Australasian College of Dermatologists 41st Annual Scientific Meeting

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Australasian College of Dermatologists 41st Annual Scientific Meeting Expert Rev. Dermatol. 3(4), 433–436 (2008)

Alex J Chamberlain Department of Dermatology and Victorian Melanoma, Service, The Alfred, Commercial Road, Prahran, VIC, Australia Tel.: +61 398 229 944 Fax: +61 398 227 090 [email protected]

Australasian College of Dermatologists 41st Annual Scientific Meeting Sydney, NSW, Australia, 17–21 May 2008 The 41st Annual Scientific Meeting of the Australasian College of Dermatologists was held at Darling Harbor (Sydney, NSW, Australia) on 17–21 May, 2008. Approximately 400 dermatologists and dermatology trainees enjoyed an excellent scientific and social program. The visiting Professor was Ilona Frieden (Professor of Pediatrics and Dermatology, University of California San Francisco, CA, USA). Other notable speakers included Jean Krutmann (Department of Dermatology and Environmental Medicine, Heinrich Heine University, Dusseldorf, Germany), Richard Gallo (Division of Dermatology, University of California, San Diego, CA, USA), Ash Marghoob (Memorial SloanKettering Cancer Centre, New York, NY, USA) and Suzanne Kilmer (Laser and Skin Surgery Center of Northern California, University of California, Davis School of Medicine CA, USA). Pediatric dermatology

Ilona Frieden (Professor of Pediatrics and Dermatology, University of California San Francisco, CA, USA) gave a number of excellent presentations on her areas of interest. These presentations included an update on hemangiomas, highlighting the major advances in the understanding of the origin and pathophysiology of these childhood tumors. She highlighted particularly the characteristics and associations of segmental hemangiomas. Her illustrative neonatal cases were well received, as was her advice on managing challenging scenarios in the newborn, such as pustular eruptions and blistering. In another session, she spoke about nevoid birthmarks and reminded us of the correct terminology and variety of bizarre patterns of distribution as fi rst outlined by Happle. Anne Halbert (University of Western Australia, Perth, WA, Australia) spoke on the challenges of managing atopic eczema and had some sound tips. She listed poor compliance, unrecognized aggravating factors and severe disease resistant to topical therapy as the major reasons why treatment fails. She felt that house dust mite immunotherapy did not tend to help severe eczema but could sometimes aid mild-to-moderate eczema. Azathioprine was favored over cyclosporine as a systemic agent for severe disease owing to the www.expert-reviews.com

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sustained remission that can be achieved in a high proportion of children. The risk of lymphoma when azathioprine is used as monotherapy is low and estimated to be approximately 1:1500. Basic skin biology & novel therapies

Jean Krutmann (Department of Dermatology and Environmental Medicine, Heinrich Heine University, Dusseldorf, Germany) enlightened the audience with his overview of the biochemical basis of photoaging, highlighting, in particular, the influence of near-infrared radiation (IR-A). IR-A deeply penetrates the skin with more than 65% reaching the dermis, causing direct mitochondrial damage. Richard Gallo (Division of Dermatology, University of California, San Diego, CA, USA) gave a number of presentations on the various antimicrobial peptides (canthelicidins) found in skin and their alterations in a range of infl ammatory dermatoses. Diona Damian (Department of Dermatology, University of Sydney, Royal Prince Alfred Hospital, Sydney, NSW, Australia) presented the results of a study of ultrasound therapy for lipodermato sclerosis with substantial improvement after a few weeks. Importantly, this therapy can be administered by physiotherapists.

