We personally were relieved when the kids went back to school. Yes, we were worried about them catching coronavirus and passing it on and then we were worried about the societal impact of children going back to school and the numbers of cases escalating across the country as a whole. However, we are all learning to adjust to the new normal with many adjusting to the new work/working from home/life balance. On a personal front, we’re back to seeing patients in face-to-face consultations but the consultations take more time due to the new COVID regulations. Many conferences, meetings and teaching had originally been cancelled.
Then, since late August, there has been a real plethora of conferences that have become virtual and hence accessible. I have even started recording the GP lectures I normally do which are now available in my VIP club. I have now ‘attended’ three conferences virtually, having done so (from recorded lectures) in a piecemeal fashion either before work, during breaks or whilst making dinner. And even though I desperately miss the social aspect of meeting up with colleagues, it has shown that anything is possible. As Professor Simpson from Oregon said at the start of his lecture, “Let the learning continue…!”
So the best tit-bits?
There were lots of good bits but to distil it down to a select few.
It started with the Gerald Levine lecture by Professor Jean Krutmann hosted by the Royal Society of Medicine that took place while I was out of the country but I was able to watch a day later. It was about the role of air pollution and its effect on the skin.
What effect does air pollution have on skin?
It was interesting to have it explained that the main air pollutants are split into particulate matter, ozone and nitrogen oxide and these have different effects on the skin. Combustion particles, organic compounds and metals are all less then 2.5 microns in size and ultrafine particles are less than 100nm in size.
Traffic related air pollution causes increases in nitrogen dioxide and ultrafine particles but there is no mechanistic evidence that nitrogen dioxide can affect skin cells. However, chronic exposure to traffic related air pollution is associated with more flat brown marks on the face, so called lentigines.
[Peng F, Xue C-H, Hwang SK et al. Exposure to fine particulate matter associated with senile lentigo in Chinese women: a cross-sectional study. J Eur Acad Dermatol Venereol. 2017;31(2):355-360.]
Also, it has been shown that repetitive application of diesel exhaust particles to skin can induce darkening due to increases in melanin content.
[Schikowski T, Krutmann J. Air pollution (particulate matter and nitrogen dioxide) and skin aging. [article in German] Hautarzt 2019;70(3):158-162.]
What I thought was particularly interesting to hear in this lecture was that seasnakes that live in polluted habitats accumulate trace elements which causes them to significantly increase their melanin content and hence, makes them look darker. These toxins are expelled when they slough their skin.
[Goiran Claire, Bustamente P, Shine R. Industrial Melanism in the Seasnake Emydocephalus annulatus. Curr Biol 2017;27(16):2510-2513.e2.]
Lastly, ozone causes a different problem in the skin, namely coarse, facial wrinkles.
[Fuks, KB, Hüls A, Sugiri D et al. Tropospheric ozone and skin aging: Results from two German cohort studies. Environ Int. 2019;124:139-144.]
The next meeting was the ISAD meeting…
ISAD stands for the International Symposium of Atopic Dermatitis. These meetings are held around every 2 years and the last one I had managed to attend was in Sao Paolo in 2016. This year’s one was due to be in Seoul but was live streamed instead and had replay functions too. The attendees spanned from the US and across the globe to South Korea and Japan (some looking rather bleary eyed too!)
This was a useful meeting, informing us of the new drugs available for atopic dermatitis.
What drugs are there then?
In the UK, we have dupilumab, a drug for those with severe, widespread eczema refractory to conventional treatments. It blocks two cellular chemicals (or cytokines) called IL4 and IL13. It is licensed in the UK for patients aged 12y and over currently.
In the US, there are phase 3 trials for a similar type of drug called tralokinumab in adults with moderate to severe eczema. Tralokinumab only blocks IL 13. These trials are showing very promising results.
There are also trials for another group of drugs called Janus Kinase inhibitors (JAK inhibitors). These initially were found to have benefits in alopecia areata and vitiligo though have not yet been approved for their use in these conditions.
[Montilla AM, Gómez-García F, Gómez-Arias PJ et al. Scoping Review on the Use of Drugs Targeting JAK/STAT Pathway in Atopic Dermatitis, Vitiligo and Alopecia Areata. Dermatol Ther (Heidelb). 2019;9(4):655-683]
One JAK inhibitor, abrocitinib is also in phase 3 trials in adolescents aged over 12y and adults with moderate to severe eczema and has shown to have some good early results in reducing itch.
[Silverberg JI, Simpson EL, Thyssen JP et al. Efficacy and Safety of Abrocitinib in Patients with Moderate-to-Severe Atopic Dermatitis: A Randomized Clinical Trial. JAMA Dermatol. 2020;156(8):863-873.]
Another JAK inhibitor, upadacitinib is also in phase 2b trials and is also showing good early results in adults with moderate to severe eczema over the 16 weeks trial period.
[Guttman-Yassky Em, Thaçi D, Pangan AL et al. Upadacitinib in adults with moderate to severe atopic dermatitis: 16-week results from a randomized, placebo-controlled trial. J Allergy Clin Immunol. 2020;145(3):877-884.]
The main benefit of the JAK inhibitors over the IL4/13 blockers is that they are oral agents and can also be started and stopped and hence might be a better option for paediatric patients with moderate to severe eczema.
There are many more interesting things to pass on but they will have to wait for another time!
Dr Sandy Flann, Consultant Dermatologist.