk factors are unknown. Urticaria is characterised by a raised itchy rash (commonly known as hives) and occasionally angioedema, which is the rapid swelling of the skin. In chronic spontaneous urticaria (CSU) there is no specific cause or trigger, but hives are present on most days of the week, for six weeks or more.

Previously, it was thought that children were more likely to experience acute urticaria rather than chronic urticaria, but this study crystalises recent evidence to suggest that chronic urticaria is a common problem that affects children. There are also disparities between adults and children in terms of response to treatment, autoimmunity and disease course.

“CSU is a common disease found in both children and adults, though there are differences between the two patient populations with respect to medical origins and other co-existing diseases,” said Professor Emek Kocaturk, Koc University Hospital in Istanbul, Turkey.

“Our research is focused on identifying these differences to help inform future treatment of chronic spontaneous urticaria and to provide more information on the effects of CSU on children – something which has previously been neglected in this field of research,”

A retrospective analysis of 755 CSU patients (171 children, 580 adult) was conducted, with a comparison of the data performed to determine distinct characteristics between paediatric versus adult CSU patients.

Findings of the study include shorter disease duration (10.0±18.2), lower occurrence of angioedema (21.8% vs 59.8%; p<0.001) and thyroid autoimmunity (8.9% vs 25.4%; <0.001) in the paediatric group vs. adult group.

Moreover, paediatric CSU patients were found to respond better to antihistamines than adult CSU patients. Resistance to antihistamines was associated with anti-TPO (the most common anti-thyroid autoantibody) positivity (p=0.02), presence of angioedema (p=0.01) and eosinopenia (an indicator of blood disorder; p<0.001) in the paediatric group while it was only associated with eosinopenia (p=0.03) in the adult group. 


Skin cancer detection apps are failing to detect life-threatening cancers

Rare and aggressive skin cancers were incorrectly classified as low-risk by machine learning models for detecting skin cancers, according to a new study presented at the EADV Congress 2021.

The research suggests that making apps based on such models available directly to the public without transparency on performance metrics for rare but potentially life-threatening skin cancers is ethically questionable.

Researchers in London focused on two types of skin cancer, Merkel cell carcinoma (MCC) and amelanotic melanoma, both of which are rare but particularly aggressive cancers that tend to grow fast and require early treatment. They created a dataset of 116 images of these rare cancers and of the benign lesions seborrahoeic keratosis and haemangiomas, and assessed these images with two machine-learning models.

The first model studied was a certified medical device, directly sold to the public via the App store and advertised as being able to diagnose 95% of skin cancers (Model 1). The second model was available for research purposes only and used as a reference (Model 2).

The results showed that Model 1 incorrectly classified 17.9% of MCCs and 22.9% of amelanotic melanomas as low-risk. In turn, 62.2% of benign lesions were classified as high risk. For detecting malignancy, Model 1’s sensitivity was 79.4% [95% confidence interval (CI) 69.3-89.4%] and specificity was 37.7% [95% CI 24.7-50.8]. For Model 2, MCC was not included in the top five diagnosis for any of the 28 MCC images analysed, raising the possibility that the model had not been trained that this disease class exists.

Study questions the safety of artificial intelligence models

The high false positive rate of Model 1 has potentially negative consequences on a personal and societal level. The results pose a bigger question of the safety of other artificial intelligence (AI) models for detecting skin cancer available on the market.

Lloyd Steele, lead author of the study at the Blizard Institute, Queen Mary University of London, said: “In order to improve, machine learning model evaluations should consider the spectrum of diseases that will be seen in practice. At the moment, most of the performance of those models is driven by the imaging data available, which is particularly scarce when it comes to rare skin cancers.”

A global collaboration between research groups and hospitals can be a step towards tackling the gap of skin cancer imaging data, which is a crucial element for a high-performance rate of machine learning.

Marie-Aleth Richard, EADV Board Member and Professor at the University Hospital of La Timone, Marseille, said: “The number of skin cancer detection apps available for consumer use is growing, but as demonstrated in this research, there must be more transparency around the safety and efficacy of these apps. Furthermore such devices detect only what they are shown to analyse and do not make systematic analysis of all the skin’s surface. Failure to be transparent could put lives at risk.”


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