© 2008 Expert Reviews Ltd

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Vulval dermatology

The vulval interest group met and heard some interesting presentations. Darion Rowan (Manukau Health Trust, Manurewa, Auckland, New Zealand) presented a number of subtle vulval cancers and illustrated that these may simply manifest as an area of thickening, patchy hyperkeratosis or masquerade as multifocal pigmented papules. Thierry Vancaillie (Royal Hospital for Women, Sydney, NSW, Australia) presented his interesting work in the field of vulval pain. He outlined the differentiating characteristics of neuropathic versus myalgic pain and suggested that reproducible pain on ischial spine pressure (Tinel’s sign equivalent) indicated pudendal nerve entrapment and that these patients responded best to botulinum toxin injections. In his experience, this technique was effective in 60% of cases. Gayle Fischer (Royal North Shore Hospital, University of Sydney, Sydney, NSW, Australia) presented her experience in the management of desquamative infl ammatory vaginitis and highlighted a novel association with chronic diarrhea. Contact dermatitis

Rosemary Nixon (Occupational Dermatology Research and Education Centre, Skin and Cancer Foundation, Carlton, VIC, Australia) presented data from her ‘Skin Watch’ project, which focused on identifying reasons why occupational dermatitis might persist. The key reasons included an incorrect diagnosis, ongoing exposure to an allergen and inadequate therapy. Patients diagnosed earlier and those who had retained the advice given in the clinic had better outcomes. Interestingly, healthcare workers were particularly poor in complying with advice regarding ongoing avoidance of exposures. Chee Leok Goh (National Skin Centre, Singapore) presented a fascinating personal series of toxic epidermal necrolysis due to organic solvent exposure (trichloroethylene). This agent is used in the metal and electronic industry. The affected patients tended to be slow acetylators and all had concomitant hepatitis. Ocular pearls for dermatologists

A number of presentations were given by oculoplastic surgeons and ophthalmologists that focused on tips for surgery in the region and the various ocular side effects of a number of common dermatologic drugs; ocular rosacea was also discussed. In particular, Anthony Maloof (Sydney Eye Hospital and Skin and Cancer Foundation, Westmead, Sydney, NSW, Australia) illustrated how forgiving periocular skin was and that relaxed skin tension lines could often be ignored. He recommended that lubricating ointments and eye shields always be used for periocular surgery. Alternatively, the lids can be sutured closed during a procedure. Paul Salmon (Tauranga, New Zealand) advocated overcorrecting lower lid margin closures to avoid ectropian. Con Petsoglou (Save Sight Institute and University of Sydney, Sydney, NSW, Australia) spoke on the effects of retinoids and steroids. He highlighted that a significant number of patients (up to 40%) on oral retinoids experience dry irritable eyes and that this symptom may, occasionally, persist permanently. He also indicated that night blindness occurs in up to 4% of patients taking isotretinoin 1 mg/kg. Steroids on 434

the other hand can also have significant adverse effects, ranging from posterior subcapsular cataracts to herpetic keratitis, ptosis, glaucoma and, most significantly, retinal artery occlusion with intralesional steroid injections to periorbital skin. Ocular rosacea occurs in over 50% of patients with rosacea and is also important for the dermatologist to identify. This occurs more so in flushers and can occur independently of cutaneous involvement. Examples of more severe cases were presented, including visionthreatening corneal neovascularisation and corneal perforation. He emphasized that the key reasons for referral were redness or discomfort, the presence of obvious corneal signs or children who are particularly at risk of blepharokeratoconjunctivitis. Nonmelanoma skin cancer

The management of skin cancer always features prominently at Australian meetings and this was no exception. Rob Paver (Skin and Cancer Foundation, Westmead, Sydney, NSW, Australia) reminded us that over 400 Australians die every year from nonmelanoma skin cancer (NMSC). He also highlighted the various scenarios when skin cancer may act aggressively and the limitations of nonsurgical treatments. In a symposium on difficult skin cancers, Michael Hughes (Westmead Hospital, Sydney, NSW, Australia) presented his approach to a number of challenging cases of advanced NMSC. He highlighted the role of imaging in these cases, in particular, ultrasound for nodal assessment, MRI for soft tissues and computed tomography for bony involvement. At present, sentinel lymph node biopsy is unproven in this area but is worth considering in cases of Merkel cell carcinoma. Michael Veness (Department of Radiation Oncology, University of Sydney, Westmead Hospital, NSW, Australia) spoke on his approach to radiotherapy in the setting of high-risk squamous cell carcinoma and Merkel cell carcinoma. He emphasized the important role of adjuvant radiotherapy, particularly in the management of Merkel cell carcinoma, and cited the important study by Otley, published in the Archives of Dermatology, which showed a reduction in locoregional recurrence [1] . Fortunately, Merkel cell carcinoma is a very radiosensitive tumor. We also heard that squamous cell carcinoma thickness is a reliable predictor of metastatic disease, although not a routine feature reported by histopathologists. Greg Siller (Princess Alexandra Hospital University of Queensland, QLD, Australia) presented the interim results of a study of ingenol-3-angelate (PEP005) gel in the treatment of actinic keratoses. Only two applications of this wart weed extract over 48 h led to a 71% clearance rate with minimal discomfort and good cosmetic outcome. Melanoma

Ash Marghoob (Memorial Sloan–Kettering Cancer Center, NY, USA) spoke at the dermoscopy breakfast symposium, emphasizing some novel tips for melanoma diagnosis, including the presence of inverse network as a sensitive sign in early lesions. This feature may also be observed in Spitz nevi. He also showed examples of chrysallis-like structures or stellate scar-like areas seen only with polarized dermoscopy and present in melanoma, Spitz nevi and basal cell carcinomas. These refractile structures probably represent remodeled Expert Rev. Dermatol. 3(4), (2008)

Australasian College of Dermatologists 41st Annual Scientific Meeting

collagen in the presence of tumor. Multiple examples of sequential digital monitoring of pigmented lesions were demonstrated to illustrate the benefit and role of this strategy. Pascale Guitera (Sydney Melanoma Diagnostic Unit, Sydney Cancer Centre, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia) spoke on reflectance confocal microscopy (RCM), particularly now that there is a compact mobile unit available. While time consuming and not necessarily simpler than histopathology, RCM has applications in determining the margins of lentigo maligna, monitoring melanomas treated by nonsurgical means (e.g., Aldara® cream or radiotherapy) and difficult or equivocal cases. The maximal depth RCM can examine to is approximately 0.2 mm. Spitz nevi are not easily discerned on RCM and there are also some anatomical limitations to imaging. Diona Damian presented some early data on the treatment of local cutaneous melanoma metastases with diphencyclopropenone immunotherapy in conjunction with cimetidine, with spectacular results in some cases. John Thompson (Sydney Melanoma Unit, Sydney, Australia) also presented some interesting work in the treatment of metastatic melanoma. Intralesional rose Bengal injections appear to cause impressive tumor necrosis in this clinical trial, with one patient suffering marked phototoxicity. Dermatologic surgery

A number of sessions were dedicated to dermatologic surgery. Interesting observations from recent literature were presented by Carl Vinciullo (Dermatology Surgery and Laser Centre, Perth, WA, Australia). He spoke about alcohol-containing hand rubs (such as DeBug™), which appear as effective as handwashing, and controversies surrounding presurgical anticoagulant management. The combination of aspirin and clopidogrel posed a very high risk for excess bleeding and perioperative management was unclear from the literature. His personal advice was to at least cease aspirin administration. He also highlighted some reports and his personal experience with hyaluronidase injections for treating nodularity from fillers. Michelle Hunt (Skin and Cancer Foundation, Westmead, Sydney, NSW, Australia) gave an excellent presentation on scar minimization and what evidence was available to support the various options that are promoted. Scar massage seems to be the most important element, with evidence that the time-honored vitamin E cream actually has the ability to weaken collagen. Aldara cream used twice weekly for 2 months has also been reported to help scars. The evidence for nonsilicone dressings was as good as for silicone gel sheeting. Laser

There were a number of presentations on the benefits of fractional ablative laser. This modality would appear to be revolutionizing the treatment of acne scarring. Other applications where the Fraxel® laser is proving useful include photoaging and refractory pigmentation. Chris Kearney (Skin and Cancer Foundation, Westmead, Sydney, NSW, Australia) presented his personal series of treatment of postoperative surgical scars on the face where Fraxel laser is instituted very early after removal of sutures. In his experience, using one to three treatments two- to four-times weekly, is likely to be of value www.expert-reviews.com

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in softening textural and pigmentary alterations, with minimal discomfort for the patient. Old scars appear to be equally responsive to treatment as new scars. Suzanne Kilmer (Laser and Skin Surgery Center of Northern California, University of California, Davis School of Medicine, CA, USA) reminded us that fractional resurfacing appeared to be safe on the neck and also spoke on the treatment of rosacea. She confirmed that pulsed dye laser treatment for erythemato–telangiectatic rosacea did help minimize flushing by reducing the cutaneous vasculature. She felt that inflammatory papules and pustules, as well as skin texture, also improved with this treatment modality. Prominent pores and sebaceous hyperplasia were also well treated with the SmoothBeam®, Fraxel and V-beam® lasers, which was interesting to hear. Suzanne also spoke on plasma skin regeneration as a novel nonablative technique for both resurfacing and treating pigmentary problems. Philip Bekhor (Royal Children’s Hospital, Flemington, VIC, Australia) spoke on his area of expertise – treating port wine stains – and suggested strategies that he had found helpful, including increased power, greater spot size, manipulating pulse duration, increasing hemoglobin volume and switching to different laser/light systems (e.g., intense pulsed light, Nd:YAG, Alexandrite or potassium titanyl phosphate [KTP]). Approximately 20–30% of port wine stains respond poorly to traditional pulsed dye laser, he said. Hypertrophic port wine stains respond well to treatment with long pulsed Nd:YAG laser or intense-pulsed light, in his experience. Medicolegal issues

A number of speakers touched on important medicolegal issues for dermatologists. In a cosmetic practice, dermatologists were advised by Michelle Hunt to maintain comprehensive cover with their medical defence organization, to adequately document consent for all procedures and to demonstrate pre- and post-images to prospective patients, as well as documenting response to treatment with good clinical photographs. Identifying dysmorphophobic patients is critical in avoiding adverse outcomes. When things go wrong, she recommended an open and honest approach where regret is expressed directly. One should avoid inflicting any out of pocket costs on the patient when further work is required to repair an unexpected problem. Maintaining a biopsy book and routinely advising patients to call for results were other tips for avoiding trouble. Ash Marghoob alerted us to the fact that 14% of all dermatology claims are related to misdiagnosis of melanoma and most of these arose from partial biopsy. He listed the major diagnostic pitfalls as the following: • Misdiagnosis of nodular melanoma by the clinician or pathologist • Misdiagnosis of nevoid melanoma by the pathologist • Misadventure by partial biopsy • Misdiagnosis of melanoma with positive margin as dysplastic or Spitz nevus • Unrecognized desmoplastic melanoma, which are frequently amelanotic 435

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• Patients presenting with metastatic melanoma with an occult primary where a previous lesion has been treated with cryotherapy or a specimen has been discarded He cautioned that unexplained scars should always be considered as possible desmoplastic melanoma. Unexpected vasculature on dermoscopy should also raise alarm bells for melanoma. In addition, blue nevi should always be documented. Conclusion

The Sydney meeting was both well coordinated and received. Abstracts can be viewed in an Australasian Journal of Dermatology supplement [2] . A successful College dinner was held at the References 1

Lewis KG, Weinstock MA, Weaver AL, Otley CC. Adjuvant local irradiation for Merkel cell carcinoma. Arch. Dermatol. 142(6), 693–700 (2006).

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historic Luna Park, beneath the iconic Harbour Bridge. We now look forward to meeting again in May, 2009 in Darwin (NT, Australia).

Financial & competing interests disclosure

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial confl ict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.

The Australasian College of Dermatologists 41st Annual Scientific Meeting, Sydney, Australia. Aust. J. Dermatol. 49(Suppl. 1), A1–A73 (2008).

Affiliation •

Alex J Chamberlain Department of Dermatology and Victorian Melanoma, Service, The Alfred, Commercial Road, Prahran, VIC, Australia Tel.: +61 398 229 944 Fax: +61 398 227 090 [email protected]

Expert Rev. Dermatol. 3(4), (2008)